Nashville, IL

Axiom Gardens of Nashville

1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $279,545 in total fines with 23 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

485 South Friendship Drive, Nashville, IL

(618) 327-3041

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

2 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

120

Certified beds

Average residents

59

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Axiom Healthcare

Operator or chain grouping

Approved since

2003-02-04

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

7 facilities

Chain averages 1 overall / 2 health / 1 staffing / 2 quality stars

Changed ownership

No

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.20

Registered nurse staffing · state 0.73 · national 0.68

LPN hours / resident day

0.85

Licensed practical nurse staffing · state 0.64 · national 0.87

Aide hours / resident day

2.39

Nurse aide staffing · state 2.13 · national 2.35

Total nurse hours

3.44

All reported nurse hours · state 3.49 · national 3.89

Licensed hours

1.05

RN + LPN hours · state 1.36 · national 1.54

Weekend hours

3.24

Weekend nurse staffing · state 3.09 · national 3.43

Weekend RN hours

0.14

Weekend registered nurse coverage · state 0.56 · national 0.47

Physical therapist

0.01

Reported PT staffing · state 0.05 · national 0.07

Adjusted RN hours

0.22

CMS adjusted RN staffing hours

Adjusted total hours

3.86

CMS adjusted total nurse staffing hours

Case-mix index

1.22

Higher values indicate more complex resident acuity

RN turnover

0%

Annual RN turnover

Total nurse turnover

77%

Annual nurse turnover · state 46% · national 46%

SNF VBP

Value-based purchasing

Program rank

12,855

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

10.02

Composite VBP score used to determine payment impact.

Payment multiplier

0.9809

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

3.72

Performance 19.71% · Measure score 3.72 · Achievement 3.72 · This facility did not have sufficient data to calculate a baseline period measure result.

Healthcare-associated infections

0

Baseline 5.86% · Performance 8.44% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

0

Baseline 43.75% · Performance 64.10% · Measure score 0 · Achievement 0 · Improvement 0

Adjusted total nurse staffing

0.29

Baseline 2.79 hours · Performance 3.02 hours · Measure score 0.29 · Achievement 0 · Improvement 0.29

SNF QRP

Medicare quality reporting measures

Measure Facility National Note
Potentially preventable 30-day readmission 11.01%
10.72%
0.3 pts worse
No Different than the National Rate · Eligible stays 60 · Observed rate 11.67% · Lower 95% interval 7.49%
Discharge to community 39.61%
50.57%
11 pts worse
No Different than the National Rate · Eligible stays 39 · Observed rate 30.77% · Lower 95% interval 30.46%
Medicare spending per beneficiary 1.18
1.02
0.2 pts worse
Drug regimen review with follow-up 95.65%
95.27%
0.4 pts better
Numerator 44 · Denominator 46
Falls with major injury 2.17%
0.77%
1.4 pts worse
Numerator 1 · Denominator 46
Discharge self-care score 53.13%
53.69%
0.6 pts worse
Numerator 17 · Denominator 32
Discharge mobility score 50%
50.94%
0.9 pts worse
Numerator 16 · Denominator 32
Pressure ulcers or injuries, new or worsened 6.52%
2.29%
4.2 pts worse
Numerator 3 · Denominator 46 · Adjusted rate 6.54%
Healthcare-associated infections requiring hospitalization 8.44%
7.12%
1.3 pts worse
No Different than the National Rate · Eligible stays 34 · Observed rate 14.71% · Lower 95% interval 4.62%
Staff COVID-19 vaccination coverage 0%
8.2%
8.2 pts worse
Numerator 0 · Denominator 71
Staff flu vaccination coverage 20.59%
42%
21.4 pts worse
Numerator 14 · Denominator 68
Discharge function score 50%
56.45%
6.5 pts worse
Numerator 16 · Denominator 32
Transfer of health information to provider Not Available
95.95%
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly.
Transfer of health information to patient Not Available
96.28%
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date 0%
25.2%
25.2 pts worse
Numerator 0 · Denominator 22

