Axiom Gardens of Nashville

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services in a manner which prevented elopement for 2 of 3 residents (R2 and R3) reviewed for safety/elopement in a sample of 12. This failure resulted in R2 exiting the locked memory care unit and observed outside the facility for an undetermined amount of time on 04/26/26 and R3 leaving the designated outdoor smoking area with no staff knowledge or supervision, walking a couple of blocks up the road and out of sight of the facility on 04/28/26. The Immediate Jeopardy began on 04/26/26 when the facility failed to provide services in a manner to prevent elopement for R2 and R3. This failure resulted in 1) R2 exiting the locked memory care unit and being observed outside the facility, unknown to staff; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a safe resident environment and protection from physical abuse for 1 of 3 (R2) residents reviewed for resident-to-resident abuse in the sample of 3. This failure resulted in R2 being punched in the face by R1, leaving slight redness to her forehead. A reasonable person getting punched in the face would feel fearful, threatened, and intimidated.

Inspectors wroteBased on record review, interview and observation the facility failed to perform treatments as ordered, assess, monitor and implement interventions for 3 of 3 residents (R2, R4, R22) reviewed for pressure ulcers in sample of 42. This failure resulted in R22 obtaining a stage 2 pressure ulcer and contributed to the decline of R4's pressure ulcers to left buttocks and coccyx.

Inspectors wroteBased on interview, observation, and record review the facility failed to provide safe transfers for 3 of 14 residents (R1, R12, R50), to initiate fall interventions for a high fall risk resident for 1 of 14 residents (R2) resulting in R2 falling and fracturing her hip, to implement fall interventions for 1 of 14 residents (R22), and to keep door alarms activated, all reviewed for resident safety in the sample of 42.

Inspectors wroteBased on interview and record review, the Facility failed to provide the services of a Registered Nurse (RN) for at least eight hours daily. This has the potential to affect all 56 residents living in the Facility. Findings Include:The Facility's February 2026 licensed nurse schedule was reviewed, and this schedule does not document a Registered Nurse (RN) worked at least eight hours on 2/7/26, 2/8/26, 2/21/26, and 2/22/26. The Facility's March 2026 licensed nurse schedule was reviewed, and this schedule does not document a RN worked at least eight hours on 3/7/26 and 3/8/26. On 3/18/26 at 12:23 PM V14 [NAME] President of Operations stated the facility did not have RN coverage every day in February and March of 2026. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to document when a multi-dose use vial of Tuberculosis (TB) testing solution was opened, date a vial of insulin when opened, date stock medications when opened, and discard expired stock medications. This has the potential to affect all 56 residents in the facility.

Inspectors wroteBased on observation, interview, record review, the facility failed to ensure foods were properly stored, labeled, dated, and discarded when expired, and failed to ensure food was prepared and handled in accordance with sanitary food services practices. This failure has the potential to affect all 56 residents receiving meals prepared by the dietary department. Findings Include: On 3/16/26 at 8:55 AM the kitchen was inspected with the following issues noted: The double door refrigerator contained 1 open bottle of nectar thickened apple juice approximately 1/4 used with no open date and 1 gallon of ranch dressing approximately 3/4 used with an expiration date of 12/2/25. V13 [NAME] agreed it was expired. The walk-in freezer was inspected, and Surveyor observed 1 box of open frozen chicken breast fillets with no open date and 1 box of cheese tortellini with no open date. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and follow its established water management program for prevention of Legionella growth, and failed to perform hand hygiene and glove changes during resident care. This failure has the potential to affect all 56 residents residing at the facility. Findings Include: 1. On 3/17/26 at 11:05 AM V27 Maintenance Director stated he does not know anything about Legionella nor the processes of the facility regarding prevention of Legionella. On 3/17/26 at 1:33 PM V1 Administrator stated she cannot find any facility legionella prevention and/or monitoring. V1 stated she started working at the facility as the Administrator just 7 days ago. V1 stated she educated V27 Maintenance Director today (3/17/26) and stated going forward V27 will follow the facility's Legionella Prevention policy and procedure. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents and employees were offered COVID-19 vaccinations in accordance with current CDC (Centers for Disease Control) guidelines and facility policy. This deficient practice has the potential to affect all residents residing in the facility who were eligible for a COVID-19 booster. Findings Include: On 3/18/26 at 11:03 AM V7 ADON/IP (Assistant Director of Nursing/Infection Preventionist) stated she did not start working at the facility until November of 2025. V7 stated she is not aware of any residents being offered the COVID booster vaccination unless it was completed prior to her working at the facility. On 3/18/26 at 11:10 AM V14 [NAME] President of Operations stated this company does offer COVID booster vaccines although they did not take over this facility until November of 2025. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to perform catheter and complete incontinent care for 4 of 4 (R4, R11, R44, R50) residents reviewed for toileting in a sample of 42.

