Axiom Gardens of Nashville

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.

39.6% 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 39 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 65.2% 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 23 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 0.23 therapist hours per resident per day in 2026Q1 — more than 28% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 10% 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 120 beds and averages 55.8 residents a day — about 46% occupied, or roughly 64 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 3.46 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.23 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.27 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 3.01 hrs/resident/day on weekends vs 3.64 on weekdays — 17% thinner on weekends. RN hours go from 0.25 to 0.18 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 64% 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 more than at the previous inspection — worsening. 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.

54 citations, most serious first. The 24 most serious are shown; the remaining 30 are one tap away and print in full.

• Immediate jeopardy · Jcited before2026-06-01 · 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 provide services in a manner which prevented elopement for 2 of 3 residents (R2 and R3) reviewed for safety/elopement in a sample of 12. This failure resulted in R2 exiting the locked memory care unit and observed outside the facility for an undetermined amount of time on 04/26/26 and R3 leaving the designated outdoor smoking area with no staff knowledge or supervision, walking a couple of blocks up the road and out of sight of the facility on 04/28/26. The Immediate Jeopardy began on 04/26/26 when the facility failed to provide services in a manner to prevent elopement for R2 and R3. This failure resulted in 1) R2 exiting the locked memory care unit and being observed outside the facility, unknown to staff; 2) R3 leaving the designated outside smoking area and found walking a couple of blocks away, without staff knowledge, in an areaobserved as being an active residential neighborhood with vehicles utilizing the roadway and no sidewalks.…

  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
• Immediate jeopardy · J2025-12-24 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Wound Nurse Practitioner (NP) orders were followed and implemented in a timely manner, failed to ensure low air loss mattress was maintained in well working order, and failed to ensure wound dressings were changed per NP orders for 1 of 3 residents (R2) in a sample of 9. This failure resulted in R2 having worsening of wounds which became infected leading to R2 being hospitalized several times, requiring surgical debridement and Intravenous (IV) antibiotics due to infections of Methicillin-resistant Staphylococcus aureus (MRSA), Pseudomonas, Enterococcus faecalis and Extended-Spectrum Beta-Lactamase (ESBL) Escherichia (E) coli.This failure resulted in R2's wounds worsening and becoming infected. R2 was hospitalized several times, during which R2's wounds required surgical debridement and Intravenous (IV) antibiotics due to multiple infections with Methicillin-resistant Staphylococcus aureus (MRSA), Pseudomonas, Enterococcus faecalis…

  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
• Immediate jeopardy · Jcited before2025-12-24 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  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 new care plan interventions were implemented to prevent new/worsening pressure ulcers. The facility failed to ensure skin assessments were completed, ensure supplies for wound care were available, and complete wound treatments as ordered for 1 of 3 residents (R1) reviewed for wounds in a sample of 10. This failure resulted in R1 developing a stage II pressure ulcer to her right buttock on 11/25/25, a stage III pressure ulcer to her left buttock on 12/02/25, and worsening/decline to the wound on R1's right heel resulting in R1 requiring antibiotic treatment. The Immediate Jeopardy began on 11/25/25 due to the facility's failure to assess, treat, and complete skin assessments to prevent and/or treat pressure wounds for R1. This failure resulted when V47 (Nurse Practitioner) discovered a Stage II pressure wound to R1's right buttock, which the facility was not aware of. Additionally, on 12/2/25, V47 discovered a Stage III pressure…

  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
• Immediate jeopardy · Jcited before2025-12-24 · 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 ensure R4 was adequately supervised, failed to ensure door alarms were turned on, and respond in a timely manner to alarms to prevent elopement for 2 of 4 residents (R4, R9) reviewed for safety in a sample of 9. These failures resulted in a severely cognitive impaired resident (R4) repeatedly eloping from the facility despite being identified as an elopement risk, and multiple failures of disabling of door alarms and delayed responses contribute to R4's elopements into unknown and unsafe conditions that include walking in middle of road and getting in a strangers vehicle.The Immediate Jeopardy began on 10/16/25 when the facility failed to properly supervise a resident (R4) to prevent an elopement from the facility. V1, Administrator, and V2, Director of Nursing (DON) were notified of the Immediate Jeopardy on 11/25/2025 at 12:58 PM. Abatement number one on 11/25/25 was not accepted. Abatement number two was accepted on 11/26/25 at 10:27…