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Number of hospitalizations per 1000 long-stay resident days 1.1
2.0
0.9 pts better
1.9
0.8 pts better
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.9 · Expected 1.6 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days 2.0
2.3
0.3 pts better
1.8
0.2 pts worse
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.8 · Expected 1.5 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 54.4%
89.6%
35.2 pts worse
93.4%
39 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 60.0% · Q2 53.6% · Q3 57.7% · Q4 47.4% · 4Q avg 54.4%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine 86.2%
91.6%
5.4 pts worse
95.5%
9.3 pts worse
Long Stay · 2024Q3-2025Q2 · 4Q avg 86.2%
Percentage of long-stay residents experiencing one or more falls with major injury 6.5%
3.3%
3.2 pts worse
3.3%
3.2 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 5.4% · Q3 5.8% · Q4 8.8% · 4Q avg 6.5% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms 0.0%
50.3%
50.3 pts better
11.4%
11.4 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents who lose too much weight 8.2%
6.5%
1.7 pts worse
5.4%
2.8 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 11.6% · Q2 13.2% · Q3 4.0% · Q4 4.1% · 4Q avg 8.2%
Percentage of long-stay residents who received an antianxiety or hypnotic medication 15.7%
18.5%
2.8 pts better
19.6%
3.9 pts better
Long Stay · 2024Q4-2025Q3 · Q1 17.4% · Q2 13.2% · Q3 15.7% · Q4 16.7% · 4Q avg 15.7%
Percentage of long-stay residents who received an antipsychotic medication 16.5%
22.8%
6.3 pts better
16.7%
0.2 pts better
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 21.4% · Q3 17.5% · Q4 15.0% · 4Q avg 16.5% · Used in QM five-star
Percentage of long-stay residents who were physically restrained 2.3%
0.1%
2.2 pts worse
0.1%
2.2 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 1.8% · Q3 1.9% · Q4 3.5% · 4Q avg 2.3%
Percentage of long-stay residents whose ability to walk independently worsened 20.6%
17.2%
3.4 pts worse
16.3%
4.3 pts worse
Long Stay · 2024Q4-2025Q3 · Q2 20.9% · Q3 17.8% · Q4 14.2% · 4Q avg 20.6% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased 25.5%
15.0%
10.5 pts worse
14.9%
10.6 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 23.5% · Q3 24.0% · Q4 35.3% · 4Q avg 25.5% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder 2.0%
1.1%
0.9 pts worse
1.0%
1 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 2.1% · Q3 0.0% · Q4 1.4% · 4Q avg 2.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection 1.9%
1.7%
0.2 pts worse
1.7%
0.2 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 1.8% · Q3 0.0% · Q4 3.8% · 4Q avg 1.9% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 15.3%
21.3%
6 pts better
19.8%
4.5 pts better
Long Stay · 2024Q4-2025Q3 · Q1 12.9% · Q2 17.6% · Q3 10.2% · Q4 20.2% · 4Q avg 15.3%
Percentage of long-stay residents with pressure ulcers 11.3%
5.2%
6.1 pts worse
5.1%
6.2 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 13.7% · Q2 16.3% · Q3 10.8% · Q4 4.3% · 4Q avg 11.3% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 14.5%
68.8%
54.3 pts worse
81.7%
67.2 pts worse
Short Stay · 2024Q4-2025Q3 · Q1 22.6% · Q2 14.8% · Q3 10.0% · Q4 9.1% · 4Q avg 14.5%
Percentage of short-stay residents who had an outpatient emergency department visit 7.5%
14.0%
6.5 pts better
12.0%
4.5 pts better
Short Stay · 20240701-20250630 · Adjusted 7.5% · Observed 8.0% · Expected 12.0% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication 1.8%
2.3%
0.5 pts better
1.6%
0.2 pts worse
Short Stay · 2024Q4-2025Q3 · 4Q avg 1.8% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 11.1%
63.0%
51.9 pts worse
79.7%
68.6 pts worse
Short Stay · 2024Q3-2025Q2 · 4Q avg 11.1%
Percentage of short-stay residents who were rehospitalized after a nursing home admission 20.7%
26.2%
5.5 pts better
23.9%
3.2 pts better
Short Stay · 20240701-20250630 · Adjusted 20.7% · Observed 20.0% · Expected 23.0% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-12-20 · Fire 2024-12-20

23 health deficiencies

Top issue: Quality of Life and Care (8 deficiencies)

2 fire-safety deficiencies

Top issue: Emergency Preparedness (2 deficiencies)

Cycle 2 Health 2024-01-09 · Fire 2024-01-09

17 health deficiencies

Top issue: Infection Control (5 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 3 Health 2023-01-26 · Fire 2023-01-26

9 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (5 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-12-20

E37 · Emergency Preparedness Deficiencies

Fire Safety

Establish staff and initial training requirements.

Corrected 2025-01-20

F · Potential for more than minimal harm 2024-12-20

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2025-01-20

Inspection history

Recent health citations

J · Immediate jeopardy 2025-12-24

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2026-01-15

J · Immediate jeopardy 2025-12-24

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2025-12-25

J · Immediate jeopardy 2025-12-24

F689 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-12-25

G · Actual harm 2025-12-24

F908 · Environmental Deficiencies

Health

Keep all essential equipment working safely.

Corrected 2025-12-25

F · Potential for more than minimal harm 2025-12-24

F838 · Administration Deficiencies

Health

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.

Corrected 2026-01-14

F · Potential for more than minimal harm 2025-12-24

F947 · Nursing and Physician Services Deficiencies

Health

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Corrected 2026-01-14

D · Potential for more than minimal harm 2025-12-24

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2026-01-15

D · Potential for more than minimal harm 2025-12-24

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2026-01-14

J · Immediate jeopardy 2025-07-17

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2025-08-06

D · Potential for more than minimal harm 2025-06-18

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2025-08-06

G · Actual harm 2025-02-11

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

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

Corrected 2025-03-11

F · Potential for more than minimal harm 2025-01-10

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-04-24

F · Potential for more than minimal harm 2025-01-10

F882 · Infection Control Deficiencies

Health

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Corrected 2025-05-15

D · Potential for more than minimal harm 2025-01-10

F689 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-02-10

G · Actual harm 2024-12-20

F689 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-02-10

G · Actual harm 2024-12-20

F692 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-02-07

F · Potential for more than minimal harm 2024-12-20

F727 · Nursing and Physician Services Deficiencies

Health

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Corrected 2025-04-29

F · Potential for more than minimal harm 2024-12-20

F732 · Nursing and Physician Services Deficiencies

Health

Post nurse staffing information every day.

