Axiom Healthcare of Flora
232 Given Street, Flora, IL 62839 · Clay County · 99 certified beds · avg 54 residents/day · certified since Feb 14, 1991
Part of chain: AXIOM HEALTHCARE (8 facilities, chain avg rating 1.4★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★★☆4/5 · CMS overall rating: 3/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Aug 8, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Sep 3, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · May 27, 2025 · F-0700 · triggered by a complaint
The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly.
Why it matters: Improperly used bed rails can trap or injure residents — in the worst cases, causing serious harm.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jul 1, 2025 (Deficient, Provider has date of correction)
All citations in the current public record (25)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jun 24, 2026 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jun 17, 2026 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Aug 8, 2025 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| May 27, 2025 | ▲ G · Actual harm, one-off | The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly. · from a complaint |
| Apr 3, 2025 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| Feb 7, 2025 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint |
| Oct 25, 2024 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Sep 20, 2024 | F · Potential for harm, facility-wide | The facility was not properly licensed, or did not operate in compliance with federal, state, and local laws, regulations, and accepted professional standards. · from a complaint |
| Nov 7, 2023 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Nov 7, 2023 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Nov 7, 2023 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Sep 16, 2022 | F · Potential for harm, facility-wide | The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. |
| Sep 16, 2022 | F · Potential for harm, facility-wide | The facility did not report COVID-19 data to residents and their families as required. Facilities must keep residents and families informed about COVID-19 cases. |
| Sep 16, 2022 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Sep 16, 2022 | D · Potential for harm, one-off | The facility did not let a resident help develop and carry out their own plan of care — the written roadmap of the services and support they'll receive, built around their personal goals and preferences. |
| Sep 16, 2022 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. |
| Sep 16, 2022 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. |
| Sep 16, 2022 | D · Potential for harm, one-off | The facility did not have working policies to ensure employees report any suspected crime against a resident on time, to post notices of employees' reporting rights, and to prevent retaliation against staff who report. |
| Sep 16, 2022 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. |
| Sep 16, 2022 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. |
| Sep 16, 2022 | D · Potential for harm, one-off | The facility did not fully assess residents on time — a complete assessment of health, abilities, and needs is required when a resident is first admitted and at least once every 12 months after that. |
| Sep 16, 2022 | D · Potential for harm, one-off | The facility did not update each resident's care assessment at least once every 3 months. These regular check-ins keep the resident's care plan matched to their current condition. |
| Sep 16, 2022 | D · Potential for harm, one-off | When a resident had a planned discharge, the facility did not make sure the necessary information was communicated to the resident and to the doctors or facility taking over their care. |
| Sep 16, 2022 | D · Potential for harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. |
| Sep 16, 2022 | D · Potential for harm, one-off | The facility did not provide or arrange dental services for its residents. Nursing homes are responsible for making sure residents can get dental care. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (3 → 1).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2022 | 14 | 0 | F |
| 2023 | 3 | 0 | D |
| 2024 | 2 | 0 | F |
| 2025 | 4 | 2 | G ▲ |
| 2026 | 2 | 0 | D |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $9,110, plus 1 Medicare payment denial period.
| Date | Type | Amount / length |
|---|---|---|
| Aug 8, 2025 | Fine | $9,110 |
| May 27, 2025 | Payment Denial | 6 days from Jun 25, 2025 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Illinois avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.19 | 2.99 | 3.95 | top 26% in Illinois; bottom 21% in the U.S. |
| Registered Nurse hours | 1.03 | 0.63 | 0.69 | top 13% in Illinois; top 14% in the U.S. |
| Weekend total nurse staffing | 2.53 | 2.67 | 3.50 | top 41% in Illinois; bottom 10% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.77 | 0.56 | 0.48 | top 20% in Illinois; top 13% in the U.S. |
| Total nursing staff turnover (%) | 43.6 | 44.5 | 45.8 | bottom 50% in Illinois; top 46% in the U.S. |
| RN turnover (%) | 20.0 | 41.8 | 42.9 | top 15% in Illinois; top 13% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.16, RN 1.02, weekend 2.51. Staffing rating: 3/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 1/5 · long-stay residents: 1/5 · short-stay residents: 1/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Axiom Care, LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 12/01/2024 |
| Axiom Care, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 11/04/2025 |
| Berkowitz, David | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 11/04/2025 |
| Curis Services LLC | Organization | ADP of the SNF | NOT APPLICABLE | 12/01/2024 |
| Dauber, Eliana | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 11/04/2025 |
| Dauber, Jonathan | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/01/2024 |
| Dauber, Jonathan | Individual | ADP of the SNF | NOT APPLICABLE | 12/01/2024 |
| Goldfarb, Brian | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 11/18/2025 |
| James, Tiffany | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/01/2024 |
| James, Tiffany | Individual | ADP of the SNF | NOT APPLICABLE | 12/01/2024 |
| Kaplan, Mordechai | Individual | Managing Control - Governing Body | NOT APPLICABLE | 12/01/2024 |
| Kaplan, Mordechai | Individual | ADP of the SNF | NOT APPLICABLE | 12/01/2024 |
| Meystel, Yosef | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 11/04/2025 |
| Petersen SNF Holdings LLC | Organization | ADP of the SNF | NOT APPLICABLE | 11/04/2025 |
| Pontious, Rachel | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/01/2024 |
| Pontious, Rachel | Individual | ADP of the SNF | NOT APPLICABLE | 12/01/2024 |
| Rajchenbach, Chaim | Individual | Managing Control - Governing Body | NOT APPLICABLE | 12/01/2024 |
| Rajchenbach, Chaim | Individual | ADP of the SNF | NOT APPLICABLE | 12/01/2024 |
| Seitler, Dovid | Individual | ADP of the SNF | NOT APPLICABLE | 12/01/2024 |
| Spector, Jennifer | Individual | Corporate Officer | NOT APPLICABLE | 12/01/2024 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "What alternatives do you try before using bed rails, and how do you involve families in that decision?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "Can you tell me about this citation and confirm your license and compliance status today?"
- "What is your approach to psychiatric medications — how do you try non-drug options first and work to reduce doses over time?"
- "How many hours a day is a registered nurse physically in the building, including weekends?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Axiom Gardens of Flora | 0.7 mi | Flora, IL | ★☆☆☆☆ | 2/5 | abuse |
| Cisne Rehabilitation and Health Care Center | 11.4 mi | Cisne, IL | ★★☆☆☆ | 2/5 |
Compare this facility with the 2 closest →
Facility data as of CMS processing date 2026-08-01. CCN 145692.