Pittsfield, IL

Pittsfield Manor

1-star overall rating with 1-star inspections with abuse icon flag with $179,354 in total fines with 14 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle

610 Lowry Street, Pittsfield, IL

(217) 285-5200

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

2 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

89

Certified beds

Average residents

72

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Unlimited Development, Inc.

Operator or chain grouping

Approved since

1995-04-27

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Staffing

Hours and turnover

RN hours / resident day

0.52

Registered nurse staffing

LPN hours / resident day

0.77

Licensed practical nurse staffing

Aide hours / resident day

2.79

Nurse aide staffing

Weekend hours

3.60

Weekend nurse staffing

RN turnover

62%

Annual RN turnover

Total nurse turnover

56%

Annual nurse turnover

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Number of hospitalizations per 1000 long-stay resident days 1.6
2.0
0.4 pts better
1.9
0.3 pts better
Long Stay · 20240701-20250630
Number of outpatient emergency department visits per 1000 long-stay resident days 3.6
2.3
1.3 pts worse
1.8
1.8 pts worse
Long Stay · 20240701-20250630
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 100.0%
89.6%
10.4 pts better
93.4%
6.6 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine 98.8%
91.6%
7.2 pts better
95.5%
3.3 pts better
Long Stay · 2024Q3-2025Q2
Percentage of long-stay residents experiencing one or more falls with major injury 5.5%
3.3%
2.2 pts worse
3.3%
2.2 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who have depressive symptoms 5.5%
50.3%
44.8 pts better
11.4%
5.9 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who lose too much weight 5.3%
6.5%
1.2 pts better
5.4%
0.1 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antianxiety or hypnotic medication 27.2%
18.5%
8.7 pts worse
19.6%
7.6 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antipsychotic medication 21.6%
22.8%
1.2 pts better
16.7%
4.9 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who were physically restrained 0.0%
0.1%
0.1 pts better
0.1%
0.1 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose ability to walk independently worsened 35.5%
17.2%
18.3 pts worse
16.3%
19.2 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose need for help with daily activities has increased 36.1%
15.0%
21.1 pts worse
14.9%
21.2 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a catheter inserted and left in their bladder 0.5%
1.1%
0.6 pts better
1.0%
0.5 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a urinary tract infection 11.1%
1.7%
9.4 pts worse
1.7%
9.4 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 27.1%
21.3%
5.8 pts worse
19.8%
7.3 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with pressure ulcers 4.2%
5.2%
1 pts better
5.1%
0.9 pts better
Long Stay · 2024Q4-2025Q3
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 99.1%
68.8%
30.3 pts better
81.7%
17.4 pts better
Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who had an outpatient emergency department visit 21.6%
14.0%
7.6 pts worse
12.0%
9.6 pts worse
Short Stay · 20240701-20250630
Percentage of short-stay residents who newly received an antipsychotic medication 0.0%
2.3%
2.3 pts better
1.6%
1.6 pts better
Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 86.7%
63.0%
23.7 pts better
79.7%
7 pts better
Short Stay · 2024Q3-2025Q2
Percentage of short-stay residents who were rehospitalized after a nursing home admission 12.9%
26.2%
13.3 pts better
23.9%
11 pts better
Short Stay · 20240701-20250630

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-12-09 · Fire 2024-12-09

14 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

3 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Cycle 2 Health 2024-01-02 · Fire 2024-01-02

20 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)

5 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)

Cycle 3 Health 2022-11-22 · Fire 2022-11-22

9 health deficiencies

Top issue: Pharmacy Service (3 deficiencies)

13 fire-safety deficiencies

Top issue: Emergency Preparedness (6 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-12-09

K345 · Smoke Deficiencies

Fire Safety

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

Corrected 2025-01-10

F · Potential for more than minimal harm 2024-12-09

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2025-01-17

F · Potential for more than minimal harm 2024-12-09

K915 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper power supply for life support equipment.

Corrected 2025-01-10

F · Potential for more than minimal harm 2024-01-02

E26 · Emergency Preparedness Deficiencies

Fire Safety

Establish roles under a Waiver declared by secretary.

Corrected 2024-01-11

F · Potential for more than minimal harm 2024-01-02

K341 · Smoke Deficiencies

Fire Safety

Install a fire alarm system that can be heard throughout the facility.

Corrected 2024-01-08

F · Potential for more than minimal harm 2024-01-02

K345 · Smoke Deficiencies

Fire Safety

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

Corrected 2024-01-16

F · Potential for more than minimal harm 2024-01-02

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-01-04

E · Potential for more than minimal harm 2024-01-02

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2024-01-07

F · Potential for more than minimal harm 2022-11-22

E13 · Emergency Preparedness Deficiencies

Fire Safety

Develop Emergency Preparedness policies and procedures.

Corrected 2022-12-06

F · Potential for more than minimal harm 2022-11-22

E29 · Emergency Preparedness Deficiencies

Fire Safety

Develop a communication plan.

Corrected 2022-12-06

F · Potential for more than minimal harm 2022-11-22

E36 · Emergency Preparedness Deficiencies

Fire Safety

Establish emergency prep training and testing.

Corrected 2022-12-06

F · Potential for more than minimal harm 2022-11-22

E37 · Emergency Preparedness Deficiencies

Fire Safety

Establish staff and initial training requirements.

Corrected 2022-12-06

F · Potential for more than minimal harm 2022-11-22

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2022-12-16

F · Potential for more than minimal harm 2022-11-22

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2022-12-09

F · Potential for more than minimal harm 2022-11-22

K341 · Smoke Deficiencies

Fire Safety

Install a fire alarm system that can be heard throughout the facility.

