Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Addolorata Villa during CMS and state inspections, most recent first.
A resident with Alzheimer’s disease, repeated falls, and unsafe transfer behaviors was not effectively supervised during incontinent care. A CNA turned away to get supplies, and the resident rolled over, struck his face on a nightstand, and sustained multiple facial lacerations requiring sutures. Staff knew the resident was confused, impatient during care, and prone to trying to stand or move without assistance, yet the resident was still left vulnerable during hands-on care.
A resident with dementia, OA, cardiomyopathy, HF, Afib, and a history of osteomyelitis with toe amputation, who required substantial/max assist for chair/bed-to-chair transfers, was observed ambulating while pushing a w/c. An activity aide, who was not trained to perform transfers, took the w/c, positioned it behind the resident, and verbally instructed him to sit without using a gait belt or standing in front to control the descent. As the resident attempted to sit, he fell forward, striking his head and face on the floor, resulting in a facial laceration, nasal fx, and a type 2 odontoid fx. PT later described that safe transfer from standing to w/c requires staff to stand in front of the resident with a gait belt, and the DON stated activity aides should call for assistance, consistent with the facility’s fall prevention policy and the resident’s care plan requirements for high-level transfer assistance.
The facility failed to follow its diet spreadsheets and menu requirements for all residents on one unit and for all residents receiving a puree diet. A cook prepared puree chicken for multiple residents using only a small number of chicken thighs, even though one full piece of chicken was designated per serving on the regular diet. A dietary server was observed using smaller scoops for rice and pork peppered steak than the 4 oz and 6 oz portions specified on the diet spreadsheet. The dining service director stated that diet spreadsheets guide portion sizes to ensure adequate nutrition, and facility policy requires that current diet extensions be available and followed at each meal, but these standards were not met for the affected residents.
A resident with quadriplegia, MS, dementia, and a Stage 2 sacral pressure ulcer had documented MASD and recurrent sacral breakdown managed with various wound treatments and placement on a low air loss mattress. The care plan called for a flat sheet and a draw sheet for turning, but surveyors observed multiple layers on the mattress, including folded sheets and a cloth incontinence pad, contrary to manufacturer guidance allowing only a single loosely tucked sheet. Staff interviews revealed inconsistent practices and conflicting descriptions of how many sheets and pads were used, while the wound physician indicated that multiple layers on the low air loss mattress could be contributing to the resident’s slow-healing pressure ulcer.
A resident with quadriplegia, right elbow contracture, and multiple comorbidities reported not being gotten out of bed and experiencing back and leg pain, and was repeatedly observed lying in bed with a contracted arm. The care plan and restorative program required passive ROM exercises five times per week, but documentation showed the resident received less than half of the scheduled sessions over an extended period. The restorative aide stated she usually provided passive ROM 2–3 times weekly but was the only restorative aide and was often pulled to work as a CNA, resulting in missed restorative therapy despite facility policy requiring maintenance and restorative services to maintain or improve function.
A resident with severe cognitive impairment and mobility deficits was not provided with required care plan interventions, including the use of a gait belt and walker during ambulation. Staff allowed the resident to ambulate without these safety measures, resulting in a fall and hip fracture. Facility policy required the use of a gait belt for assisted ambulation, but this was not followed at the time of the incident.
A resident with dementia and multiple comorbidities made a statement alleging abuse after an incident with a CNA, but staff did not report or investigate the allegation as required by facility policy. The nurse documented the statement as a behavioral issue, and neither the administrator nor the DON were notified, resulting in a failure to follow abuse reporting protocols.
A resident with a history of heart failure and a recent ankle fracture developed a facility-acquired unstageable pressure ulcer due to the facility's failure to assess and prevent pressure ulcers. Despite being at moderate risk, the resident's ulcer was not reported or documented in a timely manner, and staff failed to encourage mobility or reposition the resident regularly. The lack of communication and documentation among staff contributed to the deficiency.
A cognitively impaired resident with a high fall risk fell from a wheelchair in the common area, resulting in a hip fracture, due to inadequate supervision. Despite being aware of the resident's tendency to stand up from the wheelchair, staff failed to provide continuous monitoring, leading to the incident. The facility's fall prevention policy was not effectively implemented, contributing to the deficiency.
The facility failed to provide bed hold notifications to residents and their families when residents were discharged to a hospital. This affected several residents with various medical conditions, as the facility did not adhere to its policy requiring notification about bed hold duration and payment. The Administrator and DON acknowledged the oversight, revealing a lack of staff training and awareness of the policy.
