Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avenues At Springfield during CMS and state inspections, most recent first.
Failure to Maintain Food Sanitation and Hand Hygiene: Staff were observed handling food and kitchen items without proper hand hygiene, changing gloves improperly, and working without a hair net. Surveyors also found opened food items in refrigerator and freezer storage that were unlabeled, undated, or uncovered, including milk, butter, cookies, green beans, and fritters. A Cook, Dietary Aide, and Dietary Mgr were observed handling food with the same gloves while preparing and serving meals, contrary to facility policy requiring handwashing, glove changes, hair coverings, and labeled, dated food storage.
Failure to maintain an effective Legionella water management program was identified when maintenance could not describe the water flow, did not know whether empty resident rooms were considered, and stated the contractor checked for algae rather than Legionella. The facility’s policy states the program is intended to reduce Legionella risk in water systems, and the Administrator stated the facility should follow the water management program; the CMS 671 documented 64 residents.
The facility failed to provide a trained infection preventionist responsible for the infection prevention and control program. The DON was acting in that role but did not have a certificate and had only recently signed up for the infection prevention course. The administrator stated a trained infection preventionist was expected onsite, while the regional nurse providing oversight did not work at the facility. The facility also stated it did not have a specific policy for an infection preventionist and followed state guidelines instead.
The facility failed to provide the required square footage per resident bed in 32 occupied two-bed rooms, with each bed measuring only 76 square feet instead of 80. The Medicaid-certified rooms in two wings were occupied by 64 residents total, and the ADON and administrator confirmed that all rooms were in use and under the required square footage.
Surveyors found that the ice machine used for resident drinks and food preparation lacked a required air gap between the drain hose and sewage pipe, creating a risk of contamination. Additionally, the kitchen hand washing sink did not provide warm water, as the temperature was significantly below recommended levels for effective hand hygiene. These issues had the potential to impact all residents in the facility.
Multiple residents were unable to access comfortable hot water for daily hygiene due to a malfunctioning circulatory pump, resulting in cold water in sinks and showers. Residents reported difficulty with personal care, and temperature checks confirmed water was below acceptable levels. Facility administration was unaware of the issue until it was identified during the survey.
A resident with Alzheimer's/Dementia eloped from the facility, resulting in a fall and injuries. The resident exited through the main entrance after a fire drill, triggering an alarm that was not immediately addressed. The resident was found missing, and the police located them three blocks away. The resident sustained a laceration and nasal fracture during the incident.
The facility failed to provide 8 consecutive hours of RN coverage, affecting all 61 residents. The DON acknowledged the issue, citing difficulties in hiring RNs and the absence of a policy to ensure compliance. This deficiency was noted on multiple occasions, as revealed through interviews, observations, and record reviews.
The facility failed to maintain proper food safety and sanitation practices, affecting all 61 residents. A cook was observed without a hair net, and food temperatures were not maintained or documented correctly. Additionally, a can opener was found unclean, and the cleaning schedule did not include it. The kitchen sanitation policy lacked guidance on hair net use.
A resident with a gastrostomy tube, diagnosed with aspiration pneumonia, expressed dissatisfaction with the feeding method and desired to return to a regular diet. The facility failed to provide a plan for restoring eating skills or evaluating oral intake, despite the resident's expressed wishes and hospital recommendations. The resident exhibited non-compliant behaviors and irritability, and the facility lacked a policy on restoring eating skills, contributing to the deficiency.
The facility did not meet the required 80 square feet of floor space per resident bed in 32 two-bed rooms, affecting all 61 residents. Observations and interviews confirmed that these rooms only provide 76 square feet per bed, and the administrator acknowledged the non-compliance. The deficiency was noted in the facility's Medicare and Medicaid application.
The facility failed to maintain a nurse on duty, leaving a CNA to handle a resident's return from the hospital. The LPN on duty left for a family emergency without notifying management or arranging coverage, resulting in no nurse being present for approximately 15 minutes.
The facility failed to provide RN coverage for 8 consecutive hours on multiple dates, affecting all 62 residents. The Administrator and a CNA confirmed the absence of an RN on these days, and the facility lacked a staffing policy despite regulatory requirements.
