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Nursing HomeMedicaid Investigative

Axiom Gardens of Flora

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

701 Shadwell Avenue, Flora, IL 6283997 bedsLicensed & Active
1/5
Medicare
Inspection
Quality
Staffing
Google rating
4.9/5

based on 242 Google reviews

5
4
3
2
1
Axiom Gardens of Flora Nursing Home in Flora, IL — Street View
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8/ 10
critical Risk

Quality Concerns Identified

Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.

  • Abuse citation on record
  • Low overall rating (1/5 stars)
  • Low staffing rating (1/5 stars)
  • Above-median deficiencies (24 vs median 11.0)
  • High staff turnover (71%)
  • High RN turnover (67%)

Bottom 25% in IL · Meets national RN staffing standard · Very high staff turnover · Worst in AXIOM HEALTHCARE chain · $119,254 in fines · Abuse citation

Source: Medicare data

What this means for your family

While the facility was highly praised in 2022, recent 2025 feedback highlights critical issues regarding food safety and staff responsiveness. We strongly recommend visiting during off-hours and requesting a tour of the dining area to verify if these recent concerns have been addressed.

Google Reviews

Google Reviews

242 reviews on Google
Axiom Gardens of Flora receives an overwhelming volume of five-star reviews, primarily praising the cleanliness of the facility and the kindness of the staff. While many families express deep satisfaction with the care provided to their loved ones, recent reports from 2025 indicate serious concerns regarding food quality and staff responsiveness.

Quality Themes

Tap a score for details
Food2.0Staff9.0Clean10.0Activities8.0MedsN/AMemoryN/AComms8.0ValueN/A

Strengths

  • Clean, well-maintained facility
  • Friendly and compassionate nursing staff
  • Welcoming, family-oriented atmosphere
  • Professional and attentive care team

Concerns

  • Poor food quality and preparation (mentioned by 2 reviewers)
  • Lack of staff responsiveness to resident needs (mentioned by 2 reviewers)

Rating Trends

Tap a year to see what changed

2345.02022(195)1.02023(1)3.82025(5)

Distribution · 201 analyzed

5
197
4
0
3
1
2
0
1
3
180 reviews posted between Nov 7, 2022Nov 19, 2022 · 179 were 5-star
86 reviews posted between Nov 13, 2022Nov 19, 2022 · 86 were 5-star

How They Respond to Reviews

7%response rate

This facility rarely responds to reviews.

Questions for Your Tour

  • 1Given the recent focus on enhancing the dining experience, what steps are being taken to improve the variety and quality of the meals served to residents?
  • 2With the facility currently managing a high number of state-reported deficiencies, could you walk us through the specific quality improvement plan you have in place to address these regulatory findings?
  • 3How does your leadership team ensure consistent staff responsiveness and follow-through when a resident or family member requests assistance?
  • 4Since many families highlight the warm and welcoming atmosphere here, how do you integrate that sense of community into the daily activity schedule for residents?
  • 5In light of the current staffing ratings, what is your process for ensuring that residents receive timely, attentive care during peak hours and overnight shifts?
  • 6What protocols are in place to ensure that medical emergencies are handled promptly and that families are kept fully informed during any health-related incidents?

Personalized based on this facility's data


Key Review Excerpts

Flora Gardens took very good care of our mother. Am very glad we found a place that was so caring and catering when problems arose the tackled them with no problem!

Long-term resident's family · 2022★★★★★

Mom was a resident for a brief time earlier this year. The care and sweet attentiveness of the staff was amazing! So heartwarming to know your loved ones are under such impeccable care!

Rehab patient's family · 2022★★★★★

Staff won't help you... cooking is a joke they made meatloaf that was completely raw blood coming out of it I can't believe som

Resident/Family member · 2025☆☆☆☆
Source: 242 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.74hrs
98%
Registered nurses for medical care
Total Nursing
2.83hrs
69%
All nurses + aides combined
Staff Turnover
69%
Lower is better (< 30% = good)
RN Turnover
57%
Lower is better (< 30% = good)

Both RN and total nursing hours are below national benchmarks. This can mean less clinical attention per resident, so ask about their staffing plan.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 17 measures

Medicare Rating
1/ 5
Better Than Avg

9

measures

Worse Than Avg

8

measures

Long-Stay Residents
😔

Residents with depression symptoms

↓ Lower is better
This Facility55.2%
Worse than Avg
Here
55.2%
US
12.1%
IL
52.5%
Clay
10.6%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