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide the residents a meal that was palatable, attractive, and at a safe and appetizing temperature for 5 of 14 residents (R12, R23, R32, R35, R37) reviewed for palatable meals in the sample of 42.

Inspectors wroteBased on interview, observation, and record review, the facility failed to maintain privacy for 1 of 14 residents (R27), to maintain a clean resident refrigerator with temperature checks for 1 of 14 residents (R4) and to maintain the safety of the environment related to the presence of hazards in the resident room for 1 of 14 residents (R30) reviewed for a homelike environment in the sample of 42.

Inspectors wroteBased on interview and record review, the facility failed to prevent sexual abuse to a resident by an employee and failed to prevent physical abuse of a resident from another resident for 2 of 3 residents (R7, R22) reviewed for abuse in the sample of 42. Findings Include:1. R22's admission Record print date of 3/18/26 documents R22 has diagnoses including vascular dementia with behavioral disturbance, peripheral vascular disease, anxiety, supraventricular tachycardia, heart disease, and osteoarthritis. R22's MDS (Minimum Data Set) dated 1/31/26 documents R22 is severely cognitively impaired and requires substantial to maximal assistance with transfers. The Facility's undated Preliminary 24-hour Abuse Investigation Report documents an offense was alleged against R22 by an employee. The Facility's undated Final Abuse Investigation Report documents name of resident abuse: (R22). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's medication regimen was free from chemical restraint for 1 of 5 residents (R2) reviewed for unnecessary medications in a sample of 42. Findings Include: On 03/16/26 at 10:30 AM, R2 was lying in her bed on her back sleeping with her head slightly elevated. On 03/17/26 from 9:30 AM through 12:30 PM, with checks done in 15-minute intervals R2 was seen lying in her bed sleeping. On 03/19/2026 at 12:15 PM, R2 is sitting up in her wheelchair in the dining room with her meal tray in front of her. She only ate about half of her lasagna and R2 was just sitting and staring out the dining room window. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide a Bed Hold for 1 of 14 residents (R60) who was transferred to the hospital from the facility reviewed for proper transferring or discharging of a resident in the sample of 42.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Wound Nurse Practitioner (NP) orders were followed and implemented in a timely manner, failed to ensure low air loss mattress was maintained in well working order, and failed to ensure wound dressings were changed per NP orders for 1 of 3 residents (R2) in a sample of 9. This failure resulted in R2 having worsening of wounds which became infected leading to R2 being hospitalized several times, requiring surgical debridement and Intravenous (IV) antibiotics due to infections of Methicillin-resistant Staphylococcus aureus (MRSA), Pseudomonas, Enterococcus faecalis and Extended-Spectrum Beta-Lactamase (ESBL) Escherichia (E) coli. This failure resulted in R2's wounds worsening and becoming infected. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure new care plan interventions were implemented to prevent new/worsening pressure ulcers. The facility failed to ensure skin assessments were completed, ensure supplies for wound care were available, and complete wound treatments as ordered for 1 of 3 residents (R1) reviewed for wounds in a sample of 10. This failure resulted in R1 developing a stage II pressure ulcer to her right buttock on 11/25/25, a stage III pressure ulcer to her left buttock on 12/02/25, and worsening/decline to the wound on R1's right heel resulting in R1 requiring antibiotic treatment. The Immediate Jeopardy began on 11/25/25 due to the facility's failure to assess, treat, and complete skin assessments to prevent and/or treat pressure wounds for R1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure R4 was adequately supervised, failed to ensure door alarms were turned on, and respond in a timely