Axiom Healthcare of Flora

Inspectors wroteBased on interview, observation and record review, the facility failed to investigate a fall for 1 of 3 residents (R1) reviewed for accidents in a sample of 6.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure interventions to prevent falls were implemented for 3 of 3 (R1, R2, and R3) residents reviewed for falls in the sample of 12. Findings Include: 1. R1's Transfer/Discharge Report with a print date of 6/15/26 documents R1 was admitted to the facility on [DATE] with diagnoses that include kidney failure, heart failure, atrial fibrillation, diabetes, and anxiety disorder. R1's Minimum Data Set (MDS) dated [DATE] documents R1 has a Brief Interview for Mental Status (BIMS) score of 15, indicating R1 is cognitively intact. R1's Fall Risk assessment dated [DATE] documents a score of 21.0, which indicates R1 is at high risk for falls. R1's current Care Plan documents a Focus area of, I am at risk for fall/injury from weakness and tiredness: Date Initiated: 05/07/2026 Revision on 06/10/2026. [...]

Inspectors wroteBased on interview, and record review the facility failed to prevent a fall from a wheelchair for 1 (R1) of 3 residents reviewed for accidents in the sample of 3. This failure resulted in R1 falling forward out of the wheelchair onto the floor resulting in an acute comminuted fracture of the distal left clavicle.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure bed rails/side rails were installed in accordance with doctor's orders to prevent injury for 1 of 5 resident (R4, R5, R6, R9, and R10) reviewed for bed rails in the sample of 17. The failure resulted in R4 sustaining a fracture of left humerus bone in left upper arm.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive care plan for 1 of 5 residents (R1) reviewed for care plans in a sample of 5.

Inspectors wroteBased on interview and record review the facility failed to ensure medications were properly labeled and not accessible to residents and unlicensed staff for 1 (R1) of 4 residents reviewed for medication storage in the sample of 4. The Findings Include: R1's admission Record documented that R1 is a [AGE] year-old that was admitted to the facility on [DATE] with diagnoses listed as acute cystitis, pain in left knee, need for assistance with personal care, unspecified osteoarthritis, type 2 diabetes mellitus, essential hypertension, pain in joint and localized edema. R1's MDS (Minimum Data Set) with a date of 02/04/2025, documented as an admission set coded section C0500 BIMS (Brief Interview for Mental Status) score of 15 indicating R1 is cognitively intact. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to implement Enhanced Barrier Precautions per current standard of practice for 2 (R22 and R25) of 2 residents reviewed for infection control in the sample of 25 Findings Included: 1. R25's admission Record documented an Initial admission Date of 8/28/2024. R25's admission Record also included diagnoses of retention of urine, unspecified, type 2 diabetes mellitus without complications, hypo-osmolality, and hyponatremia. R25's Physician Orders dated 10/1/24 documented a foley catheter in place. R25's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R25 was cognitively intact. [...]

Inspectors wroteBased on interview and record review the facility failed to have a licensed administrator licensed in accordance with state law. This failure has the potential to affect all 33 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for 2 of 25 residents (R20, R33) reviewed for care plans in a sample of 25.

Inspectors wroteBased on interview, and record review the facility failed to implement new and applicable interventions to prevent further falls for 1 of 3 residents (R9) reviewed for falls in a sample of 25.

Inspectors wroteBased on interview and record review the facility failed to attempt GDR (gradual dose reduction) of psychotropic medications and failed to adequately monitor the medications effectiveness for 2 of 4 residents (R22, R18) reviewed for psychotropic medications in a sample of 25 1. Per R22's Face sheet, R22 was admitted to this facility on 9/27/2021 with diagnosis of Parkinson's Psychosis, Schizophrenia and Anxiety among others. R22's current physician's order sheet (11/1/23-11/30/23) documents R22 is ordered the anti-psychotic medication known as Haldol Decanoate 50mg (milligrams) injection every month and Haldol 5 mg tablets by mouth four times per day. Both medications are prescribed for the diagnosis of Parkinson's Psychosis and Schizophrenia. [...]

Inspectors wroteBased on interview and record review the facility failed to designate a Director of Nursing for the facility. This failure has the potential to affect all 34 residents residing in the facility. Findings Include: On 09/13/22 at 10:20 AM, V1 (Administrator) acknowledges the facility does not have a Registered Nurse (RN) working in the Director of Nursing (DON) role for the facility. V1 states that V2 (Minimum Data Set / Care Plan Coordinator) who has a Licensed Practical Nursing license works to fill the DON duties at this time. V1 states the facility has sought to hire a DON, but been unsuccessful, but that they have an interview schedule for 9/14/22. On 9/15/22 at 1:30 PM, V2 stated that they have not had a DON for a couple months but is unsure of her last date on the schedule. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed, according to its policy, to notify a resident's representative of positive COVID tests of a resident and a staff member. This has the ability to affect all 34 residents living at the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure call lights were answered timely for 2 of 2 (R23 and R281) residents reviewed for dignity in the sample of 27. Findings Include: 1. R23's undated facility face sheet documents R23 was admitted to the facility on [DATE] with diagnoses that included cerebral infarct, hemiplegia, and lack of coordination. R23's MDS (Minimum Data Set) dated 7/5/22 documents a BIMS (Brief Interview for Mental Status) score of 14, which indicates R23 is cognitively intact. This same MDS documents under section G that R23 requires one-person physical assistance for toileting. On 9/13/22 at 10:41 AM R23 was observed sitting on her bed in her room. There was a bedside commode observed sitting next to R23's bed. R23 stated it takes a while for staff to assist her when she pushes her call light. R23 stated she has wet the bed while waiting for them. [...]

