Axiom Gardens of Flora

In the surveyor’s words

From the most serious findings on record at Axiom Gardens of Flora, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Oct 11, 2023

  Based on interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for the treatment of Type II Diabetes Mellitus for 3 (R3, R19, R20) of 4 residents reviewed for labs in the sample of 21. This failure resulted in abnormal lab values not being immediately communicated with the physician and R3 experiencing altered mental status requiring transport to the Emergency Department where a blood glucose level of 819 was found. This failure resulted in an Immediate Jeopardy, which was identified to have begun on 2/8/23 when abnormal Hemoglobin A1c results for R3 were reported to the facility and staff did not complete the facility procedure of notifying the physician of these values until 3/20/23. […]

• Actual harm, isolatedF600Jan 14, 2026

  Based on interview and record review the facility failed to prevent the verbal, physical and sexual abuse of residents from another resident with a known history of abuse for 4 of 6 residents (R1, R6, R8 and R9) reviewed for abuse in the sample of 11. This failure would cause a reasonable person to experience feelings of fear, anxiety and anger while residing in their home. Findings include:1. R7's admission Records documents R7 was admitted on [DATE] with diagnoses to include: Dementia with agitation, lack of coordination, anxiety, depression. […]

• Actual harm, isolatedF803Jul 1, 2025

  Based on interview, and record review, the facility failed to provide the correct textured diet for 1 of 19 (R2) residents reviewed for diet in a sample of 19. This failure resulted in R2 choking and being sent to the hospital. Findings include: R2's admission Record documents an admission date of 10/28/2024 with diagnoses including in part dementia and dysphagia oropharyngeal phase. R2's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. […]

• Actual harm, isolatedF600Apr 17, 2025

  Based on observation, interview and record review, the facility failed to ensure residents were free from physical abuse for 2 of 3 residents (R2, and R3) reviewed for abuse in the sample of 3. The failure resulted in R3 receiving a fractured coccyx after an incident where R1 pushed R3 down. Findings Include: R1's Admission Record documents that R1 is an [AGE] year-old make that was admitted to the facility on [DATE]. Diagnoses listed are chronic obstructive pulmonary disease, spondylosis, unspecified dementia, anxiety disorder, hyperlipidemia, insomnia, and repeated falls. R1's MDS (Minimum Data Set), dated 02/07/2025, documents that R1 has a BIMS (Brief Interview for Mental Status) of 05, indicating that R1 has severe cognitive impairment. […]

• Actual harm, isolatedF689Aug 9, 2024

  Based on observation, interview, and record review the facility failed to safely secure a resident during transport for 1 of 3 residents (R2) reviewed for accidents in a sample of 3. This failure resulted in R2 sustaining a 3 by 5 inches laceration to her left leg that became infected and required a wound vac. The findings included: R2's Admission record documents an admitted to the facility of 9/08/2023 with diagnoses including morbid (severe) obesity due to excess calories, unspecified atherosclerosis of native arteries of extremities, bilateral legs, lymphedema, not elsewhere classified, other specified and diabetes mellitus with diabetic autonomic (poly) neuropathy. […]