  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
• Immediate jeopardy · Jcited before2025-07-17 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  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, record review, and interview, the facility failed to timely identify, assess and monitor, and provide treatment to prevent the worsening of pressure ulcers for 1 of 3 residents (R2) reviewed for pressure ulcers in a sample of 3. This failure resulted in R2 developing two unstageable pressure ulcers requiring debridement at the bedside and being started on an antibiotic treatment related to pressure ulcer infection. The Immediate Jeopardy began on 05/12/25 when due to the facility's failure to assess and monitor and provide progressive treatment, R2 developed an opened area to her buttocks which went untreated, worsened to R2 developing two unstageable pressure ulcers requiring bedside debridement and acquiring an infection which required antibiotic treatment. V1, Administrator was notified of the Immediate Jeopardy on 07/11/25 at 1:45 PM. The Immediate Jeopardy was determined to not be removed on 7/17/25, upon review of the implementation of the facility's abatement plan. The surveyor…

  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
• Immediate jeopardy · Jcited before2024-10-29 · 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 interview and record review, the facility failed to provide supervision/monitoring to prevent an elopement for 1 of 11 residents (R2) reviewed for supervision to prevent elopement in the sample of 11. This failure resulted in Immediate Jeopardy on 10/15/2024 with R2, eloping from the facility sometime between 3:00 PM to 4:00 PM. R2 was found by a passerby at approximately 4:30 PM, was assessed at the local hospital and returned to the facility. The Immediate Jeopardy began on 10/15/2024, when R2 eloped from the facility. On 10/22/2024 at 2:18 PM V1, Administrator and V30, Medical Records Director were notified of the Immediate Jeopardy. The surveyor confirmed by observation, interview and record review, the Immediate Jeopardy was removed on 10/29/24, but remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: R2's admission Assessment, dated 10/4/2024 at 9:45 AM, documents R2 was admitted from home. She was…

  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 before2026-04-29 · 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 ensure a safe resident environment and protection from physical abuse for 1 of 3 (R2) residents reviewed for resident-to-resident abuse in the sample of 3. This failure resulted in R2 being punched in the face by R1, leaving slight redness to her forehead. A reasonable person getting punched in the face would feel fearful, threatened, and intimidated. Findings include:R1's admission Record documents an admission date of 1/13/26 and a discharge date of 2/25/26 with included diagnoses of psychosis, transient alteration of awareness, cognitive communication deficit, dementia, and altered mental status. R1's Care Plan documents R1 has the potential to be physically aggressive punching/hitting related to dementia and poor impulse control. 1/18/26 R1 altercation with another resident, punched other resident in the shoulder two times. 1/21/26 R1 was rummaging through staff purse and hitting staff with fist. 1/27/26 R1 was grabbing residents and hit another…

  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 before2026-03-20 · 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 interview, observation, and record review the facility failed to provide safe transfers for 3 of 14 residents (R1, R12, R50), to initiate fall interventions for a high fall risk resident for 1 of 14 residents (R2) resulting in R2 falling and fracturing her hip, to implement fall interventions for 1 of 14 residents (R22), and to keep door alarms activated, all reviewed for resident safety in the sample of 42. The findings include:1. R2's Face Sheet, admission date of 12/05/25, documents that R2 has diagnoses of but not limited to bilateral primary osteoarthritis of knee and dementia other diseases classified elsewhere, severe, with psychotic disturbance. R2's Minimum Data Set (MDS), dated [DATE], documents thatR2 is severely cognitively impaired, and she is dependent or requires substantial/maximal assistance with her activities of daily living (ADLs). Walking was not attempted due to medical conditions or safety concerns. R2's Electronic Medical Record, (EMR) was reviewed and no documentation was found…

