Flora, IL

Axiom Gardens of Flora

1-star overall rating with 1-star inspections with abuse icon flag with $119,254 in total fines with 24 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle

701 Shadwell Avenue, Flora, IL

(618) 662-8361

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

2 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Axiom Healthcare

Operator or chain grouping

Approved since

1989-05-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

7 facilities

Chain averages 1 overall / 2 health / 1 staffing / 2 quality stars

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.76

Registered nurse staffing · state 0.73 · national 0.68

LPN hours / resident day

0.37

Licensed practical nurse staffing · state 0.64 · national 0.87

Aide hours / resident day

1.73

Nurse aide staffing · state 2.13 · national 2.35

Total nurse hours

2.85

All reported nurse hours · state 3.49 · national 3.89

Licensed hours

1.13

RN + LPN hours · state 1.36 · national 1.54

Weekend hours

2.54

Weekend nurse staffing · state 3.09 · national 3.43

Weekend RN hours

0.57

Weekend registered nurse coverage · state 0.56 · national 0.47

Physical therapist

0.01

Reported PT staffing · state 0.05 · national 0.07

Adjusted RN hours

0.67

CMS adjusted RN staffing hours

Adjusted total hours

2.54

CMS adjusted total nurse staffing hours

Case-mix index

1.53

Higher values indicate more complex resident acuity

RN turnover

67%

Annual RN turnover · state 44% · national 45%

Total nurse turnover

71%

Annual nurse turnover · state 46% · national 46%

SNF VBP

Value-based purchasing

Program rank

13,726

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

Composite VBP score used to determine payment impact.

Payment multiplier

0.9803

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Total nurse turnover

Baseline 56.76% · Performance 62.79% · Measure score 0 · Achievement 0 · Improvement 0

Adjusted total nurse staffing

Baseline 2.86 hours · Performance 2.61 hours · Measure score 0 · Achievement 0 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.01%	10.72% 0.7 pts better	No Different than the National Rate · Eligible stays 45 · Observed rate 6.67% · Lower 95% interval 6.54%
Discharge to community	33.01%	50.57% 17.6 pts worse	No Different than the National Rate · Eligible stays 30 · Observed rate 20% · Lower 95% interval 20.67%
Medicare spending per beneficiary	1.09	1.02 0.1 pts worse
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 30 · Denominator 30
Falls with major injury	3.33%	0.77% 2.6 pts worse	Numerator 1 · Denominator 30
Discharge self-care score	18.18%	53.69% 35.5 pts worse	Numerator 4 · Denominator 22
Discharge mobility score	50%	50.94% 0.9 pts worse	Numerator 11 · Denominator 22
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 30 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	3.85%	8.2% 4.3 pts worse	Numerator 2 · Denominator 52
Staff flu vaccination coverage	81.25%	42% 39.2 pts better	Numerator 65 · Denominator 80
Discharge function score	40.91%	56.45% 15.5 pts worse	Numerator 9 · Denominator 22
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	38.1%	25.2% 12.9 pts better	Numerator 8 · Denominator 21

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.5	2.0 0.5 pts worse	1.9 0.6 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.5 · Expected 1.9 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	4.5	2.3 2.2 pts worse	1.8 2.7 pts worse	Long Stay · 20240701-20250630 · Adjusted 4.5 · Observed 5.0 · Expected 1.8 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	89.6% 10.4 pts better	93.4% 6.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	91.6% 8.4 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	9.1%	3.3% 5.8 pts worse	3.3% 5.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 8.9% · Q3 9.4% · Q4 6.1% · 4Q avg 9.1% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	36.7%	50.3% 13.6 pts better	11.4% 25.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 22.6% · Q3 44.1% · Q4 66.7% · 4Q avg 36.7%
Percentage of long-stay residents who lose too much weight	2.0%	6.5% 4.5 pts better	5.4% 3.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.1% · Q3 5.1% · Q4 0.0% · 4Q avg 2.0%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	17.4%	18.5% 1.1 pts better	19.6% 2.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q2 22.9% · Q3 16.9% · Q4 15.0% · 4Q avg 17.4%
Percentage of long-stay residents who received an antipsychotic medication	40.7%	22.8% 17.9 pts worse	16.7% 24 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 48.3% · Q2 42.4% · Q3 41.5% · Q4 33.3% · 4Q avg 40.7% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.1% 0.1 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	24.8%	17.2% 7.6 pts worse	16.3% 8.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 50.4% · Q2 16.4% · Q3 15.9% · Q4 24.1% · 4Q avg 24.8% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	28.9%	15.0% 13.9 pts worse	14.9% 14 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 51.3% · Q2 21.3% · Q3 19.3% · Q4 29.3% · 4Q avg 28.9% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.3%	1.1% 0.8 pts better	1.0% 0.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	3.1%	1.7% 1.4 pts worse	1.7% 1.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.6% · Q3 3.1% · Q4 4.8% · 4Q avg 3.1% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	15.4%	21.3% 5.9 pts better	19.8% 4.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 19.1% · Q2 18.9% · Q3 11.5% · Q4 13.6% · 4Q avg 15.4%
Percentage of long-stay residents with pressure ulcers	9.9%	5.2% 4.7 pts worse	5.1% 4.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 10.3% · Q3 7.6% · Q4 10.8% · 4Q avg 9.9% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	96.2%	68.8% 27.4 pts better	81.7% 14.5 pts better	Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 96.6% · Q3 91.7% · Q4 96.3% · 4Q avg 96.2%
Percentage of short-stay residents who had an outpatient emergency department visit	10.0%	14.0% 4 pts better	12.0% 2 pts better	Short Stay · 20240701-20250630 · Adjusted 10.0% · Observed 11.4% · Expected 12.8% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.0%	2.3% 2.3 pts better	1.6% 1.6 pts better	Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	96.7%	63.0% 33.7 pts better	79.7% 17 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 96.7%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	11.1%	26.2% 15.1 pts better	23.9% 12.8 pts better	Short Stay · 20240701-20250630 · Adjusted 11.1% · Observed 11.4% · Expected 24.6% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-03-11 · Fire 2025-03-11

