Axiom Gardens of Nashville

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Jun 1, 2026

  Based 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. […]

• Immediate jeopardy, isolatedF684Dec 24, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF686Dec 24, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF689Dec 24, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF686Jul 17, 2025

  Based 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. […]