  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 · G2025-12-24 · tag F0908 — failed to keep essential equipment working — isolated
  Keep all essential equipment working safely.
  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 a low air loss mattress was in proper working order for 1 of 3 residents (R2) reviewed for essential equipment, safe operating condition in a sample of 10. This resulted in R2 being in extreme pain due to R2 having multiple pressure ulcers/injuries, the mattress not staying properly inflated, and R2 laying on a hard metal bed frame. Findings Include: R2's Minimum Data Set (MDS), dated [DATE], documented R2 is cognitively intact with a Brief Interview for Mental Status (BIMS) of 15 out of 15 and she requires substantial/maximal assistance for rolling left to right, sitting to lying and lying to sitting.R2's Face Sheet, print date of 12/04/25, documented R2 has diagnoses including pressure ulcer of right buttock, stage 3, dependence on renal dialysis, chronic kidney disease, stage 4 (severe), and chronic combined systolic and diastolic (congestive) heart failure. R2's Care Plan, admission date of 08/18/25, documented Potential 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.

  Environmental Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-02-11 · 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 interviews, observations, and record reviews the facility failed to prevent verbal and mental abuse for 4 out of 6 residents (R3, R4, R6, R7). This failure resulted in R3, R4, R5 and R7 experiencing psychosocial harm. Using the reasonable person concept, R3, R4, R6 and R7 experienced psychosocial harm with feelings of shame, embarrassment, humiliation or insignificance. Findings include: 1 R3 was admitted to the facility on [DATE] with diagnosis of, in part, atherosclerosis of extremities (bilateral legs), unsteadiness on feet, and unspecified displace fracture of right humerus. R3's MDS dated [DATE], documents she is cognitively intact, and requires partial/moderate assistance from staff for upper and lower body dressing as well as putting on/taking off footwear. R3's Care Plan dated 12/3/24, documents she requires assistance with activities of daily living (ADL's) related to (r/t) weakness, arthritis, history of falls, fracture of right humerus, osteoporosis and for staff to provide privacy and offer…

  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 before2024-12-20 · 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 progressive fall interventions in 2 of 11 residents (R18, R25) reviewed for accidents and hazards in the sample of 40. This failure resulted in R18 sustaining lacerations requiring emergency room (ER) transfer and repair with sutures and R25 sustaining bruising to forehead. Findings include: 1-R18's Face Sheet documents R18 was admitted to the facility on [DATE] with diagnoses including weakness, polyneuropathy, right foot drop, lack of coordination, abnormalities of gait and mobility, age-related cognitive decline, and muscle wasting and atrophy. R18's Minimum Data Set (MDS) dated [DATE] documented R18 was moderately cognitively impaired and ambulated via wheelchair. R18's Undated Care Plan documents R18 is at risk for falls related to weakness, incontinence, history of falls, and leaning when tired. R18's 4/17/24 Progress Note documents R18 was found lying on the floor next to her bed on her right side with a significant…

  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 · G2024-12-20 · 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 implement nutritional interventions to prevent weight loss in 1 of 3 residents (R37) reviewed for nutrition in the sample of 40. This failure resulted in R37 sustaining significant, severe weight loss at the one, three, and six month marks. Findings include: R37's Face Sheet documents R37 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, anemia, right hip pain, weakness, constipation and dehydration. R37's Minimum Data Set (MDS) dated [DATE] documented R37 was severely cognitively impaired, had impairment on one side upper extremity, and was dependent with bed mobility and transfer. R37's Care Plan initiated 6/18/24 documents R37 has a nutritional deficit. Documented interventions include, Provide and serve supplements as ordered. R37's Monthly Weight Report documents R37 weighed 99.0 pounds in June 2024 and 93.2 pounds in July 2024. This reflects a weight loss of 5.8 pounds or 5.8% body weight loss in…