The facility exhibited deficiencies in food handling and hygiene practices, including improper food storage, inadequate dishwasher temperatures, and poor hand hygiene. Carrots were stored on the floor, and containers lacked labeling. The dishwasher failed to reach the required final rinse temperature, and a dietary server did not perform hand hygiene between tasks. These issues were acknowledged by the Director of Dining Services, the Director of Nursing, and the Infection Preventionist.
A resident with dementia and other medical conditions experienced an unwitnessed fall and complained of hip pain. The facility failed to implement a STAT X-ray order and did not document the fall in the medical record. The resident was transferred to the hospital ten hours later, where a hip fracture was diagnosed. The facility lacked proper documentation and communication protocols, contributing to the deficiency.
A resident with dementia and poor impulse control kicked another resident, causing a 7 cm skin tear, after becoming frustrated with the loud speaking of the first resident. The incident occurred in the common area, and staff did not anticipate the aggressive behavior despite the facility's policy against abuse.
A resident did not receive prescribed medications upon admission due to a delay in pharmacy delivery. The facility's staff communicated with the resident's family about the delay, but the medications were not administered as per the prescriber's orders. The resident's sarcastic demeanor added to the communication challenges faced by the staff.
Failure to Supervise High-Risk Resident During ADL Care
Penalty
Summary
The facility failed to effectively address one resident’s behaviors, implement effective fall interventions, and provide appropriate hands-on ADL care for a resident who was high risk for falls. The resident had diagnoses including Alzheimer’s disease, dysphagia, cognitive communication deficit, muscle weakness, and repeated falls, and the care plan identified him as at risk for falls due to Alzheimer’s disease, lack of safety awareness, sleep pattern disturbance, insomnia, and restless behavior at night. The care plan also directed staff to anticipate and meet his needs, position him near staff for closer monitoring and redirection, and keep him properly positioned in the middle of the mattress while in bed. Staff interviews showed multiple employees knew the resident was confused, impatient during care, and would try to stand or move around without assistance, and that he needed increased supervision during care. Despite this knowledge, the resident fell out of bed while receiving incontinent care when a CNA turned away to retrieve supplies from a wheelchair positioned at the foot of the bed. The resident rolled over, was hanging on the bed, and struck his face on the nightstand, causing active bleeding. A hospital record documented four facial lacerations requiring six sutures total, including injuries near the right eye, right nose, right chin, and inside the right chin. The facility incident report also stated the resident had a history of attempting to self-transfer and intermittent agitation during care. The DON later stated staff were educated to keep supplies within reach and maintain contact with the resident during care, and the facility began two-person assistance for incontinent care due to the resident’s unpredictable behaviors.
Unsafe Transfer by Activity Aide Leads to Resident Fall and Serious Injuries
Penalty
Summary
The deficiency involves the facility’s failure to implement safe transfer and supervision practices during a wheelchair-to-standing and return-to-sitting transfer, resulting in a resident fall with serious injuries. An activity aide (V6) reported witnessing the resident ambulating while pushing his wheelchair, then taking the wheelchair from the resident, turning it around, placing it behind him, and verbally instructing him to sit. V6 stated she positioned herself behind the wheelchair, did not use a gait belt, and did not stand in front of the resident to control the descent. As the resident attempted to sit, he fell forward, striking his head and face on the floor. The resident sustained a facial laceration, nasal fracture, and a type 2 odontoid (neck) fracture and was hospitalized, later returning to the facility where the family chose hospice care. The resident had multiple medical diagnoses including Alzheimer’s disease, unspecified dementia with agitation, osteoarthritis, cardiomyopathy, heart failure, atrial fibrillation, and a history of left foot osteomyelitis with toe amputation. The care plan and MDS indicated the resident had ADL self-care and mobility performance deficits related to dementia and other conditions, and required substantial/max assistance for chair/bed-to-chair transfers, with interventions specifying transfer assistance at a moderate to maximum level with two staff. Physical therapy documentation showed the resident ambulated with minimal assist and wheelchair follow using a front-wheeled walker, and PT later stated that for safe transfer from standing to sitting in a wheelchair, staff should stand in front of the resident, apply a gait belt, and assist back to the wheelchair to prevent frontal falls. The DON confirmed that activity aides were not trained to perform transfers and should call for assistance, and the facility’s fall prevention policy required assessment of fall risk and implementation of appropriate interventions, including determining and addressing factors contributing to falls.