Inspectors wroteBased on interview and record review, the facility failed to involve a resident's representative in care planning for one resident of 27 residents (R17) reviewed for care plans in the sample of 27.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were safe from abuse for 1 of 4 residents (R25) reviewed for abuse in a sample of 27.

Inspectors wroteBased on interview and record review the facility failed to implement their abuse policy by failing to notify the Illinois Department of Public Health, notify the local police, and initiate abuse investigations for allegations of abuse for 3 of 4 residents (R25, R12 and R20) residents reviewed for abuse in the sample of 27.

Inspectors wroteBased on interview and record review the facility failed to notify the local police on an allegations of misappropriation of resident property for 1 of 3 (R20) reviewed for abuse allegations in a sample of 27. The Findings Include: R20's profile face sheet documents an original admission date of 7/13/18. R20's most recent MDS (Minimum Data Set) section C notes that she has a BIMS (Brief Interview Mental Status) of 15, indicating that she is cognitively intact. On 9/15/22 at 12:00 PM, V5 (Family) stated that R20 had an electric razor that was delivered from her sister in the mail and has not been found. V5 went on to state that R20 received the package and left for dialysis and when she returned the razor was missing. [...]

Inspectors wroteBased on interview and record review the facility failed to report allegation of abuse to the Department of Public Health for 3 of 4 residents (R25, R12, R20) reviewed for abuse in a sample of 27.

Inspectors wroteBased on interview and record review the facility failed to initiate, thoroughly investigate, and maintain documentation of a thorough investigation for an allegations of abuse for 3 of 4 residents (R25, R12,R20) reviewed for abuse in a sample of 27. The Findings Include: R25's Face Sheet documents he was admitted to this facility on 05/23/14 with diagnoses in part of invert lumbar disc with myelopathy lumbar region, spinal stenosis cervical region, crushing injury multiple sites, agoraphobia with pan disorder, injury of unspecified blood vessel at neck level, difficulty in walking, post-traumatic stress disorder, personal history of traumatic brain injury, low back pain, post-traumatic . R25's September Physician's Order Sheet (POS) documents he is prescribed Olanzapine 15 mg (milligram) tablet take 1 tablet by mouth once daily; [...]

Inspectors wroteBased on interview and record review the facility failed to ensure comprehensive assessments were completed timely for 1 of 27 (R281) residents reviewed for assessments in the sample of 27. Findings Include: R281's facility undated New admission Information documents R281 was admitted to the facility on [DATE]. R281's Physician's Order sheet dated 9/2/22 documents diagnoses that include acute kidney failure and prostate cancer. On 9/15/22 at 1:02 PM, V2 (LPN/MDS Coordinator) stated R281 did not have a current MDS (Minimum Data Set) assessment completed. V2 stated it should have been done but has not. On 9/16/22 at 10:14 AM, V2 (LPN/MDS Coordinator) stated R281 should have had a five-day MDS assessment completed on 9/9/22 and a 14 day MDS assessment completed on 9/14/22. V2 stated the assessments were not done.

Inspectors wroteBased on record review and interview the facility failed to ensure quarterly assessments were completed timely for 2 of 27 (R1 and R3) residents reviewed for timely quarterly assessments reviewed for in a sample of 27. The Findings Include: 1. R1's facility undated New admission Information documents R1 was admitted to the facility on [DATE]. On 9/16/22 at 10:14 AM, V2 (LPN/MDS Coordinator) confirmed that the most recent MDS (Minimum Data Set) completed for R1 was on 4/20/22. 2. R3's facility undated New admission Information documents that R3 was admitted to the facility on [DATE]. On 9/16/22 at 10:14 AM, V2 confirmed the most recent MDS completed for R3 was done on 4/29/22 On 9/15/22 at 1:02 PM, V2 (LPN/MDS Coordinator) stated R1 and R3 did not have a current up to date quarterly MDS assessments completed. [...]

Inspectors wroteBased on record review and interview the facility failed to ensure that a recapitulation of stay was completed for 1 of 2 residents (R30) reviewed for discharge in a sample of 27. The Findings Include: R30's profile face sheet documents an admission date of 12/22/21. R30's nursing progress notes documents on 6/23/22 that resident was discharged home with family. Review of R30's closed record had no copy of a discharge summary, or a recapitulation of stay found in the document. On 9/15/22 at 10:15AM, V3 (Social Services) reviewed the closed record and confirmed that there was no indication other than a nursing progress note stated that resident was discharged home. V3 went on to state that they should be doing a discharge summary or recapitulation of stay with all departments documenting when a resident is discharged .

Inspectors wroteBased on observation, interview, and record review, the facility failed to check the placement of a gastrostomy feeding (G) tube prior to administering medication for one resident of one resident (R228 ) reviewed tube feeding in the sample of 27.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure timely dental care was provided for 1 of 1 (R11) resident reviewed for dental services in the sample of 27. Findings Include: R11's undated face sheet documents R11 was admitted to the facility on [DATE]. R11's MDS (Minimum Data Set) dated 8/31/22 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R11 is cognitively intact. R11's nurse's notes dated 8/9/22 at 3:15 PM documents, Resident (R11) c/o (complains of) R (right) tooth pain. Notified transportation to check on a dentist appt (appointment) for resident. R11's progress notes were reviewed 8/1/22 through 9/15/22 with no further documentation related to tooth pain and/or a dental appointment being scheduled. [...]