  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 before2024-01-09 · 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 mental and physical abuse by a staff member for 1 of 3 residents (R28) reviewed for abuse. This deficient practice resulted in R28 feeling sad, scared, and crying hysterically. Findings include: 1. R28's Care Plan, dated 10/10/23, documented, (R28) has Diagnosis of Dementia with agitation, has anxiety about daughter not being here, daughter restricted from visiting per adult protective services. Assist gently and kindly. If resident becomes agitated or combative; stop care, assure safety, and re approach in 10-15 minutes. R28's Minimum Data Set (MDS), dated [DATE], documents R28 is severely impaired cognitively. R28's Detailed Incident Summary, dated 12/21/2023, documented, The investigation resulted in a conclusive finding that V11, Certified Nurse's Assistant (CNA), did make contact with R28, which is by definition abuse. The investigation specifically revealed R28 has a diagnosis of unspecified dementia unspecified severity with other…

  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 before2024-01-09 · 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 ensure there were foot pedals on a wheelchair while transporting 1 of 1 (R2) resident reviewed for accidents in a sample of 41. This failure resulted in R2 sustaining a right femur fracture. Findings include: On 1/2/24 at 12:28 pm, R2 was observed wearing a cast from hip to ankle on her right leg. V17, CNA (Certified Nurse Assistant), stated R2 was still in a cast from the fracture she sustained last summer. On 1/4/24 at 2:30 pm, V25, CNA, stated he recalled the incident with R2's leg fracture. V25 stated he remembers R2 having foot pedals in her room, but they were not always on her wheelchair. On 1/4/24 at 2:40 pm, V19, CNA, stated R2 was supposed to have foot pedals on her wheelchair at the time R2's leg was fractured. On 1/8/24 at 11:08 am, V26, CPC, (Care Plan Coordinator), stated she does not recall if R2 was supposed to have foot pedals on her wheelchair at the time R2 sustained the leg fracture. On 1/9/24 at 11:00 am, V1,…

  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 · Ecited before2026-03-20 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — pattern
  Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
  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 catheter and complete incontinent care for 4 of 4 (R4, R11, R44, R50) residents reviewed for toileting in a sample of 42.Findings include: 1 R4's Care plan, dated 12/17/2025, documents that (R4) has a Hx (history) of UTI (urinary tract infection) and is At Risk for Recurrent/Chronic Urinary Tract Infection 12/3/25 Foley cath (catheter) placed due to pressure ulcers. 12/3/25 Indwelling urine cath care, peri care, and change per MD (doctor)orders. Check at least every 2 hours for incontinence. Wash, rinse and dry soiled areas. R4's Minimum Data Set (MDS), dated [DATE], documents that R4 is cognitively impaired, always incontinent of bowel, has an indwelling catheter, and dependent on staff for toileting. On 3/16/2026 at 1:00 PM observed V9, Certified Nurses Assistance (CNA) and V11, CNA, performed incontinent of care. R4 was incontinent of bowel. V9 and V11 assisted R4 onto her left side. V9 using wet wash clothes wiped the anal…

  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 plan of correction
• Potential for harm · Dcited before2026-03-20 · 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 sexual abuse to a resident by an employee and failed to prevent physical abuse of a resident from another resident for 2 of 3 residents (R7, R22) reviewed for abuse in the sample of 42.Findings Include:1.R22's admission Record print date of 3/18/26 documents R22 has diagnoses including vascular dementia with behavioral disturbance, peripheral vascular disease, anxiety, supraventricular tachycardia, heart disease, and osteoarthritis. R22's MDS (Minimum Data Set) dated 1/31/26 documents R22 is severely cognitively impaired and requires substantial to maximal assistance with transfers. The Facility's undated Preliminary 24-hour Abuse Investigation Report documents an offense was alleged against R22 by an employee. The Facility's undated Final Abuse Investigation Report documents name of resident abuse: (R22). The original allegation: unknown date and time. Allegedly this incident happened in her room. This was reported to Administrator by Activity…

