Addolorata Villa

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.

47.3% 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 147 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 69.1% 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 68 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 0.27 therapist hours per resident per day in 2026Q1 — more than 41% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 12% 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 86 beds and averages 72.0 residents a day — about 84% occupied, or roughly 14 beds typically open. It usually has some room. 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 4.97 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.47 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.97 is at or above 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 4.47 hrs/resident/day on weekends vs 5.17 on weekdays — 14% thinner on weekends. RN hours go from 1.61 to 1.15 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 19% is below the national median of 45%.

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

Inspection trend

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

Inspection deficiencies

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

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

24 citations, most serious first. The 18 most serious are shown; the remaining 6 are one tap away and print in full.

• Actual harm · Gcited before2026-05-28 · 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 effectively address R2's behaviors, put effective fall interventions in place, and provide appropriate hands-on ADL care to one resident (R2) who is high risk for falls. This failure resulted in R2 falling out of bed while being provided with care and sustaining multiple lacerations to his face requiring six sutures in total.Findings Include:R2 is a [AGE] year-old male who originally admitted to the facility on [DATE] and continues to reside in the facility. R2 has multiple diagnoses including but not limited to the following: Alzheimer's disease, dysphagia, cognitive communication deficit, muscle weakness, and repeated falls.Facility Reported Incident dated 4/19/2026 states in part but not limited to the following: On 4/19/2026 at 5:20AM, V5 (Certified Nursing Assistant) provided care to R2. V5 was obtaining supplies from the wheelchair that was positioned at the foot of the bed when R2 was observed to be in a sitting position, feet on the ground and…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2026-03-27 · 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

  Based on interviews and record reviews, the facility failed to implement safety measures during transfer back to wheelchair from standing position resulting in R1's fall, hospitalization and sustaining a facial laceration, nasal fracture and neck fracture (type 2 odontoid fracture) and R1 passing in the facility.Findings Include:On 3/26/2026 at 12:13 PM V6 (Activity Aide/Assistant) stated she witnessed R1 pushing his wheelchair while walking. V6 demonstrated and said she took the wheelchair from R1, turned the wheelchair around by placing it behind R1 and verbally instructed R1 to sit down. In the process of R1 trying to sit back down, R1 fell forward hitting his head and face to the floor. V6 said she positioned herself behind the wheelchair. V6 said there was no gait belt used. V6 screamed and asked for assistance after learning R1 had injuries from the fall. During demonstration, V1(Administrator) was present.On 3/26/2026 at 9:52 AM V1 (Administrator) and V2 (Director of Nursing) stated R1 returned to facility and family opted for hospice care for remainder of his stay.On…

  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 · G2025-12-07 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement care plan interventions during ambulation and transfer which affected one resident (R1) that required hospital transfer. This failure resulted in staff's inability to prevent a fall and R1 sustaining a hip fracture.Findings include:R1 is an [AGE] year-old, originally admitted on [DATE] with medical diagnosis that include and are not limited to: Parkinson's Disease, Dementia and Obstructive and Reflux Uropathy, according to Minimum Data Set (MDS), R1 has a Brief Interview for Mental Status (BIMS) score of 3/15, indicating severe cognitive impairment. According to R1's electronic medical record, care plan dated: 9-9-2025 reads: R1 has an Activities of Daily living (ADL) self-care and mobility usual performance deficit related to Parkinson's dementia with agitation, insomnia and behaviors. Interventions: R1 to ambulate with contact guard in the hallway and a gait belt on for safety with a wheeled walker.On 12-6-2025 AT 3:10 pm V3 (Registered…

  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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-01-16 · 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, interviews and record reviews, the facility failed to assess and prevent the development of a pressure ulcer for one ((R28) of two residents reviewed for pressure ulcers. This deficiency resulted in R28's intact skin developing a facility acquired Unstageable pressure ulcer. Findings include: R28 is a [AGE] year-old, female, admitted in the facility on 11/22/24 with diagnoses of Heart Failure, Unspecified; and Nondisplaced Fracture of Medial Malleolus of Right Tibia, Subsequent Encounter for Closed Fracture with Routine Healing; Other Fracture of Upper and Lower End of Right Fibula, Subsequent Encounter for Closed Fracture with Routine Healing. MDS (Minimum Data Set) dated 11/28/24 documented R28's BIMS (Brief Interview for Mental Status) score of 11 which means moderate impairment in cognition. MDS also recorded R28 has no pressure ulcer. R28's 11/29/24 Braden score for predicting pressure sore risk was 13, which means moderate risk. R28's progress notes recorded the following in part but…