manner to alarms to prevent elopement for 2 of 4 residents (R4, R9) reviewed for safety in a sample of 9. These failures resulted in a severely cognitive impaired resident (R4) repeatedly eloping from the facility despite being identified as an elopement risk, and multiple failures of disabling of door alarms and delayed responses contribute to R4's elopements into unknown and unsafe conditions that include walking in middle of road and getting in a strangers vehicle. The Immediate Jeopardy began on 10/16/25 when the facility failed to properly supervise a resident (R4) to prevent an elopement from the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a low air loss mattress was in proper working order for 1 of 3 residents (R2) reviewed for essential equipment, safe operating condition in a sample of 10. This resulted in R2 being in extreme pain due to R2 having multiple pressure ulcers/injuries, the mattress not staying properly inflated, and R2 laying on a hard metal bed frame. Findings Include: R2's Minimum Data Set (MDS), dated [DATE], documented R2 is cognitively intact with a Brief Interview for Mental Status (BIMS) of 15 out of 15 and she requires substantial/maximal assistance for rolling left to right, sitting to lying and lying to sitting. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure their facility assessment was updated to include all necessary components per the current standards of practice. This failure has the potential to affect all 60 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure nurse aides completed the required 12 hours of education per year. This has the potential to affect all 60 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to notify a resident representative after the resident was found outside of the facility for 1 of 3 residents (R4) reviewed for representative notification in a sample of 10. Findings Include: R4's Face Sheet, print date of 12/02/25, documented R4 has diagnoses of but not limited to Alcohol dependence with alcohol induced persisting dementia, Wernicke's encephalopathy, and chronic kidney disease, stage3. R4's Minimum Data Set (MDS), dated [DATE], documented R4 is severely cognitively impaired with a Brief Interview for Mental Status (BIMS) of two out of 15 and is independent with ambulation. R4's Progress Notes, dated 10/16/2025 at 8:15 PM, documented Nurses Note Text: Around 1815 (6:15 PM), resident was found by CNA (Certified Nursing Assistant) outside by the dumpster. Door alarm and (electronic monitoring device) were sounding. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure infection control standards of practice for hand hygiene, wound dressing disposal, and contaminated linen disposal were followed for 1 (R10) of 3 reviewed for infection control in the sample of 10. Findings Include:R10's admission Record dated [DATE] documented R10's initial admit date to the facility as [DATE]. This same document lists diagnoses for R10 including but not limited to Asymptomatic Human Immunodeficiency Virus (HIV) Infection Status and Chronic Viral Hepatitis B without Delta-Agent. The Weekly Wound Committee Review Pressure Ulcer Cumulative Report dated [DATE] documented R10 admitted to the facility with an unstageable wound to his coccyx with moderate drainage noted. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to timely identify, assess and monitor, and provide treatment to prevent the worsening of pressure ulcers for 1 of 3 residents (R2) reviewed for pressure ulcers in a sample of 3. This failure resulted in R2 developing two unstageable pressure ulcers requiring debridement at the bedside and being started on an antibiotic treatment related to pressure ulcer infection. The Immediate Jeopardy began on 05/12/25 when due to the facility's failure to assess and monitor and provide progressive treatment, R2 developed an opened area to her buttocks which went untreated, worsened to R2 developing two unstageable pressure ulcers requiring bedside debridement and acquiring an infection which required antibiotic treatment. V1, Administrator was notified of the Immediate Jeopardy on 07/11/25 at 1:45 PM. [...]