  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 · Fcited before2025-12-24 · tag F0838 — failed to assess facility resources and resident needs — widespread
  Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
  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 their facility assessment was updated to include all necessary components per the current standards of practice. This failure has the potential to affect all 60 residents residing in the facility. Findings include:The Facility assessment dated [DATE] did not include the following in the plan: identification of current Administrator nor current DON (Director of Nursing), identifying resources to provide necessary care and services the residents require during both day-to-day operations and emergencies (including nights and weekends) and emergencies; evaluation of the overall number of facility staff needed to ensure sufficient number of qualified staff are available to meet each resident's needs as identified through resident assessments and care plans; pertinent information about the resident population the facility serves may include race, ethnicity, disability, sexual orientation, gender identity, socioeconomic status, preferred language,…

  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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-12-24 · tag F0947 — failed to train nurse aides adequately — widespread
  Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
  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 nurse aides completed the required 12 hours of education per year. This has the potential to affect all 60 residents residing in the facility. Findings include:The facility's CNA (Certified Nurse Assistant) hire date list documented the following: V32 CNA hire date of 7/26/2011.V33 CNA hire date of 1/21/2002.V34 CNA hire date of 11/12/2018.V35 CNA hire date of 11/4/1999.V36 CNA hire date of 3/18/2019.V37 CNA hire date of 11/19/2019. The facility's in-service records for 2025 documented the following: V32 had 1 hour of education for the past year.V33 had 2 hours of education for the past year. V34 had 1 hour of education for the past year. V35 had 2 hours of education for the past year. V36 had no education documented for the past year.V37 had 2.5 hours of education for the past year. On 12/2/25 at 12:29 AM V1 Administrator stated I have to be honest, that is all we have for the CNA in-services/education for the past year. V1 stated CNAS are supposed to have 10 or 12 hours of continuing education per year. V1 stated…

  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 before2025-12-24 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect 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 notify a resident representative after the resident was found outside of the facility for 1 of 3 residents (R4) reviewed for representative notification in a sample of 10.Findings Include: R4's Face Sheet, print date of 12/02/25, documented R4 has diagnoses of but not limited to Alcohol dependence with alcohol induced persisting dementia, Wernicke's encephalopathy, and chronic kidney disease, stage3.R4's Minimum Data Set (MDS), dated [DATE], documented R4 is severely cognitively impaired with a Brief Interview for Mental Status (BIMS) of two out of 15 and is independent with ambulation. R4's Progress Notes, dated 10/16/2025 at 8:15 PM, documented Nurses Note Text: Around 1815 (6:15 PM), resident was found by CNA (Certified Nursing Assistant) outside by the dumpster. Door alarm and (electronic monitoring device) were sounding. CNA heard the alarm and immediately went to check on alarm. Alarm sounded until this nurse turned it off. Doors at the top 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-12-24 · 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 ensure infection control standards of practice for hand hygiene, wound dressing disposal, and contaminated linen disposal were followed for 1 (R10) of 3 reviewed for infection control in the sample of 10.Findings Include:R10's admission Record dated [DATE] documented R10's initial admit date to the facility as [DATE]. This same document lists diagnoses for R10 including but not limited to Asymptomatic Human Immunodeficiency Virus (HIV) Infection Status and Chronic Viral Hepatitis B without Delta-Agent.The Weekly Wound Committee Review Pressure Ulcer Cumulative Report dated [DATE] documented R10 admitted to the facility with an unstageable wound to his coccyx with moderate drainage noted.R10's Plan of Care with a revision date of [DATE] documented, R10 is to have Enhanced Barrier Precautions in relation to coccyx pressure ulcer.On [DATE] at 10:39 AM, R10 is observed as residing in a single occupancy room with a sign posted on the door to his…

