Axiom Healthcare of Flora

In the surveyor’s words

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

• Actual harm, isolatedF689Aug 8, 2025

  Based 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.The findings include:R1's admission Record documents an admission date of 6/20/2025 and included diagnoses of cardiac arrhythmia, essential hypertension, personal history of transient ischemic attack, hyperlipidemia, unspecified atrial fibrillation, gastro-esophageal reflux disease, gastritis, and age-related osteoporosis. […]

• Actual harm, isolatedF700May 27, 2025

  Based 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. Findings include: R4's admission record documented R4 was admitted to the facility on [DATE] and included diagnoses of nondisplaced [NAME] fracture of right tibia, multiple fractures of ribs, left side, multiple fractures of ribs, right side, mood disorder, alcohol abuse, anxiety, insomnia, and chronic obstructive pulmonary disease. […]

• Actual harm, isolatedF697Jun 18, 2021

  Based on observation, interview, and record review, the facility failed to assess a resident's pain, document the effectiveness of pain medication, notify the physician that pain medications were ineffective, and provide non pharmacological interventions to assist with pain relief for one (R1) of two residents reviewed for pain in the sample of 28. This failure resulted in psychosocial and physical harm as evidenced by R1 expressing that the pain was so severe that R1 wanted to die, of which the facility did not notify R1's physician. Findings include: On 06/15/21 at 11:12am, R1 was observed in her room laying on her bed. R1 was alert and oriented to self. […]

• No harm, potential for more than minimal, widespreadF836Sep 20, 2024

  Based 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. Findings include: On [DATE] V1's Administrator license that was posted on the wall titled Licensed Nursing Home Administrator Temporary documented an expiration date of [DATE]. On [DATE] at 3:37 PM, V1 (Administrator) via phone stated her temporary license expired on [DATE]. V1 stated temporary license are only valid for 2 years. V1 stated she received her temporary license in 2021. V1 was asked if she was working under a Licensed Administrator and V1 stated I didn't know. […]

• No harm, potential for more than minimal, widespreadF727Sep 16, 2022

  Based 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. […]