Inspectors wroteBased on interview and record review the facility failed to obtain timely treatment orders and complete physician ordered treatments for one (R1) of three residents reviewed with pressure ulcers in the sample of 10.

Inspectors wroteBased on interviews, observations, and record reviews the facility failed to prevent verbal and mental abuse for 4 out of 6 residents (R3, R4, R6, R7). This failure resulted in R3, R4, R5 and R7 experiencing psychosocial harm. Using the reasonable person concept, R3, R4, R6 and R7 experienced psychosocial harm with feelings of shame, embarrassment, humiliation or insignificance.

Inspectors wroteBased on interview, record reveiw, and observation the facility failed to ensure staff readily had access to and donned appropriate personal protective equipment prior to entering COVID positive resident rooms, failed to ensure isolation signage was placed to identify type of isolation required for resident rooms on isolation for COVID, and failed to document COVID testing. These failures affect 3 of 3 residents (R1, R2, R3) reviewed for infection control with the potential to affect all 59 residents residing in the facility. Findings Include: 1. R1's MDS (Minimum Data Set) dated 11/14/24 documents R1 is moderately cognitively impaired. R1's Nurses Note dated 1/7/24 documents (R1) tested positive during routine COVID test. (R1) is currently afebrile and asymptomatic. R1's Nurses Note dated 1/7/24 documents Contact Isolation precautions started related to COVID positive. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure they had a qualified Infection Control Preventionist (ICP) working full time in the facility. This has the potential to affect all 59 residents living in the facility.

Inspectors wroteBased on interview, observation and record review the facility failed to provide a safe and hazard free environment for three of three residents (R4, R5, R6) on the dementia unit reviewed for accidents and hazards in the sample of 6. Findings Include: 1. R4's MDS (Minimum Data Set) dated 12/10/24 documents R4 severely cognitively impaired, and she can walk independently. R4's Electronic Health Record documents R4 has diagnoses of Alzheimer Disease, Anxiety Disorder, and Restlessness and Agitation. On 1/9/25 9:03 AM R4 was sitting in the dining room with peers. V8 Activities stated, she does walk up and down the hallway and V8 did not know that window was broken and the door is not locked. R4 unable to answer questions. 2. R5's MDS dated [DATE] documents R4 is severley cognitively impaired and she walks independently. [...]

Inspectors wroteBased on observation, interview, and record review, the Facility failed to implement nutritional interventions to prevent weight loss in 1 of 3 residents (R37) reviewed for nutrition in the sample of 40. This failure resulted in R37 sustaining significant, severe weight loss at the one, three, and six month marks.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Registered Nurse (RN) was working in the facility for at least 8 consecutive hours a day, 7 days a week. This failure has the potential to affect all 56 residents living in the facility.

Inspectors wroteBased on observation and interview the Facility failed to post staffing schedules in a clear and readable format and posted in a prominent place, readily accessible to residents and visitors. This has the potential to affect all 56 residents living in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure food was stored and prepared in a manner which prevents potential contamination. This has the potential to affect all 56 residents living in the facility.

Inspectors wroteBased on interview and record review, the Facility failed to ensure the Facility Assessment was current and up to date and reviewed annually. This has the potential to affect all 56 residents living in the facility.

Inspectors wroteBased on interview and record review the facility failed to follow a comprehensive surveillance program to collect and analyze data to control infection in the facility. This had the potential to affect all 56 resident in the facility

Inspectors wroteBased on interview and record review, the Facility failed to ensure they had a qualified Infection Control Preventionist (ICP) working full time in the facility. This has the potential to affect all 56 residents living in the facility.

Inspectors wroteBased on observation, interview, and record review, the Facility failed to maintain dignified existence for 1 of 1 residents (R11) reviewed for resident rights in the sample of 40.