Failure to Maintain Food Sanitation and Hand Hygiene
Penalty
Summary
The facility failed to perform hand hygiene and glove changes appropriately during food preparation and service, and failed to label, date, and cover food stored in the kitchen refrigerators and freezer. On 01/27/2026, surveyors observed in refrigerator #1 a gallon of opened 2% milk with an expiration date of 1/25/26, and in refrigerator #2 an opened 1/2 pound of butter that was not labeled or dated. In the freezer, a sandwich bag of green beans and a bag of frozen fritters were also not labeled or dated. The Dietary Manager was made aware of the unlabeled and undated items. The Dietary Manager later stated that food in the refrigerators should be labeled and dated and discarded when out of date, and that hair nets should always be worn in the kitchen. On 01/27/2026, a Dietary Aide was observed wrapping silverware without a hair net on, then placing the hair net back on his head without hand hygiene before continuing the task. On 01/28/2026, the same opened, unlabeled, and undated butter remained in refrigerator #2, and three trays of cookies were also observed without labels or dates. A Regional Dietary Manager stated she believed items did not have to be covered, labeled, or dated if they were being used the same day for supper. Later that day, a Cook donned gloves without hand hygiene, handled refrigerated grilled cheese sandwiches and the unlabeled butter, used the same gloves while working at the griddle and stove, and touched equipment and food items. A Dietary Manager and a Dietary Aide were also observed donning gloves without hand hygiene while handling food and serving lunch. The facility policy stated that hands should be washed frequently, hairnets or hair coverings should be worn at all times, unused food should be covered, timed, labeled and dated, and hands should be washed before putting on disposable gloves and after gloves are removed.
Failure to Maintain Legionella Water Management Program
Penalty
Summary
Provide and implement an infection prevention and control program was deficient because the facility failed to implement and maintain effective measures to prevent the growth and transmission of Legionella bacteria within the water system. During interview, maintenance stated the facility calls a contractor for Legionella prevention, but the contractor checks for algae. Maintenance was unable to describe the water flow, stated he would need to check his book for a water flow diagram, and did not know whether the facility had empty resident rooms in relation to Legionella prevention. The maintenance book was also unavailable because it was not complete. The facility’s Water Management Program for Prevention of Legionella Growth, last revised in 1/2026, states its purpose is to reduce Legionella risk in the facility water systems and prevent cases and outbreaks of Legionnaires’ Disease. The policy identifies water systems and components such as hot and cold-water storage tanks, water heaters, pipes, valves, fittings, filters, showerheads, hoses, eyewash stations, and ice machines as potential risks, and states the program should be reviewed at least once a year. The Administrator stated she would expect the facility to follow the water management program for prevention and growth of Legionella, and the CMS 671 dated 1/27/2026 documented a census of 64 residents.
Untrained Infection Preventionist
Penalty
Summary
The facility failed to provide a trained infection preventionist responsible for the infection prevention and control program. The administrator stated that the DON was serving as the infection preventionist, but also stated the DON did not have a certificate and was working under the regional nurse. The DON confirmed she did not have a certificate and had only signed up for the infection prevention course the day before, with plans to take the course that weekend. The administrator further stated she would expect a trained infection preventionist to be onsite at the facility and acknowledged that the regional nurse does not work at the facility. The facility also stated it did not have a specific policy for an infection preventionist and instead followed state guidelines. The CMS 671 dated 1/27/2026 documented a census of 64.
Insufficient Room Square Footage in Multiple Occupied Resident Rooms
Penalty
Summary
The facility failed to provide at least 80 square feet of floor space per resident bed in 32 two-bed resident rooms, with historical room measurements showing only 76 square feet per bed in those rooms. The deficiency involved the facility’s Medicaid-certified rooms A1 through A16 and B1 through B16, which were occupied by 64 residents in total. On 1/29/26 at 1:01 PM, the ADON stated that all rooms in the facility were being occupied, and on 1/27/26 at 9:26 AM, the administrator stated that all rooms in the facility were under the required square footage. The Long-Term Application for Medicare and Medicaid dated 1/27/26 documented that the facility had 64 residents living in the facility.
