Axiom Healthcare of West Frankfort

In the surveyor’s words

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

• Immediate jeopardy, isolatedF605Dec 20, 2024

  Based on interview and record review the facility failed to ensure residents were free from chemical restraints when staff administered an injectable anti-psychotic medication twice within an 8 hour time frame without the resident's consent and without a physician's order to include adequate indications for use, and failed to attempt less restrictive alternative treatments prior to administration of the medication for 1 (R1) of 3 residents reviewed for chemical restraints in the sample of 7. […]

• Immediate jeopardy, isolatedF600May 21, 2024

  Based on interview and record review the facility failed to ensure residents are free from physical and verbal abuse for 2 of 5 residents (R26, R44) reviewed for abuse in the sample of 14. This failure resulted in R26 experiencing incidents of mental anguish, fear, anxiety, and feeling unsafe as a result of V34's (Certified Nursing Assistant/CNA) mental and verbal abuse. The Immediate Jeopardy began on 5/7/24 at approximately 2:00 AM when V34 (Certified Nursing Assistant/ CNA) verbally and physically abused R26 by ripping R26's clothing while transferring R26 to the wheelchair and wheeling R26 to the dining room to wait for breakfast. V44 (Regional Director of Operations) was notified of the Immediate Jeopardy on 5/15/24 at 12:35 PM. […]

• Actual harm, isolatedF627May 12, 2026

  Based on interview and record review, the facility failed to ensure the notifications and required reasons for transfer/discharge were adequately communicated and documented in the medical record and failed to permit a resident to return to the facility after hospitalization for two (R1 and R2) of three residents reviewed for inappropriate transfer and discharge in the sample of 32. This failure would cause a reasonable person to experience feelings of fear, agitation, anxiety, and distress as a result of being removed from their home and taken to an unfamiliar location with unfamiliar people, far away from family. Findings include:1. […]

• Actual harm, isolatedF689Apr 16, 2026

  Based on interview, observation, and record review, the facility failed to implement care plan fall interventions for 3 (R2, R4, and R13) of 5 residents reviewed for accidents in a sample of 46. This failure resulted in R2 being sent to the hospital after a fall and diagnosed with a closed fracture of left orbit and closed fracture of left side maxilla. The findings include:1. R2's admission record documents an admission date of 11/06/25 with diagnoses of Parkinson's disease, vitamin d deficiency, muscle wasting and atrophy, lack of coordination, dementia, and need for assistance with personal care.R2's MDS (Minimum Data Set) dated 02/13/26 documents in Section C a BIMS (Brief Interview for Mental Status) score of 13 which indicates R2 is cognitively intact. […]

• Actual harm, isolatedF689Sep 16, 2025

  Based on observation, interview, record review the facility failed to provide supervision during smoking to prevent an accident and failed to provide an appropriate intervention to prevent future falls for 1 of 15 residents (R27) reviewed for accidents in a sample of 48. This failure resulted in R27 falling outside in the designated smoking area and then having to be sent out to the emergency room for laceration on her left and right arm and having to be seen by a wound care specialist. Findings include: R27's admission Record dated 09/10/25 documents an admission date of 06/06/25 with diagnoses of history of falling, tobacco use, type 2 diabetes mellitus with diabetic neuropathy, unspecified sequelae of nontraumatic intracerebral hemorrhage. […]