Corrected 2025-01-18

F · Potential for more than minimal harm 2024-12-20

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2025-04-24

F · Potential for more than minimal harm 2024-12-20

F838 · Administration Deficiencies

Health

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.

Corrected 2025-01-21

F · Potential for more than minimal harm 2024-12-20

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-04-24

F · Potential for more than minimal harm 2024-12-20

F882 · Infection Control Deficiencies

Health

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Corrected 2025-05-15

D · Potential for more than minimal harm 2024-12-20

F550 · Resident Rights Deficiencies

Health

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

Corrected 2025-01-18

D · Potential for more than minimal harm 2024-12-20

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2025-01-18

D · Potential for more than minimal harm 2024-12-20

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

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

Corrected 2025-03-11

D · Potential for more than minimal harm 2024-12-20

F698 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected 2025-04-19

D · Potential for more than minimal harm 2024-12-20

F811 · Nutrition and Dietary Deficiencies

Health

Ensure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised.

Corrected 2025-01-21

J · Immediate jeopardy 2024-10-29

F689 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-11-22

E · Potential for more than minimal harm 2024-10-29

F725 · Nursing and Physician Services Deficiencies

Health

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

Corrected 2024-11-22

E · Potential for more than minimal harm 2024-06-07

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected 2024-07-08

G · Actual harm 2024-01-09

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

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

Corrected 2024-02-09

G · Actual harm 2024-01-09

F689 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-02-09

F · Potential for more than minimal harm 2024-01-09

F727 · Nursing and Physician Services Deficiencies

Health

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Corrected 2024-02-09

F · Potential for more than minimal harm 2024-01-09

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected 2024-02-09

F · Potential for more than minimal harm 2024-01-09

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2024-02-09

F · Potential for more than minimal harm 2024-01-09

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-02-09

F · Potential for more than minimal harm 2024-01-09

F882 · Infection Control Deficiencies

Health

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Corrected 2024-03-19

E · Potential for more than minimal harm 2024-01-09

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2024-02-09

E · Potential for more than minimal harm 2024-01-09

F881 · Infection Control Deficiencies

Health

Implement a program that monitors antibiotic use.

Corrected 2024-02-09

D · Potential for more than minimal harm 2024-01-09

F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Corrected 2024-02-09

E · Potential for more than minimal harm 2023-10-31

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2023-11-22

E · Potential for more than minimal harm 2023-09-21

F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from the wrongful use of the resident's belongings or money.

Corrected 2023-10-13

E · Potential for more than minimal harm 2023-09-21

F755 · Pharmacy Service Deficiencies

Health

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

Corrected 2023-10-13

D · Potential for more than minimal harm 2023-09-21

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2023-10-13

E · Potential for more than minimal harm 2023-08-14

F755 · Pharmacy Service Deficiencies

Health

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

Corrected 2023-09-22

D · Potential for more than minimal harm 2023-08-14

F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from the wrongful use of the resident's belongings or money.

Corrected 2023-09-22

F · Potential for more than minimal harm 2023-08-08

F727 · Nursing and Physician Services Deficiencies

Health

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Corrected 2023-09-08

E · Potential for more than minimal harm 2023-08-08

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

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

Corrected 2023-09-08

E · Potential for more than minimal harm 2023-08-08

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2023-09-08

Penalties and ownership

What sits behind the stars

$0 2025-06-18

Payment Denial

Payment Denial · denial start 2025-07-20 · 17 days

17 day denial

$265,965 2024-12-20

Fine

Fine · fine $265,965

Fine

$0 2024-12-20

Payment Denial

Payment Denial · denial start 2025-01-22 · 113 days

113 day denial

$13,580 2024-10-29

Fine

Fine · fine $13,580

Fine

Ownership

Davidson, Robert

Operational/Managerial Control · Individual

0% 3 facilities 2018-01-01
Frances, Danny

5% Or Greater Direct Ownership Interest · Individual

0% 1 facilities 2008-11-01
Frances, Danny

Operational/Managerial Control · Individual

0% 1 facilities 2016-01-01
Frances, Jay

5% Or Greater Direct Ownership Interest · Individual

0% 5 facilities 2008-11-01
Legacy Health Services Inc

Operational/Managerial Control · Organization

0% 5 facilities 2008-11-01
Scharlemann, Mary

Operational/Managerial Control · Individual

0% 2 facilities 2024-08-15
Smith, Kimberly

5% Or Greater Direct Ownership Interest · Individual

0% 7 facilities 2011-03-01

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