Axiom Gardens of Flora
701 Shadwell Avenue · Flora, IL · 62839 · 6186628361
97 certified beds For profit - Corporation Chain: Axiom Healthcare
Why this verdict
- Carries CMS’s abuse warning icon.
- Inspection record is far worse than the national median (deficiency count and severity).
- Federal penalties on record: $104,959 in fines in the last 24 months.
- 4 citations involved actual harm to residents.
- Inspection results have improved across recent cycles.
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Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
CMS abuse warning
CMS flags this facility with its abuse icon: cited for abuse that caused harm in the past year, or potential harm in the past two years.
1 immediate-jeopardy citation in prior inspection cycles
Serious past findings — check whether the underlying problems were fixed and stayed fixed.
2 abuse-related citations at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
2 actual-harm citations in the most recent cycle
Inspectors found deficiencies that caused real harm to residents, beyond potential-harm paperwork findings.
$104,959 in federal fines in the last 24 months
3 fines — CMS fines are reserved for verified, serious non-compliance.
Total nurse staffing below 3.0 hours per resident-day
2.83 reported hours vs the 3.48 minimum CMS's own staffing study recommends.
69% of nursing staff left within a year
High turnover disrupts continuity of care; the national median is 45%.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 2 of 5 Staffing: 1 of 5 Quality measures: 1 of 5
| Total nurse hours / resident-day | 2.83 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.74 | 0.55–0.75 |
| Weekend hours / resident-day | 2.59 | ≈ weekday level |
| Nursing turnover / year | 69% | median 45% |
| Fines (3-yr window) | 4 · $184,358 |
Inspection citations (40 in the current record)
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Potential for harm · D April 29, 2026 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected May 1, 2026 · Quality of Life and Care
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Potential for harm · F April 29, 2026 · found via complaint
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected May 1, 2026 · Nursing and Physician Services
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Potential for harm · D March 19, 2026 · found via complaint
Provide and implement an infection prevention and control program.
Corrected March 28, 2026 · Infection Control
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Potential for harm · D March 2, 2026
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected March 11, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D March 2, 2026
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected March 10, 2026 · Quality of Life and Care
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Potential for harm · D March 2, 2026
Provide enough food/fluids to maintain a resident's health.
Corrected March 10, 2026 · Quality of Life and Care
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Potential for harm · D March 2, 2026
Provide safe, appropriate pain management for a resident who requires such services.
Corrected March 10, 2026 · Quality of Life and Care
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Potential for harm · D March 2, 2026
Provide and implement an infection prevention and control program.
Corrected March 28, 2026 · Infection Control
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Potential for harm · E March 2, 2026
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected March 10, 2026 · Environmental
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Actual harm · G January 14, 2026 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected January 29, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D November 20, 2025 · found via complaint
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected December 5, 2025 · Resident Rights
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Potential for harm · D November 20, 2025 · found via complaint
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected December 15, 2025 · Quality of Life and Care
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Potential for harm · F November 20, 2025 · found via complaint
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected December 15, 2025 · Nursing and Physician Services
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Potential for harm · D November 20, 2025 · found via complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected December 4, 2025 · Pharmacy Service
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Potential for harm · D November 20, 2025 · found via complaint
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 December 17, 2025 · Nutrition and Dietary
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Potential for harm · E November 20, 2025 · found via complaint
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected December 17, 2025 · Nutrition and Dietary
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Actual harm · G July 1, 2025 · found via complaint
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 July 2, 2025 · Nutrition and Dietary
-
Actual harm · G April 17, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected April 30, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D April 17, 2025 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected April 30, 2025 · Quality of Life and Care
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Potential for harm · D April 4, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected April 30, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D April 4, 2025 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected April 9, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D April 4, 2025 · found via complaint
Respond appropriately to all alleged violations.
Corrected April 30, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D April 4, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected April 23, 2025 · Quality of Life and Care
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Potential for harm · D March 11, 2025
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected March 28, 2025 · Resident Rights
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Potential for harm · E March 11, 2025
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 March 17, 2025 · Resident Rights
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| January 14, 2026 | Fine | $70,315 |
| July 1, 2025 | Fine | $10,358 |
| March 11, 2025 | Fine | $24,286 |
| October 11, 2023 | Fine | $79,399 |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 145624 · certified since May 1, 1989. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.