Inspection·August 9, 2024

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 admission date 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. R2's Minimum Data Set (MDS) dated [DATE], documents in Section C, Cognitive Patterns, that R2 has a Brief Interview for Mental Status (BIMS) score of 15 indicating R2 is cognitively intact. The same MDS section GG0170, Mobility documents the use of a motorized scooter and section I8000, Active diagnoses documents lymphedema, not elsewhere classified. R2's care plan documents a focus area of, The resident has limited physical mobility with a documented intervention of the resident uses a motorized wheelchair with supervision from staff. On 8/07/2024 at 11:33 AM, R2 was observed sitting in her recliner in her room reading a book. R2's left leg had an ace bandage wrap applied around her left lower leg with a wound vacuum in place. R2 had a scant amount of reddish colored drainage in the wound vacuum line. On 8/07/2024 at 11:35 AM, R2 stated that V12 (Social Service Director) had been transporting her in the facility van to her eye appointment. R2 stated V12 did not buckle her scooter in the van because they were not going very far from the facility. R2 stated she held on to the cup holders on both sides of her in the van during transport to and from the eye appointment. R2 stated on the way back to the facility from her eye appointment, V12 missed the street to turn on to go back to the facility and slammed on the brakes to make a turn into the local diner parking lot. R2 stated when V12 hit the van brakes, her scooter went forward, and she hit her left lower leg on a metal piece on the seat in front of her. R2 stated after hitting the seat with her leg, she looked down and she noticed she was bleeding and that there was a gash in her leg. R2 stated she requested V12 take her to the emergency room. R2 stated when they arrived at the emergency room, a nurse came outside, applied some gauze to her leg and took her in to be evaluated. R2 stated she is under the care of a wound physician at this time to help her leg heal. R2 stated that she had never asked staff to not buckle her in. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 145624 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145624 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Axiom Gardens of Flora 701 Shadwell Avenue Flora, IL 62839 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)