Ice Machine Lacks Air Gap and Inadequate Hand Washing Water Temperature
Penalty
Summary
Surveyors observed that the facility failed to maintain proper food safety standards in two key areas. First, the ice machine used for resident drinks and food preparation did not have an appropriate air gap between the ice storage bin drain and the floor sewage drain. The hose from the ice machine was submersed directly into the drain pipe, with no visible gap to prevent potential sewage backflow into the ice machine. Staff, including the Administrator and Dietary Manager, were unaware of the requirement for an air gap and confirmed that the current setup had been in place for years. Additionally, the kitchen hand washing sink did not provide warm water for staff use. When tested, the water temperature at the hand washing station was only 69.5°F after running for one minute, which is below the expected temperature for effective hand hygiene. The maintenance staff member confirmed that the water should be much warmer, indicating a problem with the sink's water temperature. These deficiencies had the potential to affect all 61 residents in the facility.
Failure to Provide Comfortable Hot Water Temperatures for Residents
Penalty
Summary
The facility failed to provide comfortable hot water temperatures for resident use, as evidenced by observations, interviews, and temperature measurements. Multiple residents reported that the water in their sinks and showers was consistently cold, making it difficult or impossible to perform daily hygiene tasks such as washing hair. Water temperature readings taken with a calibrated thermometer confirmed that several sinks used by residents registered at 69.5 degrees Fahrenheit, which is below the standard for comfortable hot water. Residents sharing bathrooms and sinks all experienced similar issues, and these concerns were corroborated by direct resident statements during the survey. The facility administrator was unaware of any water temperature issues prior to the survey. A maintenance staff member from a sister facility was called in and identified that the circulatory pump required repair, which had resulted in inadequate hot water distribution throughout the building. The deficiency affected at least ten residents, all of whom were unable to access safe and comfortable water temperatures for daily living activities, as required by resident rights and facility regulations.
Resident Elopement and Injury Due to Inadequate Supervision
Penalty
Summary
The facility failed to prevent an elopement incident involving a resident identified as R2, who was one of four residents reviewed for elopement and supervision. On the early morning of 12/30/24, R2, who has Alzheimer's/Dementia and is not cognitively intact, managed to leave the facility unsupervised. The resident exited through the main entrance after a fire drill, following a staff member out the door, which triggered an alarm. However, the alarm was not immediately acted upon, leading to R2 being found missing from the facility. R2 was discovered missing at approximately 4:30 AM, and the facility initiated an elopement protocol. Despite efforts to locate R2 within the facility, including checking the resident's room and conducting a headcount, R2 was not found. The police were notified, and R2 was located three blocks away from the facility by the police and taken to a hospital for evaluation. During the time R2 was missing, the resident sustained a fall resulting in a laceration to the forehead and a nasal fracture. The resident's medical history includes diagnoses such as Major Depressive Disorder, Generalized Anxiety Disorder, and Unspecified Dementia, among others. R2's care plan, dated 8/2/23, already documented a risk for elopement, but there was no documented Elopement Risk Assessment or Community Survival Skills Assessment in R2's medical record prior to the incident. The facility's failure to adequately supervise and prevent R2's elopement resulted in Immediate Jeopardy, which was identified and addressed by the surveyors.
Failure to Provide 8 Consecutive Hours of RN Coverage
Penalty
Summary
The facility failed to provide 8 consecutive hours of Registered Nurse (RN) coverage, which is a requirement for the care of all 61 residents residing in the facility. This deficiency was identified through interviews, observations, and record reviews. On multiple occasions, specifically on 6/3/24, 6/8/24, 6/9/24, 6/17/24, 6/28/24, 7/2/24, 7/6/24, 7/7/24, 7/20/24, and 7/29/24, the facility did not have the required RN coverage. The Director of Nurses (DON) acknowledged the issue, stating that there have been days when the facility could not staff 8 consecutive hours of RN coverage due to a lack of applicants for RN positions. Additionally, the facility does not have a policy in place to ensure 8 hours of consecutive RN coverage, although the DON attempts to meet this regulation.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to proper food safety and sanitation practices, which could potentially affect all 61 residents. During an observation, a preparation cook was seen without a hair net properly covering her hair while assisting in food preparation and serving. The hair net was improperly positioned, failing to cover any hair, which could lead to contamination of food items being served to residents. Additionally, the facility did not maintain safe food temperatures or document them as required. A cook was observed with macaroni salad at an unsafe temperature of 60.2 degrees Fahrenheit, which was not immediately chilled to the required 41 degrees Fahrenheit or below. The cook also failed to document the food temperatures on the log before serving the meal. Furthermore, the can opener blade in the kitchen was found covered in a thick black substance, indicating a lack of cleanliness and sanitation. The facility's cleaning schedule did not include the can opener, and the kitchen sanitation policy did not address the use of hair nets.