Failure to Follow Menus and Portion Requirements for 2-East and Puree Diet Residents
Penalty
Summary
The facility failed to follow its posted menus and diet spreadsheets and did not provide adequate food portions to residents on the 2-East unit and to all residents receiving a puree diet. Surveyors observed that, for a lunch meal, the cook prepared puree chicken for 14 residents by blending only six chicken thighs with broth, even though the diet spreadsheet indicated that residents on a regular diet receive one full piece of chicken per serving. During the same survey, a dietary server on 2-East was seen using a 3-ounce spoon to serve rice and a 4-ounce scoop to serve pork peppered steak, despite the diet spreadsheet specifying 4 ounces of rice and 6 ounces (3/4 cup) of pork peppered steak per resident. The dining service director later confirmed that diet spreadsheets are the tool used to determine appropriate portion sizes and that serving correct portions is important to ensure residents receive proper and adequate nutrition. The facility’s written policy on meal/tray assembly requires that current diet extensions be available and followed at each meal period to preserve the nutrient content of food, but these specified portions and procedures were not followed for the 18 residents residing on the 2-East unit. This deficiency applied to all 18 residents on the 2-East unit and all residents receiving a puree diet at the time of the survey, as identified by the facility census and diet spreadsheets reviewed by surveyors.
Failure to Follow Low Air Loss Mattress Guidelines and Implement Pressure Ulcer Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to implement care plan interventions for the treatment and management of a resident’s pressure ulcer and failure to follow manufacturer guidelines for use of a low air loss mattress. The resident is an older female with quadriplegia, multiple sclerosis, Alzheimer’s disease, and contractures of both hands, with a BIMS score indicating moderate cognitive impairment. Wound documentation shows that she initially developed moisture-associated skin damage (MASD) on the right buttock in October, which resolved in November after treatment with calcium alginate with silver and bordered gauze. Later in November, MASD was identified on the lower sacrum, described as a recently healed wound that had reopened, and treated similarly. By late December, this sacral wound was reclassified as a Stage 2 pressure ulcer, noted as slow to heal due to multiple factors including immobility, quadriplegia, multiple sclerosis, and dementia, and the resident was placed on a low air loss mattress with documented wound care treatments including collagen sheet and island gauze. Surveyor observations on multiple days showed that the low air loss mattress was not used in accordance with the manufacturer’s guidelines or the resident’s care plan. On one observation, the mattress was covered with a flat sheet and an additional white sheet folded in two; on another, the mattress had a flat sheet, a white sheet folded into four, and a cloth incontinence pad on top. The manufacturer’s instructions indicated that patients may lie directly on the mattress or it may be covered with a sheet tucked loosely, without reference to multiple layers. The resident’s care plan intervention for the low air loss mattress specified use of a flat sheet on the mattress and a draw sheet for turning and repositioning, with no mention of folding the draw sheet into multiple layers or adding extra sheets and pads. Interviews with staff revealed inconsistent practices and understandings regarding the appropriate number and configuration of sheets on the low air loss mattress. A CNA reported that for low air loss mattresses they usually use one sheet and a draw sheet folded into four, while the wound care nurse stated they use a flat sheet and a draw sheet folded into two, asserting that these allow alternating pressure and air circulation. In contrast, an RN stated that only a flat sheet and a single, unfolded draw sheet should be used because multiple sheets would cause the air mattress to lose its alternating pressure purpose. The DON and ADON gave differing descriptions, including use of a draw sheet and cloth incontinence pad or a flat sheet with an unfolded draw sheet if care planned. The wound physician noted that the resident’s Stage 2 sacral pressure ulcer had reopened and was slow to heal, and stated that multiple sheets used on the low air loss mattress could possibly be contributing to the slow healing, emphasizing that mattress manufacturers standardly intend for only one sheet to be used to maintain pressure relief and heat dissipation.
Failure to Provide Planned Restorative ROM Services
Penalty
Summary
Surveyors identified that the facility failed to provide restorative services as care planned to maintain range of motion (ROM) for one resident. The resident is an adult male with multiple diagnoses including dysphagia, right elbow contracture, urinary retention, type II DM, quadriplegia, Bell's palsy, and heart failure, who remains in the facility. During interviews, the resident reported that staff do not get him out of bed and that he experiences pain in his back and legs. On multiple observations over several days, the resident was seen lying in bed with a contracted right arm. The Master Restorative Program List indicated the resident was to receive passive ROM exercises through restorative therapy five times per week. However, the Restorative Monthly Report showed that between late November and mid-January, the resident received only 10 restorative therapy sessions out of 26 scheduled sessions. The restorative aide reported that she typically works with the resident 2–3 times per week providing passive ROM for contractures, but also stated she is the only restorative aide in the building and is sometimes pulled to work as a CNA when there are call-offs, which prevents her from providing restorative therapy on those days. This pattern of missed restorative sessions occurred despite a facility policy stating that maintenance and restorative services are to be provided to maintain or improve residents' abilities to the highest practicable level.