  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 before2025-01-16 · 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, interviews and record reviews, the facility failed to adequately monitor and supervise a cognitively impaired resident in preventing a fall for one (R120) of five residents reviewed for accidents and supervision. This deficiency resulted in R120 falling from a wheelchair in the common area in the facility and sustaining an acute subcapital femoral neck fracture. R120 underwent a surgical procedure called left hip hemiarthroplasty. Findings include: R120 is a [AGE] year-old female, initially admitted in the facility on 12/11/24 with diagnoses of Dementia in other Diseases Classified Elsewhere, Unspecified Severity with other Behavioral Disturbance; Unspecified Lack of Coordination; and Repeated falls. R120 was readmitted on [DATE] with diagnosis of Displaced Fracture of Base of Neck of Left Femur, Subsequent Encounter for Closed Fracture with Routine Healing. MDS (Minimum Data Set) dated 01/09/25 documented a BIMS (Brief Interview for Mental Status) score of 3, which means severe impairment…

  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 before2024-03-27 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to protect the residents' right to be free from physical, verbal, and mental abuse by an employee, and failed to follow its abuse policy related to prevention, identification of abuse. These failures affected one (R55) of six residents in the sample of 37 residents reviewed for abuse. These failures resulted in R55 feeling angry, uncomfortable, and humiliated by the employees physical and verbal actions towards R55. R55 is a [AGE] year-old female who has resided at the facility since 6/1/2022 with past medical history including, but not limited to [NAME] ataxia, age-related osteoporosis without current pathological fracture, vitamin D deficiency, thoracogenic scoliosis, thoracic region, overactive bladder, pain in right leg, pain in left hip. Minimum Data Set (MDS) assessment dated [DATE], section C (Cognitive) documented R55 has a BIMs (Brief Interview for mental Status) score of 13, section GG (functional abilities and goals) of the same…

  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 · G2024-02-08 · tag F0697 — failed to manage pain — isolated
  Provide safe, appropriate pain management for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow physician's orders to administer appropriate pain medications for a post- surgical resident experiencing extreme pain and failed to assess the severity of pain for 1(R4) of 4 residents reviewed for pain management in the sample. This failure resulted in R4 being unable to sleep due to extreme hip pain from post-surgical hospitalization for a hip fracture due to a fall sustained in the facility. Findings include: R4 is an alert and oriented [AGE] year old with diagnosis of pneumonia, muscle weakness, difficulty walking, and spinal stenosis. On 2/1/24 R4 was receiving continued strength training related to balance and gait issues due to a recent fall that occurred on 1/26/24. The resident, while receiving this therapy session had a mechanical fall leading to the emergent transfer to the hospital where the resident was diagnosed with left hip fracture with surgical intervention (Open Reduction Internal Fixation surgery). Hospital record reads 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 before2023-08-25 · 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

  Based on interviews and record reviews the facility failed to supervise/monitor a resident identified to have a lack of safety awareness. This affected one of three residents (R1) reviewed for supervision and fall prevention. This failure resulted in R1 having a fall incident and sustaining a left intertrochanteric femur fracture. The findings include: R1's diagnosis include but are not limited to Supraventricular Tachycardia, Hyperlipidemia, Dementia, Depressive Disorder, Alzheimer's Disease, and Osteoarthritis. On 8/22/23 at 11:08AM R1 observed in her bed resting and did not acknowledge the surveyor. On 8/22/23 at 12:00PM V1, Dining Services, said there had been an activity in the dining room on 8/3/23 and it was over so she and V2, Dining Services, were setting up for the meal. V1 said only herself, V2, and R1 were in the room. V1 said R1 was sitting in a chair near a table. V1 said I had never met R1 before. V1 said we were left about 15 minutes with R1 in the dining room. V1 said when we walked in there was no staff in the room. V1 said in her department she tries to keep an…