  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 · Dcited before2025-06-18 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  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 obtain timely treatment orders and complete physician ordered treatments for one (R1) of three residents reviewed with pressure ulcers in the sample of 10. Findings include: R1's face sheet documents an admission date of 10/10/2024. Diagnosis include Congestive Heart Failure, Pneumonia, Urinary Tract Infection, Type 2 Diabetes. R1's Minimum Data Set, MDS, dated [DATE] documents R1 has no cognitive deficits. R1's MDS dated [DATE] documents R1 has 2 stage 2 unhealed pressure ulcers and is at risk for pressure ulcers. R1's care plan updated 1/23/2025 documents Potential for skin breakdown related to bowel incontinence, weakness, redness to peri area. 11/26/24 Stage 2 left buttock 3/5/25 Stage 2 right buttock; Interventions include reposition every 1-2 hours. Monitor for redness or discoloration to skin. Weekly skin checks. R1's Braden Scale for Predicting Pressure Sore Risk dated 10/31/2024 documents R1 is at high risk for pressure ulcer development. R1's…

  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 · Fcited before2025-01-10 · tag F0880 — failed to prevent and control infections — widespread
  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, record reveiw, and observation the facility failed to ensure staff readily had access to and donned appropriate personal protective equipment prior to entering COVID positive resident rooms, failed to ensure isolation signage was placed to identify type of isolation required for resident rooms on isolation for COVID, and failed to document COVID testing. These failures affect 3 of 3 residents (R1, R2, R3) reviewed for infection control with the potential to affect all 59 residents residing in the facility. Findings Include: 1. R1's MDS (Minimum Data Set) dated 11/14/24 documents R1 is moderately cognitively impaired. R1's Nurses Note dated 1/7/24 documents (R1) tested positive during routine COVID test. (R1) is currently afebrile and asymptomatic. R1's Nurses Note dated 1/7/24 documents Contact Isolation precautions started related to COVID positive. COVID Positive residents should also be on droplet precautions. On 1/9/25 at 8:45 AM, R1 is lying in bed with the door open. R1 was not…

  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 before2025-01-10 · tag F0882 — widespread
  Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
  What the surveyor found here — the official record, unedited, may be distressing

  Based on observation, interview and record review, the facility failed to ensure they had a qualified Infection Control Preventionist (ICP) working full time in the facility. This has the potential to affect all 59 residents living in the facility. Findings include: On 1/9/25 at 9:15 AM V1 Administrator stated, we dont have an ICP and are trying to hire one now. On 1/9/25, the facility was observed as having residents who had tested positive for COVID residing in the facility. On 1/9/25 at 1:15 PM, V2 Director of Nursing (DON) stated I believe V1 Administrator was trying to interpret the facility policy. I am off with COVID infection and I just don't know what's going on. The Facility's Daily Census Sheets dated 1/9/25 documents a total of 59 residents living in the facility.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-01-10 · 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 interview, observation and record review the facility failed to provide a safe and hazard free environment for three of three residents (R4, R5, R6) on the dementia unit reviewed for accidents and hazards in the sample of 6. Findings Include: 1. R4's MDS (Minimum Data Set) dated 12/10/24 documents R4 severely cognitively impaired, and she can walk independently. R4's Electronic Health Record documents R4 has diagnoses of Alzheimer Disease, Anxiety Disorder, and Restlessness and Agitation. On 1/9/25 9:03 AM R4 was sitting in the dining room with peers. V8 Activities stated, she does walk up and down the hallway and V8 did not know that window was broken and the door is not locked. R4 unable to answer questions. 2. R5's MDS dated [DATE] documents R4 is severley cognitively impaired and she walks independently. R5's Electronic Health Record (EHR) documents R5 has diagnoses of Alzheimer Disease and Vascular Dementia. On 1/9/25 9:05 AM R5 was walking up and down the hall constantly, passing the room with…

  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

“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

$541,045 in federal fines across 3 penalties. 2 Medicare payment denials on record.

• $261,500 — penalty dated 2025-12-24
• $265,965 — penalty dated 2024-12-20
• $13,580 — penalty dated 2024-10-29
• Medicare payment denial — starting 2025-07-20 for 17 days
• Medicare payment denial — starting 2025-01-22 for 113 days

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 13 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted.

4 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.

A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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