Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Axiom Healthcare Of Flora during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and a history of falls sustained a clavicle fracture after falling from a wheelchair while being pushed by a CNA. The resident, who typically self-propelled and did not use foot pedals, dropped her feet during transport, causing them to get caught and resulting in the fall. Staff and therapy had not implemented or communicated necessary safety interventions, such as evaluating the need for foot pedals, despite the resident's known risks.
A resident with multiple medical conditions and a history of fractures sustained a displaced left humerus fracture after her arm became caught in improperly installed bed rails. Staff assessments indicated a need for half rails, but quarter rails were installed without clear communication or proper training on assessment and installation. Documentation and interviews revealed inconsistencies in the assessment process and a lack of staff training, contributing to the incident.
A resident with severe cognitive impairment and multiple medical conditions did not have a comprehensive care plan addressing all triggered care areas, such as cognition, ADLs, incontinence, nutrition, and pressure ulcer risk. Staff reported ongoing issues with care refusal and hygiene, but these were not included in the care plan, and key team members were not involved in care planning as required.
A resident in an LTC facility was mistakenly administered diclofenac sodium gel instead of a barrier cream due to improper labeling and storage. The gel was left in an unlabeled cup by an RN after an emergency, leading a CNA to apply it to the resident's abdominal fold. The resident, who is cognitively intact, reported a tingling sensation, and the cream was promptly removed. The facility's policy against leaving medications in unlabeled containers was not followed.
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents with indwelling catheters, as required by their policy and CDC guidelines. Observations showed no signage or PPE outside the residents' rooms, and staff were unaware of any residents on isolation or transmission-based precautions. The Director of Nursing and the facility's administrator admitted to not being aware of the EBP policy until the day of the survey.
The facility failed to have a licensed administrator as required by state law, affecting all 33 residents. The administrator's temporary license expired, and she was not working under a licensed administrator. The Regional Director confirmed the absence of a licensed administrator, and the Director of Nursing noted that the administrator did not pass the exam for a permanent license.
Failure to Prevent Wheelchair Fall Due to Inadequate Supervision and Lack of Safety Interventions
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment and multiple medical diagnoses, including osteoporosis and a history of falls, was being transported in a wheelchair by a CNA. The resident, who typically self-propelled her wheelchair and did not use foot pedals, was being pushed by staff to the bathroom. During this transport, the resident dropped her feet, which became caught under the wheelchair, causing her to fall forward onto her knees and then onto her left side. This incident resulted in an acute comminuted fracture of the distal left clavicle. The resident's care plan documented a history of falls and included interventions such as therapy evaluation for wheelchair positioning and consideration of foot pedals. However, there was no evidence that these interventions were implemented prior to the incident. Staff interviews revealed that the resident had never used foot pedals on her wheelchair, as she used her feet to self-propel. The CNA pushing the wheelchair did not notice the resident's feet dropping, and the Therapy Director was not made aware of the need to evaluate for foot pedals until after the incident. Observations after the fall showed the resident continued to self-propel, with her left foot occasionally dragging and getting stuck on the floor. Documentation and interviews indicated a lack of communication and follow-through regarding the resident's need for wheelchair safety interventions. The Therapy Director stated she was not informed about the incident or the need for evaluation, and the DON and Administrator were unaware that therapy had not completed the assessment for foot pedals. The facility's fall prevention policy required individualized assessment and implementation of appropriate interventions, but these measures were not effectively carried out, resulting in the resident's fall and injury.
Improper Bed Rail Installation and Assessment Leads to Resident Injury
Penalty
Summary
A deficiency occurred when the facility failed to ensure that bed rails were installed and used in accordance with physician orders and proper assessment protocols for a resident. The resident, who had a history of multiple fractures, mood disorder, alcohol abuse, anxiety, insomnia, and chronic obstructive pulmonary disease, was assessed as cognitively intact but dependent on staff for most activities of daily living, including bed mobility and transfers. The resident's care plan and side rail assessment indicated a need for half rails on both sides of the bed, but the physician's order did not specify the size of the rails, and quarter rails were installed instead. The incident leading to the deficiency involved the resident getting her left arm caught between the bed rail while reaching for an item, resulting in a painful and displaced fracture of the left humerus. Staff interviews revealed that the resident frequently moved her arms through the side rails and used them for repositioning. The staff responsible for assessing and installing bed rails reported a lack of training on how to properly assess the need for side rails and how to determine the appropriate size or type of rail for each resident. Maintenance staff installed the rails that fit the bed without specific instructions regarding the size, and there was no clear communication between nursing and maintenance regarding the correct rail type. Documentation and interviews further indicated inconsistencies in the assessment and documentation process. The MDS did not list side rails as a restraint, as staff believed they were being used solely for bed mobility. There was also uncertainty among staff about whether the benefits of side rail use outweighed the risks for this resident, especially given her restlessness and history of injury related to side rails. The facility's policy required proper installation and maintenance of bed rails, but gaps in staff training and communication contributed to the improper use and installation of the bed rails, ultimately resulting in the resident's injury.