  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 · E2026-01-15 · tag F0803 — failed to meet residents' dietary needs — pattern
  Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow their menu and provide adequate portions to all residents residing on unit 2-East and all residents receiving a puree diet. This failure applied to all 18 residents currently on the 2East unit of the facility.Findings Include:Per facility census dated 1/12/2026, 18 residents are residing on the 2-East unit.On 1/13/2026 at 9:45AM, V14 (Cook) was observed to be pureeing chicken [NAME] for lunch. V14 said we need 14 servings of puree chicken for lunch today.V14 was observed adding 6 chicken thighs to the blender along with chicken broth. This surveyor asked V14 if he felt that was enough puree to serve 14 servings, in which he said yes.It is to be noted that per diet spread sheet, one full piece of chicken is served to residents on a regular diet.At 11:30AM, V21 (Dietary Server) was observed serving the 2-East unit. V21 was observed serving with a 3-ounce (ivory) spoon for rice and a 4-ounce scoop for the pork peppered steak.Diet…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-01-15 · 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, interviews and records review, the facility failed to implement care plan interventions for the treatment and management of pressure ulcers; and failed to ensure multiple sheets are not used on low air loss mattress per manufacturer's guidelines. These deficiencies affect one (R20) of three residents reviewed for pressure ulcers.Findings include: R20 is a [AGE] year-old, female, admitted in the facility on 12/16/2020 with diagnoses of Quadriplegia, Unspecified; Multiple Sclerosis, Unspecified; Alzheimer's Disease, Unspecified; Contracture, Right Hand; and Contracture, Left Hand. MDS (Minimum Data Set) dated 12/10/25 recorded R20's BIMS (Brief Interview for Mental Status) score is 11, which means moderate impairment in cognition. R20's Wound Evaluation and Management Summary recorded the following: 10/23/25: Non-pressure wound of the right buttock, Moisture Associated Skin Damage (MASD), wound size: 0.5 x 0.6 x 0.1 cm (centimeters). Treatment: Alginate calcium with silver, apply once daily…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-01-15 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
  Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
  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 a resident with restorative services to aid in maintaining range of motion per resident's plan of care. This failure applied to one (R42) of three residents reviewed for restorative services.Findings include:R42 is an [AGE] year-old male who originally admitted to the facility on [DATE] and continues to reside in the facility. R42 has multiple diagnoses including but not limited to the following: dysphagia, right elbow contracture, urine retention, type II DM, quadriplegia, bell's palsy, and heart failure.On 1/12/2026 at 11:00AM, R42 said the staff does not get me up out of bed. I am in pain in my back and legs.On 1/12/2026 and 1/13/2026, R42 was observed on multiple occasions laying in bed. This surveyor observed resident to have a contracted right arm.On 1/14/2026 at 2:07PM, V20 (Restorative Aide) said I do work with R42. We do passive range of motion exercises to help with his contractures. I'd say on average I work with him…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-08-14 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  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 and record reviews the facility failed to follow their policy and procedures for abuse prevention by not reporting an allegation of abuse for a resident with a history of making abuse allegations. This failure applies to one of four residents (R1) reviewed for abuse.Findings include: R1 is a [AGE] year-old female with a diagnosis's history of Dementia with Behavioral Disturbance, Chronic Venous Hypertension with Ulcers of Right and Left Lower Extremities, Stage 3 Chronic Kidney Disease, Hypothyroidism, and Recurrent Severe Major Depressive Disorder who was admitted to the facility 05/04/2025. R1's Behavior Progress Note dated 5/21/2025 documents a CNA (Certified Nursing Assistant) informed that R1 went to the bathroom by herself, urine was all over the floor in the bathroom, R1 was then brought to common area and said, The lady abused me. I'm gonna call V7 (Family Member). The facility did not have an abuse investigation report for R1's abuse allegation from 05/21/2025. On 08/13/2025 at 1:34…

  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 · D2025-08-14 · tag F0610 — failed to investigate and act on abuse reports — isolated
  Respond appropriately to all alleged violations.
  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 and record reviews the facility failed to follow their policy and procedures for abuse prevention by not investigating an allegation of abuse for a resident with a history of making abuse allegations. This failure applies to one of four residents (R1) reviewed for abuse.Findings include: R1 is a [AGE] year-old female with a diagnosis's history of Dementia with Behavioral Disturbance, Chronic Venous Hypertension with Ulcers of Right and Left Lower Extremities, Stage 3 Chronic Kidney Disease, Hypothyroidism, and Recurrent Severe Major Depressive Disorder who was admitted to the facility 05/04/2025. R1's Behavior Progress Note dated 5/21/2025 documents a CNA (Certified Nursing Assistant) informed that R1 went to the bathroom by herself, urine was all over the floor in the bathroom. R1 was then brought to common area and said, The lady abused me. I'm gonna call V7 (Family Member). The facility did not have an abuse investigation report for R1's abuse allegation from 05/21/2025. On 08/13/2025 1:53…

  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 · F2025-01-16 · tag F0625 — widespread
  Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
  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 reviews, the facility failed to provide bed hold notifications to residents and/or family members when residents were discharged to a local hospital. This failure affected 5 residents (R5, R19, R37, R64 and R120) reviewed for bed hold notification in a total sample of 38. This failure had the potential to affect all residents in the facility. Findings include: R5 originally admitted on [DATE] with diagnosis that include and are not limited to: pneumonia, sepsis, dysphagia and acute kidney failure. Resident was transferred to a local hospital on 1/6/2025 per progress notes. Per record review no bed hold notification on record. R19 originally admitted on [DATE] with most recent readmission on [DATE] with diagnosis that include and are not limited to: pick's disease, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dysphagia and aphasia. Resident was transferred to a local hospital on [DATE] and 12/30/2024 per progress notes. Per record review no…