24 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (5 deficiencies)

4 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 2 Health 2023-12-21 · Fire 2023-12-21

2 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

9 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 3 Health 2023-03-03 · Fire 2023-03-03

8 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)

4 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-03-11

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-04-16

F · Potential for more than minimal harm 2025-03-11

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2025-03-17

E · Potential for more than minimal harm 2025-03-11

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2025-03-17

E · Potential for more than minimal harm 2025-03-11

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2025-03-17

F · Potential for more than minimal harm 2023-12-21

E26 · Emergency Preparedness Deficiencies

Fire Safety

Establish roles under a Waiver declared by secretary.

Corrected 2024-01-10

F · Potential for more than minimal harm 2023-12-21

E6 · Emergency Preparedness Deficiencies

Fire Safety

Conduct risk assessment and an All-Hazards approach.

Corrected 2024-01-10

F · Potential for more than minimal harm 2023-12-21

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-01-10

F · Potential for more than minimal harm 2023-12-21

K354 · Smoke Deficiencies

Fire Safety

Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

Corrected 2024-01-10

F · Potential for more than minimal harm 2023-12-21

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2024-01-10

F · Potential for more than minimal harm 2023-12-21

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2024-01-10

F · Potential for more than minimal harm 2023-12-21

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-01-19

E · Potential for more than minimal harm 2023-12-21

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2024-01-10

E · Potential for more than minimal harm 2023-12-21

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2024-01-10

F · Potential for more than minimal harm 2023-03-03

E37 · Emergency Preparedness Deficiencies

Fire Safety

Establish staff and initial training requirements.

Corrected 2023-03-27

E · Potential for more than minimal harm 2023-03-03

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2023-04-05

E · Potential for more than minimal harm 2023-03-03

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2023-03-20

E · Potential for more than minimal harm 2023-03-03

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2023-03-21

Inspection history

Recent health citations

G · Actual harm 2026-01-14

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2026-01-29

F · Potential for more than minimal harm 2025-11-20

F725 · Nursing and Physician Services Deficiencies

Health

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Corrected 2025-12-15

E · Potential for more than minimal harm 2025-11-20

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2025-12-17

D · Potential for more than minimal harm 2025-11-20

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2025-12-05

D · Potential for more than minimal harm 2025-11-20

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2025-12-15

D · Potential for more than minimal harm 2025-11-20

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2025-12-04

D · Potential for more than minimal harm 2025-11-20

F803 · Nutrition and Dietary Deficiencies

Health

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Corrected 2025-12-17

G · Actual harm 2025-07-01

F803 · Nutrition and Dietary Deficiencies

Health

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Corrected 2025-07-02

G · Actual harm 2025-04-17

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2025-04-30

D · Potential for more than minimal harm 2025-04-17

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-04-30

D · Potential for more than minimal harm 2025-04-04

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2025-04-30

D · Potential for more than minimal harm 2025-04-04

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2025-04-09

D · Potential for more than minimal harm 2025-04-04

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2025-04-30

D · Potential for more than minimal harm 2025-04-04

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2025-04-23

F · Potential for more than minimal harm 2025-03-11

F712 · Nursing and Physician Services Deficiencies

Health

Ensure that the resident and his/her doctor meet face-to-face at all required visits.

Corrected 2025-04-25

F · Potential for more than minimal harm 2025-03-11

F725 · Nursing and Physician Services Deficiencies

Health

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Corrected 2025-03-31

E · Potential for more than minimal harm 2025-03-11

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2025-03-17