Inspectors wroteBased on interview, record review, and observation the facility failed to notify the physician and obtain an order to treat non pressure areas for one of one resident (R36) reviewed for physcian notification in the sample of 40. Findings Include: R36's Electronic Health Record (EHR) documents R36 has diagnoses in part Acquired Absence of right leg above the knee unspecified, and Peripheral Vascular Disease. R36's Minimum Data Set (MDS) dated [DATE] documents R36 is cognitively intact. On 12/17/24 01:17 PM R36 has a sore on her lower leg left that has a dressing on it, and an order was not found in the Electronic Health Record for this dressing. On 12/17/24 at 10:00 AM R36 stated my leg is leaking. R36's Nurses Note dated 12/16/24 documents resident has a sore on her lower left leg, Dressed and covered wound with TAO and bandage. No warmth or Redness around the sore. [...]

Inspectors wroteBased upon interview, observation, and record review the facility failed to protect a resident from abuse for 1 of 1 (R207) reviewed for abuse in the sample of 40.

Inspectors wroteBased on observation, interview, and record review, the Facility failed to implement progressive fall interventions in 2 of 11 residents (R18, R25) reviewed for accidents and hazards in the sample of 40. This failure resulted in R18 sustaining lacerations requiring emergency room (ER) transfer and repair with sutures and R25 sustaining bruising to forehead.

Inspectors wroteBased on interview and record review the facility failed to monitor the resident post dialysis and paracentesis for one of one resident (R34) reviewed for quality of care in the sample of 40. Finding Include: R34's Electronic Health Record (EHR) documents R34 diagnoses in part are End Stage Renal Disease, Alcoholic Cirrhosis of Liver with Ascites, and Dependence on Dialysis. R34's Minimum Data Set MDS dated [DATE] documents R34 is moderately cognitively impaired. R34's Care Plan dated 10/31/24 documents resident (R34) at risk for complications r/t (related to) dx (diagnosis) of end stage renal disease and requires dialysis, occ.(occasionally) nauseas r/t (related to) dialysis, does not stay for entire length of dialysis, had paracentesis about every 4 weeks but now not needing as often. [...]

Inspectors wroteBased on observation, interview, and record review the Facility failed to ensure residents who were being fed by staff had staff who were properly trained and under the supervision of a RN (Registered Nurse or LPN (Licensed Practical Nurse) for 1 out of 5 residents (R1) reviewed for need for assistance with feeding in the sample of 40.

Inspectors wroteBased on interview and record review, the facility failed to provide supervision/monitoring to prevent an elopement for 1 of 11 residents (R2) reviewed for supervision to prevent elopement in the sample of 11. This failure resulted in Immediate Jeopardy on 10/15/2024 with R2, eloping from the facility sometime between 3:00 PM to 4:00 PM. R2 was found by a passerby at approximately 4:30 PM, was assessed at the local hospital and returned to the facility. The Immediate Jeopardy began on 10/15/2024, when R2 eloped from the facility. On 10/22/2024 at 2:18 PM V1, Administrator and V30, Medical Records Director were notified of the Immediate Jeopardy. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure adequate staffing for the memory care locked unit. This failure affects all 11 residents residing on the unit (R1, R2, R3, R4, R5, R22, R23, R24, R25, R26 and R27.) Reviewed for elopement on the sample list of 27.

Inspectors wroteBased on observation, interview and record review, the facility failed to secure and control the disposition of administered medications for 5 of 5 residents (R1, R2, R3, R6, R7) in the sample of 10 reviewed for disposition of medication.

Inspectors wroteBased on interview and record review, the facility failed to prevent mental and physical abuse by a staff member for 1 of 3 residents (R28) reviewed for abuse. This deficient practice resulted in R28 feeling sad, scared, and crying hysterically.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there were foot pedals on a wheelchair while transporting 1 of 1 (R2) resident reviewed for accidents in a sample of 41. This failure resulted in R2 sustaining a right femur fracture.

