Axiom Gardens of Flora

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

33.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 30 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 34.4% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 32 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.10 therapist hours per resident per day in 2026Q1 — more than 6% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 19% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 97 beds and averages 62.0 residents a day — about 64% occupied, or roughly 35 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.13 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.81 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.84 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.90 hrs/resident/day on weekends vs 3.23 on weekdays — 10% thinner on weekends. RN hours go from 0.87 to 0.64 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 69% is well above the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

40 citations, most serious first. The 15 most serious are shown; the remaining 25 are one tap away and print in full.

• Immediate jeopardy · Jcited before2023-10-11 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for the treatment of Type II Diabetes Mellitus for 3 (R3, R19, R20) of 4 residents reviewed for labs in the sample of 21. This failure resulted in abnormal lab values not being immediately communicated with the physician and R3 experiencing altered mental status requiring transport to the Emergency Department where a blood glucose level of 819 was found. This failure resulted in an Immediate Jeopardy, which was identified to have begun on 2/8/23 when abnormal Hemoglobin A1c results for R3 were reported to the facility and staff did not complete the facility procedure of notifying the physician of these values until 3/20/23. V1 (Administrator) was notified of the Immediate Jeopardy on 10/4/23 at 1:10 PM. The surveyors confirmed by observations, interview, and record review that the Immediate Jeopardy was removed on 10/5/23 but noncompliance remains at Level Two due to additional time needed to evaluate the implementation and…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2026-01-14 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to prevent the verbal, physical and sexual abuse of residents from another resident with a known history of abuse for 4 of 6 residents (R1, R6, R8 and R9) reviewed for abuse in the sample of 11. This failure would cause a reasonable person to experience feelings of fear, anxiety and anger while residing in their home. Findings include:1. R7's admission Records documents R7 was admitted on [DATE] with diagnoses to include: Dementia with agitation, lack of coordination, anxiety, depression. R7's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) of 01, indicating R7 has severe cognitive impairment.R7's current Care Plan documents a focus area: I have behavior problems related to verbally/physically aggressive with staff during care, wander/elopement risk with an initiation date of 11/18/25. The only mention in R7's care plan about any resident to resident altercation is listed on 12/11/25 under intervention for this focus…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-07-01 · tag F0803 — failed to meet residents' dietary needs — isolated
  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.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to provide the correct textured diet for 1 of 19 (R2) residents reviewed for diet in a sample of 19. This failure resulted in R2 choking and being sent to the hospital. Findings include: R2's admission Record documents an admission date of 10/28/2024 with diagnoses including in part dementia and dysphagia oropharyngeal phase. R2's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. R2's most recent Care Plan documents a focus area of R2 has nutritional problem or potential nutritional problem and interventions include in part provide and serve diet as ordered, dated 6/9/23. R2's Diet order dated 3/12/25 11:48 PM through 6/14/25 3:16 PM documents regular diet, mechanical soft texture, nectar/mildly thick consistency. R2's diet order dated 6/14/25 3:16 PM through 6/18/25 2:02 PM documents regular diet, pureed texture, nectar/mildly thick consistency. R2's current…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-04-17 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents were free from physical abuse for 2 of 3 residents (R2, and R3) reviewed for abuse in the sample of 3. The failure resulted in R3 receiving a fractured coccyx after an incident where R1 pushed R3 down. Findings Include: R1's admission Record documents that R1 is an [AGE] year-old make that was admitted to the facility on [DATE]. Diagnoses listed are chronic obstructive pulmonary disease, spondylosis, unspecified dementia, anxiety disorder, hyperlipidemia, insomnia, and repeated falls. R1's MDS (Minimum Data Set), dated 02/07/2025, documents that R1 has a BIMS (Brief Interview for Mental Status) of 05, indicating that R1 has severe cognitive impairment. R1's care plan with a revision date of 02/07/2025 has a focus area of, I have a behavior problem. The interventions listed for the focus area are administer medications as ordered, anticipate and meet resident's needs, assist the resident to develop more appropriate ways of…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-08-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to safely secure a resident during transport for 1 of 3 residents (R2) reviewed for accidents in a sample of 3. This failure resulted in R2 sustaining a 3 by 5 inches laceration to her left leg that became infected and required a wound vac. The findings included: R2's admission record documents an admission date to the facility of 9/08/2023 with diagnoses including morbid (severe) obesity due to excess calories, unspecified atherosclerosis of native arteries of extremities, bilateral legs, lymphedema, not elsewhere classified, other specified and diabetes mellitus with diabetic autonomic (poly) neuropathy. R2's Minimum Data Set (MDS) dated [DATE], documents in Section C, Cognitive Patterns, that R2 has a Brief Interview for Mental Status (BIMS) score of 15 indicating R2 is cognitively intact. The same MDS section GG0170, Mobility documents the use of a motorized scooter and section I8000, Active diagnoses documents lymphedema, not elsewhere…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2026-04-29 · tag F0726 — failed to have competent, trained nursing staff — widespread
