Inspection·June 18, 2025

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to obtain timely treatment orders and complete physician ordered treatments for one (R1) of three residents reviewed with pressure ulcers in the sample of 10. Residents Affected - Few Findings include: R1's face sheet documents an admission date of 10/10/2024. Diagnosis include Congestive Heart Failure, Pneumonia, Urinary Tract Infection, Type 2 Diabetes. R1's Minimum Data Set, MDS, dated [DATE] documents R1 has no cognitive deficits. R1's MDS dated [DATE] documents R1 has 2 stage 2 unhealed pressure ulcers and is at risk for pressure ulcers. R1's care plan updated 1/23/2025 documents Potential for skin breakdown related to bowel incontinence, weakness, redness to peri area. 11/26/24 Stage 2 left buttock 3/5/25 Stage 2 right buttock; Interventions include reposition every 1-2 hours. Monitor for redness or discoloration to skin. Weekly skin checks. R1's Braden Scale for Predicting Pressure Sore Risk dated 10/31/2024 documents R1 is at high risk for pressure ulcer development. R1's shower sheets dated 6/5/2025, 6/9/2025, and 6/12/2025 all circled left heel as area of abnormality. No progress notes, treatments, or orders on corresponding dates noted. R1's weekly wound evaluation dated 6/10/2025 has no documentation of left heel. R1's weekly wound evaluation dated 6/17/2025 documents left heel stage 3. Comments stated resident does not sleep in bed, he sleeps in recliner. treatment order 6/14. May refer to wound company. Follow up in place. Medical Doctor to be consulted with Nurse Practitioner from wound company. R1's order sheet dated 6/14/2025 documents Left Heel, cleanse with normal saline or wound cleaner. Apply calcium alginate to wound and cover with dry dressing. One time a day. R1's treatment administration records, TARS, dated June 2025 document Left Heel, cleanse with normal saline or wound cleaner. Apply calcium alginate to wound and cover with dry dressing. one time a day -Order Date 6/14/2025 5:00AM. Treatments completed on 6/16/2025, 6/17/2025, and 6/18/2025. No treatment completed on 6/14/2025 and 6/15/2025. (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 2 Event ID: 146043 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 146043 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Axiom Gardens of Nashville 485 South Friendship Drive Nashville, IL 62263 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)