Inspectors wroteBased on observation, interview, and record the facility failed to employ a Registered Nurse as Director of Nursing. This failure has the potential to affects all 64 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store medication, label tuberculin vial and insulin pens. This has the potential to affect all 64 residents living in the facility.

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure Dietary Staff wore appropriate hair and/or beard nets and failed to properly perform hand hygiene while checking the temperature of food, and while serving food, including all diets (regular diets, special diets, and pureed foods), on the resident plates to prevent contamination and foodborne illness. This failure has the potential to affect all 64 residents living in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to remove soiled gloves, perform proper hand hygiene, and dispose of soiled linen properly for 5 of 5 resident (R2, R6, R13, R15, R36) reviewed for infection control in a sample of 41.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure an Infection Control Specialist was available to answer questions and responsible for the facility's Infection Control Program. This has the potential to affect all 64 residents living in the Facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide complete incontinent care as well as proper catheter care according to standards of care for 4 of 4 residents (R2, R6, R15, and R36) reviewed for incontinent care, in the sample of 41.

Inspectors wroteBased on interview and record review, the facility failed to follow up with hospital orders and clarify the need for an antibiotic for 5 of 5 (R31, R35, R38, R53, R164) residents reviewed for unnecessary mediations in the sample of 41.

Inspectors wroteBased on observation, interview and record review the facility failed to properly assess and monitor the ability for a resident to release a seat belt for 1 of 1 (R52) resident reviewed for restraints, in a sample of 41.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a clean and sanitary environment for 5 of 5 residents (R3, R4, R6, R14 and R15) reviewed for safe/clean/comfortable environment in the sample of 15.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were free from misappropriation of medications for 19 of 21 residents (R1, R4, R5, R6, R12-R26) reviewed for abuse in the sample of 26. Findings Include: 1. The facility Long-Term Care Facility and IID (Individuals with Intellectual Disabilities)- Serious Injury Incident and Communicable Disease Report dated [DATE] documents under Detailed Incident Summary, On [DATE] at 2200 (11:00 PM), when Morphine Sulfate for (R1) was drawn up by V6 (LPN/Licensed Practical Nurse), it was clear in color. V6 notified DON (Director of Nurses/V2) that he thought the bottle had been tampered with, as the color of Morphine Sulfate is usually red or pink in color and the side of the bottle is pink, but the Morphine is drawing up clear color. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate records of narcotics, destroy narcotics per facility policy and standards of practice, and administer medications to meet the needs of the residents for 19 of 21 residents (R1, R4, R5, R6, R12-R26) reviewed for pharmacy services in the sample of 26. Findings Include: 1. The facility Long-Term Care Facility and IID (Individuals with Intellectual Disabilities)- Serious Injury Incident and Communicable Disease Report dated [DATE] documents under Detailed Incident Summary, On [DATE] at 2200 (11:00 PM), when Morphine Sulfate for (R1) was drawn up by V6 (LPN/Licensed Practical Nurse), it was clear in color. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a thorough investigation was completed after an allegation of misappropriation of narcotics was made for 1 of 1 (R1) resident reviewed for exploitation in the sample of 26. Findings Include: R1's admission Record with a print date of 9/20/23 documents R1 was admitted to the facility on [DATE] with diagnoses that include atrial fibrillation, chronic obstructive pulmonary disease, dementia, hypertension, dyspnea, and anorexia. R1's MDS (Minimum Data Set) dated 9/4/23 documents a BIMS (Brief Interview for Mental Status) score of 01, which indicates a severe cognitive deficit. R1's Order Summary Report documents a physician order with a start date of 8/28/23 for Morphine Sulfate 20 milligrams/milliliters to give 0.25 milliliters every four hours as needed for moderate pain related to chronic obstructive pulmonary disease. [...]