Failure to Restore Eating Skills for Resident with Feeding Tube
Penalty
Summary
The facility failed to provide services to a resident with a gastrostomy tube to restore or maintain eating skills. The resident, who has a history of schizophrenia, major depressive disorder, anxiety, COPD, Parkinson's, and other conditions, was admitted to the hospital for COPD exacerbation and pneumonia. Upon returning to the facility, the resident was diagnosed with aspiration pneumonia and was placed on a feeding tube with orders for nothing by mouth (NPO). Despite this, the resident expressed dissatisfaction with the feeding tube and a desire to return to a regular diet, indicating a lack of agreement with the current feeding method. The facility did not have a plan for the resident to be evaluated for oral intake or to receive speech therapy, despite the resident's expressed desire and the initial hospital suggestion for a dysphagic diet plan. The resident exhibited behaviors such as hiding snacks and consuming ice, which were against medical advice, and displayed anger and irritability, possibly due to the lack of a plan to restore eating skills. The Director of Nursing confirmed that there were no orders for speech therapy and that the facility lacked a policy on restoring eating skills, contributing to the deficiency in care for the resident.
Non-Compliance with Resident Room Space Requirements
Penalty
Summary
The facility failed to provide the required 80 square feet of floor space per resident bed in 32 two-bed resident rooms, affecting all 61 residents. Observations, interviews, and record reviews revealed that these rooms only offer 76 square feet per bed, which does not meet the regulatory requirements. The facility's administrator confirmed that none of the rooms meet the square footage requirement, with only one private room available, which is currently unoccupied. The deficiency was documented in the Long-Term Application for Medicare and Medicaid, indicating the facility's non-compliance with space requirements for resident rooms.
Failure to Maintain Nurse on Duty
Penalty
Summary
The facility failed to maintain a nurse on duty to meet the needs and safety of all residents. On 4/19/2024, an ambulance staff member reported that upon returning a resident to the facility around 8 PM, there was no nurse present to receive the resident. The Certified Nursing Assistant (CNA) on duty informed the ambulance staff that the Licensed Practical Nurse (LPN) had left the facility and would return shortly. The LPN confirmed that she had left the facility to deal with a family emergency and did not notify management or arrange for coverage during her absence. This left the facility without a nurse on duty for approximately 15 minutes, during which time the ambulance staff had to leave the resident with the CNA without a proper transfer of care. The facility's administrator and Director of Nursing were unaware of the incident until four days later. They confirmed that the LPN was the only nurse scheduled for that shift and that there was no policy in place to ensure coverage during such absences. The facility's schedule for the day in question corroborated that the LPN was the only nurse on duty. The lack of a nurse on duty during the LPN's absence had the potential to affect the care and safety of all 62 residents in the facility.
Failure to Provide RN Coverage for 8 Consecutive Hours
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for 8 consecutive hours on multiple dates, specifically 04/01/2024, 04/06/2024, 04/15/2024, 04/18/2024, 04/19/2024, and 04/20/2024. This deficiency was identified through record reviews and interviews, which revealed that the absence of an RN on these dates had the potential to affect all 62 residents in the facility. The Administrator confirmed that there were days without an RN for 8 consecutive hours and acknowledged the current census of 62 residents. Nursing schedules provided by the facility corroborated the absence of an RN on the specified dates. Additionally, a Certified Nursing Assistant (CNA) stated that there were days when no RN was present for 24 hours. The Administrator also admitted that the facility lacked a staffing policy but was supposed to follow regulatory staffing requirements.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Springfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Arcadia Care On The Hill | 2.9 mi | ★★★★★ | 4 | 0 |
| Regency Care | 3.7 mi | ★★★★★ | 1 | 0 |
| Springfield Suites Rehab And Nursing | 4.5 mi | ★★★★★ | 15 | 0 |
| Arc At Sangamon Valley | 4.9 mi | ★★★★★ | 9 | 0 |
| Concordia Village Care Center | 5.3 mi | ★★★★★ | 8 | 0 |
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