💊

Residents on antipsychotic medication

↓ Lower is better
This Facility36.3%
Worse than Avg
Here
36.3%
US
15.5%
IL
21.8%
Clay
17.5%
💉

Residents vaccinated for pneumonia

↑ Higher is better
This Facility100.0%
Better than Avg
Here
100.0%
US
93.4%
IL
90.0%
Clay
96.4%
🛏️

Residents needing more daily help over time

↓ Lower is better
This Facility23.6%
Worse than Avg
Here
23.6%
US
14.4%
IL
14.2%
Clay
14.8%
💉

Residents vaccinated for the flu

↑ Higher is better
This Facility100.0%
Better than Avg
Here
100.0%
US
95.5%
IL
91.8%
Clay
96.5%
🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility13.0%
Better than Avg
Here
13.0%
US
19.4%
IL
21.1%
Clay
19.0%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility96.7%
Better than Avg
Here
96.7%
US
79.8%
IL
63.1%
Clay
80.9%
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility96.4%
Better than Avg
Here
96.4%
US
81.8%
IL
69.0%
Clay
85.4%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility2.8%
Worse than Avg
Here
2.8%
US
1.6%
IL
2.4%
Clay
2.6%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

17deficiencies
4penalties
Above state avg (12.0)
24 complaint-triggered
$119,254 in fines

Axiom Gardens of Flora has significant recurring problems, with families filing 22 complaints that triggered inspections revealing deficiencies in nursing staffing, abuse protection, and medication management. The facility has repeatedly struggled with inadequate nursing staff levels, failure to protect residents from abuse and neglect, and pharmacy service issues across multiple surveys from 2023 through 2025, indicating persistent care quality concerns that families should carefully consider.

Apr 29, 2026Complaint
2
0726Potential for harm · WidespreadCorrected

Nursing and Physician Services Deficiencies

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.

0689Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

Mar 19, 2026Complaint
1
0880Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Mar 2, 2026Routine
9
0345Potential for harm · WidespreadCorrected

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

0712Potential for harm · WidespreadCorrected

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

0919Potential for harm · PatternCorrected

Environmental Deficiencies

Make sure that a working call system is available in each resident's bathroom and bathing area.

0324Potential for harm · PatternCorrected

Smoke Deficiencies

Provide properly protected cooking facilities.

0605Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

0677Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0692Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

0697Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

0880Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Jan 14, 2026Complaint
1
0600Actual harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

Nov 20, 2025Complaint
6
0725Potential for harm · WidespreadCorrected

Nursing and Physician Services Deficiencies

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

0804Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

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

0550Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

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

0677Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0755Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

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

0803Potential for harm · IsolatedCorrected

Nutrition and Dietary Deficiencies

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.

Jul 1, 2025Complaint
1
0803Actual harm · IsolatedCorrected

Nutrition and Dietary Deficiencies

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.

Federal Penalties

Fine

Jan 14, 2026

$70,315

Fine

Jul 1, 2025

$10,358

Fine

Mar 11, 2025

$24,286

Fine

Oct 11, 2023

$79,399

Ownership & Operations

Who Operates This Facility

Owner / Operator

Axiom Gardens of Flora

Organization Type

for profit

Chain Affiliation

Chain Name

Axiom Healthcare

Chain Size

7 facilities nationwide

Chain avg rating: 1.3/5 · Rank 4 of 7 (Worst)

Ownership & Management

Owners

Berkowitz, David

Individual is an Owner, Partner or Trustee of Any Adp of the Snf

Dauber, Eliana

Individual is an Owner, Partner or Trustee of Any Adp of the Snf

Goldfarb, Brian

Individual is an Owner, Partner or Trustee of Any Adp of the Snf

Meystel, Yosef

Individual is an Owner, Partner or Trustee of Any Adp of the Snf

Seitler, Dovid

Individual is an Owner, Partner or Trustee of Any Adp of the Snf

Turofsky, Steven

Individual is an Owner, Partner or Trustee of Any Adp of the Snf

Key personnel

Kaplan, MordechaiManaging Control - Governing BodyRajchenbach, ChaimManaging Control - Governing BodyVaughn, LatoshaManaging Control - Governing BodyWebb, JessicaManaging Control - Governing BodySpector, JenniferOfficer / Director
Source: Medicare provider data

Contact

Get in Touch

Contact this facility directly and verify the details that matter most to your family.

References & Resources

EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.

Safer Alternatives Nearby

Based on current clinical data, we identified 1 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.

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