Failure to Develop and Implement Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for one resident with multiple complex medical conditions, including unspecified dementia, depression, hypertension, polyneuropathy, idiopathic urticaria, and hyperlipidemia. The resident's Minimum Data Set (MDS) assessment indicated severely impaired cognition, partial to maximal assistance needed for activities of daily living (ADLs), and triggered care areas such as cognitive loss/dementia, ADL/rehabilitation potential, urinary incontinence, nutritional status, and pressure ulcer risk. Despite these identified needs, the resident's care plan only addressed limited focus areas, omitting critical issues such as cognition, ADL functions, urinary incontinence, nutrition, and pressure ulcer risk, all of which were triggered in the MDS assessment. Interviews with facility staff, including the MDS/Care Plan Coordinator, RNs, and CNAs, revealed that the comprehensive care plan was not completed due to time constraints and competing duties. Staff reported ongoing issues with the resident, such as frequent refusal of care, digging in the rectum resulting in feces on hands and under nails, and refusal to participate in ADLs like showering and toileting. These behaviors and care needs were not addressed in the care plan, and several staff members indicated they were not included in care plan meetings, contrary to facility policy requiring interdisciplinary team involvement. The deficiency was further substantiated by the facility's own policy, which mandates timely and comprehensive care planning involving all relevant staff and the resident or their representative.
Medication Mislabeling and Storage Deficiency
Penalty
Summary
The facility failed to ensure medications were properly labeled and stored securely, leading to an incident involving a resident who was mistakenly administered the wrong topical medication. The resident, who is cognitively intact and has a history of acute cystitis, knee pain, osteoarthritis, type 2 diabetes, and hypertension, was admitted with an order for diclofenac sodium gel to be applied to the left knee. However, a Registered Nurse left a cup containing the gel in the resident's room after an emergency, and it was not discarded. Subsequently, a Certified Nurse Assistant, while providing care, found the unlabeled cup and assumed it contained a barrier cream for the resident's abdominal fold. Upon application, the resident immediately reported a tingling sensation, prompting the CNA to remove the cream and notify the nurse. The facility's policy prohibits leaving medications in unlabeled containers at the bedside, and the incident highlights a breach in this protocol, as the medication was accessible to unlicensed staff and not properly labeled or stored.
Failure to Implement Enhanced Barrier Precautions for Residents with Indwelling Catheters
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents, R22 and R25, who were reviewed for infection control. Both residents had indwelling catheters, which required the use of EBP according to the facility's policy and CDC guidelines. Observations revealed that there was no signage or personal protective equipment (PPE) available outside the residents' rooms to indicate that EBP was in place. Additionally, staff members, including a registered nurse and certified nurse assistants, were unaware of any residents on isolation or transmission-based precautions, and they did not use barrier gowns during catheter care for R25. The Director of Nursing (DON) admitted to being unaware of the EBP policy and procedures until the day of the survey, when she received the information from the corporate office. The facility's administrator also confirmed that they were not aware of the EBP policy prior to the survey. The facility's policy stated that EBP should be used for residents with indwelling medical devices, such as catheters, to prevent the transfer of multidrug-resistant organisms (MDROs). However, the lack of awareness and implementation of these precautions led to the deficiency identified during the survey.
Facility Lacks Licensed Administrator
Penalty
Summary
The facility failed to have a licensed administrator in accordance with state law, which has the potential to affect all 33 residents residing in the facility. The administrator, identified as V1, had a temporary license that expired, and she was not working under a licensed administrator. V1 acknowledged that her temporary license expired and that she did not know if she was working under a licensed administrator. The Regional Director of Operations, V3, confirmed that there is no licensed administrator employed at the facility at this time, and the current Regional Director, V4, does not utilize her administrator license for this facility. The Director of Nursing, V2, stated that V1's temporary license expired because she did not pass the exam to acquire a permanent administrator license. V2 also mentioned that V1 was out due to illness and that the Regional Administrator was on vacation and unavailable. Despite these issues, V2 stated that she was not aware of any problems related to the administrator situation. The facility census sheet documented that there are 33 residents residing in the facility, highlighting the potential impact of this deficiency.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Flora
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Axiom Gardens Of Flora | 0.7 mi | ★★★★★ | 19 | 0 |
| Cisne Rehabilitation And Health Care Center | 11.4 mi | ★★★★★ | 6 | 0 |
| Fairfield Senior Living & Rehabilitation Llc | 21.5 mi | ★★★★★ | 15 | 0 |
| Fairfield Memorial Hospital | 21.6 mi | ★★★★★ | 0 | 0 |
| Helia Healthcare Of Olney | 22.6 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.