  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.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure only staff with appropriate competencies provided resident care. This failure has the potential to affect all 62 residents living in the facility. The findings include:On 4/28/26 at 9:26 AM, V5 (Certified Nursing Assistant/CNA) stated Unit Aides (UA) can perform vital signs, answer call lights, make beds, and pass snacks and ice water, but they are not allowed to do any hands-on care.On 4/28/26 at 10:21 AM, R5, who was alert to person, place, and time, stated V8 (UA) helps them with their bed bath sometimes. R5 stated V8 helps them wash the areas of their body they cannot reach.On 4/28/26 at 10:29 AM, R12, who was alert to person, place, and time, stated (V8) works as another CNA when you all (public health surveyors) aren't here. R12 stated V8 has assisted CNAs provide incontinence care because R12 is a two person assist. R12 also stated that prior to this survey, V8 was working on the hall as another CNA, but once this surveyor entered the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-04-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to implement fall prevention interventions for 2 of 3 residents (R1 and R2) reviewed for accidents/incidents in the sample of 12.The findings include:1. R1's admission Record documents an admission date of 1/21/22 with diagnoses including displaced fracture of right femur and dementia.R1's Minimum Data Set (MDS) dated [DATE] documents R1 has a Brief Interview for Mental Status (BIMS) score of 00 indicating R1 is not cognitively intact and not aware of safety needs. The same MDS documents R1's mobility was supervision/touching assistance prior to her most recent fall on 4/12/26.R1's IDT (Interdisciplinary Team) Fall Committee Meeting Note dated 4/12/26 documents R1 had experienced an unwitnessed fall in the dining room on the same date.R1's X-ray report dated 4/12/26 documents an Impression of Acute hip fracture of right.R1's records from the local hospital document that R1 was admitted to the hospital on [DATE] and had surgical repair for a…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-03-19 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement infection tracking, contact tracing and environmental infection control precautions per its policy for one resident (R2) with a presumptive diagnosis of Scabies out of 7 residents reviewed for infection control in the sample of 7. Findings include:R2's admission Record documented an admission date of 8/8/26 and included diagnoses of Paranoid Schizophrenia and Unspecified Convulsions. R2's Minimum Data Set assessment dated [DATE] documented R2 has moderate deficits in cognition. R2's Care Plan dated 12/24/25 documented a problem area of I have a rash of the stomach, left hand, bilateral sides, and back related to allergies, Eczema, Psoriasis. Date Initiated: 12/24/2025. R2's Hospital Discharge summary dated [DATE] documented, Admitting Diagnoses: 1. Hypercapnia. 2. Dehydration. During the admission, she also required management for a diffuse pruritic rash resembling scabies, for which permethrin cream was applied and subsequently washed off…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-03-02 · tag F0919 — failed to provide a working call system — pattern
  Make sure that a working call system is available in each resident's bathroom and bathing area.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review the facility failed to provide a functioning call light in the south hall shower room. This has the potential to affect all 36 residents that reside on the south hall reviewed for call lights in a sample 52. Findings include: On 02/26/26 at 11:50 AM, V2 (Director of Nursing) stated they use the two shower rooms on the south halls for all the residents on the south hall. On 02/26/26 at 12:24 PM, V21 (Certified Nursing Assistant/CNA) stated the shower room across from the nurses' station and the one next to it are both used to give showers to residents on the south halls.On 02/26/26 at 12:36 PM, the call light in the shower room across from the nurses' station on the south hall did no function and was not accessible from the floor. The shower stall had water on the floor and walls giving the appearance the shower stall had just been used.On 02/26/26 at 12:39 PM, V21 (CNA) stated it has been a couple days since the call light has worked in that shower room.On 02/26/26 at 12:53 PM, V24 (Maintenance) stated he does not have a work order…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-03-02 · tag F0605 — failed to not use drugs as a restraint — isolated
  Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to attempt non-pharmacological interventions prior to administering a PRN (as needed) psychotropic medication for 1 of 5 residents (R7) reviewed for unnecessary medications in a sample of 52.Findings include:R7's admission record documents R7 was admitted to the facility on [DATE] with diagnoses of Alzheimer's dementia with behavioral disturbance, cerebrovascular disease and oral phase dysphagia.R7's MDS (Minimum Data Set) dated 1/5/2026 documented R7 has a BIMS (Brief Interview for Mental Status) score of 1 out of 15 total, which indicates R7 has severe cognitive impairment.R7's Care Plan documents a Problem of resident is/has potential to be physically aggressive towards staff during care with an initiation date of 7/19/23 with interventions including: Monitor and document observed behavior and attempted interventions in behavior log; and when the resident