Corrected 2022-12-31

F · Potential for more than minimal harm 2022-11-22

K345 · Smoke Deficiencies

Fire Safety

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

Corrected 2022-12-09

F · Potential for more than minimal harm 2022-11-22

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2022-12-09

F · Potential for more than minimal harm 2022-11-22

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2022-12-31

E · Potential for more than minimal harm 2022-11-22

K133 · Construction Deficiencies

Fire Safety

Install a two-hour-resistant firewall separation.

Corrected 2022-12-31

E · Potential for more than minimal harm 2022-11-22

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2022-12-31

D · Potential for more than minimal harm 2022-11-22

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2022-12-31

Inspection history

Recent health citations

G · Actual harm 2024-12-09

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-01-15

F · Potential for more than minimal harm 2024-12-09

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 2025-01-15

F · Potential for more than minimal harm 2024-12-09

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 2024-12-18

E · Potential for more than minimal harm 2024-12-09

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 2024-12-19

E · Potential for more than minimal harm 2024-12-09

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-12-18

D · Potential for more than minimal harm 2024-12-09

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 2024-12-19

D · Potential for more than minimal harm 2024-12-09

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2024-12-18

D · Potential for more than minimal harm 2024-12-09

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2024-12-18

D · Potential for more than minimal harm 2024-12-09

F623 · Resident Rights Deficiencies

Health

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected 2024-12-18

D · Potential for more than minimal harm 2024-12-09

F644 · Resident Assessment and Care Planning Deficiencies

Health

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Corrected 2024-12-18

D · Potential for more than minimal harm 2024-12-09

F677 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-12-20

D · Potential for more than minimal harm 2024-12-09

F692 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-12-18

D · Potential for more than minimal harm 2024-12-09

F698 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-12-18

D · Potential for more than minimal harm 2024-12-09

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2024-12-18

E · Potential for more than minimal harm 2024-10-08

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 2024-10-15

D · Potential for more than minimal harm 2024-10-08

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 2024-10-15

D · Potential for more than minimal harm 2024-10-08

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 2024-10-15

D · Potential for more than minimal harm 2024-10-08

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-10-15

G · Actual harm 2024-05-22

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 2024-05-31

D · Potential for more than minimal harm 2024-05-06

F583 · Resident Rights Deficiencies

Health

Keep residents' personal and medical records private and confidential.

Corrected 2024-05-10

D · Potential for more than minimal harm 2024-05-06

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 2024-05-10

D · Potential for more than minimal harm 2024-05-06

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2024-05-10

D · Potential for more than minimal harm 2024-05-06

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2024-05-10

L · Immediate jeopardy 2024-01-02

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-01-18

G · Actual harm 2024-01-02

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 2024-02-08

F · Potential for more than minimal harm 2024-01-02

F576 · Resident Rights Deficiencies

Health

Ensure residents have reasonable access to and privacy in their use of communication methods.

Corrected 2024-01-05

F · Potential for more than minimal harm 2024-01-02

F585 · Resident Rights Deficiencies

Health

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Corrected 2024-01-15

F · Potential for more than minimal harm 2024-01-02

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 2024-01-04

F · Potential for more than minimal harm 2024-01-02

F804 · Nutrition and Dietary Deficiencies

Health

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

Corrected 2024-01-08

F · Potential for more than minimal harm 2024-01-02

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 2024-01-12

F · Potential for more than minimal harm 2024-01-02

F867 · Administration Deficiencies

Health

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Corrected 2024-01-17

F · Potential for more than minimal harm 2024-01-02

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 2024-01-18

E · Potential for more than minimal harm 2024-01-02

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 2024-01-17

E · Potential for more than minimal harm 2024-01-02

F881 · Infection Control Deficiencies

Health

Implement a program that monitors antibiotic use.

Corrected 2024-01-18

D · Potential for more than minimal harm 2023-06-20

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 2023-07-07

D · Potential for more than minimal harm 2023-06-20

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 2023-07-07

G · Actual harm 2022-11-22

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2022-12-16

F · Potential for more than minimal harm 2022-11-22

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 2022-12-26

F · Potential for more than minimal harm 2022-11-22

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 2022-12-23

F · Potential for more than minimal harm 2022-11-22

F868 · Administration Deficiencies

Health

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Corrected 2022-12-27

F · Potential for more than minimal harm 2022-11-22

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 2022-12-26

D · Potential for more than minimal harm 2022-11-22

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2022-12-16

D · Potential for more than minimal harm 2022-11-22

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2022-12-16

Penalties and ownership

What sits behind the stars

$51,051 2024-12-09

Fine

Fine · fine $51,051

Fine

$0 2024-12-09

Payment Denial

Payment Denial · denial start 2024-12-31 · 15 days

15 day denial

$24,027 2024-05-06

Fine

Fine · fine $24,027

Fine

$104,276 2024-01-02

Fine

Fine · fine $104,276

Fine

$0 2024-01-02

Payment Denial

Payment Denial · denial start 2024-01-26 · 13 days

13 day denial

Ownership

Finke, Audrey

Corporate Director · Individual

0% 10 facilities 2018-09-05
Finke, Audrey

Corporate Officer · Individual

0% 10 facilities 2018-09-05
Gilmore, Jerry

Corporate Director · Individual

0% 10 facilities 2006-04-26
Haney, David

Corporate Director · Individual

0% 11 facilities 2006-04-26
Titus, Billye

W-2 Managing Employee · Individual

0% 1 facilities 2018-09-05
Udi #9, LLC

Operational/Managerial Control · Organization

0% 1 facilities 2006-04-26
Wagner, Robert

Corporate Director · Individual

0% 10 facilities 2006-04-26
Wagner, Robert

Corporate Officer · Individual

0% 10 facilities 2018-09-05
Wilson, Ronald

Corporate Officer · Individual

0% 17 facilities 2018-09-05

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