  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 · F2025-01-16 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  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 proper hand hygiene, failed to follow proper food storage practices, and failed to ensure dishwasher maintained proper temperature during final rinsing cycles to prevent the spread of food-borne illness and contamination. These failures have the potential to affect all 87 residents receiving meals from the kitchen. Findings include: On 01/13/25 at 09:25AM during the initial kitchen tour with V4 (Director of Dinning Services), surveyor observed three 50 pound bags of carrots on the floor, half full containers of: flour, salt, sugar, and navy beans without open and used by dates. V4 said, the carrots should not be placed directly on the floor and the flour, salt, sugar, and navy beans must be labeled with the open date and used by date. V4 said, he did not know what happened and that the staff are expected to follow the facility policy to label and date food when it is opened. On 01/14/25 at 09:25AM surveyor checked the temperature…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-12-22 · 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 interview and record review, the facility failed to implement a physician's order for an as soon as possible (STAT) X-ray after one resident (R1) sustained an unwitnessed fall and complained of pain in the right hip area; and the facility failed to document in the medical record after one resident (R1) sustained an unwitnessed fall. This failure affected one resident (R1) who was transferred to a local emergency room ten hours after the unwitnessed fall took place and was diagnosed with a right hip fracture. Findings include: R1 is a [AGE] year-old male originally admitted on [DATE] with medical diagnoses that include and are not limited to: dementia without behavioral disturbances, chronic obstructive pulmonary disease, and hypertension. According to the Minimum Data Set (MDS) R1 had a brief interview for mental status (BIMS) dated: 9-26-2024 with a score of 5/15, which indicate impaired cognition. On 12-21-2024 at 2:40 pm V10 (Certified Nurse Assistant) said, on 10-27-2024 I went to R1's room since…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-09-29 · 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

  Based on interview and record review, the facility failed to prevent an incident of resident to resident physical aggression. This affected two of three residents (R1, R2) reviewed for physical abuse. This failure resulted in R2 kicking R1 in the leg and R1 sustaining a 7 cm skin tear. Findings Include: Facility Reported Incident reviewed, and reads in part: On 9/2/24 at 2:20PM, R1 was in the common area when R1 began talking in a loud voice at a R3 who was trying to push a table over. R2 approached R1 while R1 was speaking to the R3 and kicked R1 in the left lower leg, resulting in a skin tear. R1 has a diagnosis of Dementia and Restlessness and Agitation. R1's most recent BIMs score conducted on 8/16/2024 was 03/15 indicating severe impairment. R1 has diagnosis of Dementia, R1 exhibits poor safety awareness and poor impulse control. R1 also has a care planned behavior of becoming verbally agitated, which has caused peers to become agitated. R2 has a diagnosis of Dementia and Generalized Anxiety Disorder. R2's most recent BIMs score conducted on 07/02/2024 was 03/15 indicating…

  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 · D2024-07-19 · tag F0755 — failed to provide safe pharmacy services — isolated
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  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 resident received her medications as ordered. This applies to 1 of 3 residents (R5) reviewed for medication administration in the sample of 11. The findings include: R5's EMR (Electronic Medical Record) shows that R5's admission Evaluation was created at 1:47 PM on 5/29/24. R5's Medication Administration Record for May 2024 shows that R5 was admitted to the facility on [DATE]. This same document shows that R5 was ordered to receive Allegra (Allergy) 24hr 1 tablet, Amlodipine (Antihypertensive) 2.5mg, Cefpodoxime Proxetil (Antibiotic) 200mg, Januvia (Antidiabetic) 25mg, Telmisartin (Antihypertensive) 80mg, Bisoprolol Fumarate (Antihypertensive) 10mg, and Preservision (Supplement) 1 tablet. None of these medications are signed out as given. A Pharmacy Manifest Document dated 5/30/24 shows that R5's medications were not delivered until 4:36 AM on 5/30/24. On 7/19/24 at 2:05 PM V23 (RN) stated, (V22) worked the PM shift on the day of admission. I…

  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.

  Pharmacy Service 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

$181,021 in federal fines across 6 penalties.

• $19,610 — penalty dated 2026-05-28
• $32,980 — penalty dated 2025-12-07
• $26,894 — penalty dated 2025-01-16
• $63,544 — penalty dated 2024-03-27
• $26,813 — penalty dated 2024-02-08
• $11,180 — penalty dated 2023-08-25

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 FRANCISCAN COMMUNITIES — 6 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 12 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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.

This home reported $744K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. 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, FY2024). 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