becomes agitated: Intervene before agitation escalates, guide away from source of distress, engage…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-03-02 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to perform nail care for 3 of 3 residents (R22, R44, and R68) reviewed for ADL (Activities of Daily Living) care in a sample of 52.Finding include:1. R44's admission Record documents an admission date of 02/26/21 with diagnoses including: adult pulmonary Langerhans cell histiocytosis, moderate protein calorie malnutrition, dementia, delusional disorders, anemia, Alzheimer's disease, hyper lipidemia, acute coronary thrombosis, altered mental status, depression, disorientation, hearing loss, and dysphagia. R44's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 01, indicating R44 has severe cognitive impairment. The same MDS documents R44's personal hygiene performance as substantial/maximal assistance indicating helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. On 02/23/26 at 3:00 PM, 02/24/26 at 12:32 PM, 02/25/26 at 12:35 PM, and…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-03-02 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide supplementation to maintain or gain weight for residents with low body weights for 1 of 5 residents (R10) reviewed for nutrition in a sample of 52.Findings include:R10's admission Record documents an admission date of 01/02/26 with diagnoses including: chronic obstructive pulmonary disease, respiratory failure, severe protein calorie malnutrition, chronic diastolic heart failure, disorder of bilirubin metabolism, rhabdomyolysis, encephalopathy, hyperlipidemia, chronic cholecystitis, gastro esophageal reflux disease without esophagitis, neuromuscular dysfunction of bladder, and essential hypertension. R10's Minimum Data Set, dated [DATE] documents a Brief Interview for Mental Status score of 11, indicating R10 has moderate cognitive impairment. R10's Care Plan documents a focus area of R10 has pressure ulcers dated 01/14/26 with an intervention of monitor nutritional status, serve diet as ordered, and monitor intake and record dated…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-03-02 · tag F0697 — failed to manage pain — isolated
  Provide safe, appropriate pain management for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow the facility's policy and perform pain assessments to assist with pain management for 1 of 1 resident (R68) reviewed for pain in a sample of 52.Findings include:R68's admission Record documents an admission date of 08/08/25 with diagnoses including: acute and chronic respiratory failure, severe sepsis with septic shock, encounter for other orthopedic aftercare, displaced fracture of second metatarsal bone, right foot, muscle wasting and atrophy, unsteadiness on feet, lack of coordination, body mass index of 50.0-59.9, major depressive disorder, and unilateral primary osteoarthritis of the left knee. R68's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 10, indicating R68 has moderately impaired cognition. Section J of the same MDS documents that R68 receives PRN (as needed) pain medication and receives non-medication interventions for pain. Under Pain Assessment Interview, it…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-03-02 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow guidelines consistent with current standard of practices to prevent/decrease risk of infection to wounds for 2 of 2 residents (R1 and R16) observed for infection control in the sample of 52.The findings include:1. R1's admission Record documents an admission date of 9/8/23 with diagnoses including but not limited to Type II Diabetes Mellitus, Atherosclerosis of both legs, and lymphedema.R1's Physician's Order Sheet (POS) with a print date of 2/26/26 documents a current physician's order for left lateral lower leg: cleanse with wound cleanser. Apply Santyl to wound bed, ABD (abdominal pad), (gauze wrapping), wrap with (elastic) wrap daily and PRN (as needed).R1's most recent Care Plan documents Resident has other potential/actual impairment to skin integrity r/t (related to) fragile skin Date Initiated: 7/12/2024 Revision on: 10/23/2025. Interventions for this focus area include but are not limited to, Follow facility protocols for…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2025-11-20 · tag F0725 — failed to have enough nursing staff — widespread
  Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure they maintained sufficient staff to meet the needs of the residents timely for 4 of 4 residents (R4, R7, R11, and R13) reviewed for staffing in the sample of 21. This failure has the potential to affect all 70 residents who currently reside at the facility.Findings Include:The facility Resident List Report dated 11/16/25 documents 70 residents currently reside at the facility.1.R13's admission Record with a print date of 11/18/25 documents R13 was admitted to the facility on [DATE] with diagnoses that include spastic quadriplegic cerebral palsy and epilepsy.R13's MDS (Minimum Data Set) dated 8/24/25 documents R13 has a BIMS (Brief Interview for Mental Status) score of 15 which indicates he is cognitively intact. This same MDS documents R13 requires substantial/maximal assistance with toileting and bathing.R13's current Care Plan documents a Focus area of I have an ADL (activities of daily living) self-care performance deficit. Date Initiated:…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$159,748 in federal fines across 4 penalties.

• $45,705 — penalty dated 2026-01-14
• $10,358 — penalty dated 2025-07-01
• $24,286 — penalty dated 2025-03-11
• $79,399 — penalty dated 2023-10-11

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to AXIOM HEALTHCARE — 8 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 34 rows in the source record cover these 20 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

5 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

About 75% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $218K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in IL