Failure to Implement Care Plan Interventions During Ambulation
Penalty
Summary
A deficiency occurred when staff failed to implement care plan interventions for a resident with severe cognitive impairment, Parkinson's Disease, and dementia. The resident's care plan required ambulation with contact guard, use of a gait belt, and a wheeled walker for safety. On the day of the incident, the resident was observed ambulating without the walker and without a gait belt. Although staff intervened and provided supervision, the resident continued to ambulate without the required gait belt and at times refused to use the walker. Despite being positioned next to the resident, staff were unable to prevent a fall when the resident lost balance and fell after standing up and walking away from the nurse station. The resident sustained a left hip fracture as a result of the fall and required hospital admission. Interviews with staff confirmed that the gait belt, a required intervention per the care plan and facility policy, was not used at the time of the fall. The facility's policy mandates the use of gait belts for all transfers and assisted ambulation according to assessed needs and care plans. The failure to follow these interventions directly contributed to the resident's fall and subsequent injury.
Failure to Report and Investigate Resident Abuse Allegation
Penalty
Summary
The facility failed to follow its abuse prevention policy by not reporting and investigating an allegation of abuse made by a resident with a history of making such claims. The resident, an elderly female with diagnoses including dementia with behavioral disturbance, chronic venous hypertension with ulcers, stage 3 chronic kidney disease, hypothyroidism, and recurrent severe major depressive disorder, was admitted to the facility and had documented behavioral issues. On one occasion, after an incident in the bathroom, the resident stated that she had been abused and expressed a desire to contact a family member. This statement was documented in the behavior progress note, but no abuse investigation report was completed for the allegation. Interviews with facility staff revealed that the administrator and DON were not made aware of the resident's statement, and the nurse involved considered the comment to be a manifestation of the resident's psychiatric behavior rather than a reportable abuse allegation. The facility's policy requires all allegations of abuse, including resident reports, to be immediately reported to the administrator and state authorities. However, in this case, the staff did not follow the required protocol, and the incident was not reported or investigated as an abuse allegation.
Failure to Prevent and Manage Pressure Ulcer
Penalty
Summary
The facility failed to assess and prevent the development of a pressure ulcer for a resident, resulting in the resident developing a facility-acquired unstageable pressure ulcer. The resident, a female with a history of heart failure and a recent ankle fracture, was admitted with intact skin and a Braden score indicating moderate risk for pressure sores. Despite this, the resident developed a pressure ulcer on the sacrum, which was first noted on December 4th, 2024, and later became unstageable due to necrosis. The deficiency was exacerbated by a lack of communication and documentation among the staff. The resident's pressure ulcer was not reported or documented in a timely manner, as evidenced by the absence of skin alterations noted in the shower sheets and the surprise expressed by staff members upon discovering the ulcer. The facility's policy required immediate initiation of treatment for newly identified pressure ulcers, but this was not effectively implemented, leading to a delay in appropriate care. Interviews with staff revealed that the resident was often in bed due to her ankle injury, which increased her risk for pressure ulcers. The staff failed to consistently encourage mobility or reposition the resident every two hours, as recommended. Additionally, there was a lack of consistent monitoring and documentation of the resident's skin condition, contributing to the development and progression of the pressure ulcer.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to adequately monitor and supervise a cognitively impaired resident, identified as R120, which resulted in a fall from a wheelchair in the common area and an acute subcapital femoral neck fracture. R120, a female resident with severe cognitive impairment and a high fall risk, was initially admitted with diagnoses including dementia and repeated falls. Despite being identified as a high fall risk, the facility did not implement sufficient interventions to prevent her from standing up and falling from her wheelchair. On the day of the incident, R120 was left unsupervised in the common area while staff were occupied with other duties. The nurse on duty, V24, was attending to a phone call and medication cart when R120 attempted to stand and subsequently fell. The incident report and interviews with staff revealed that R120 frequently attempted to stand from her wheelchair, and staff were aware of her behavior but failed to provide continuous supervision. The care plan for R120 included interventions for fall risk and poor safety awareness, but these were not effectively implemented or updated to address her behavior of standing up in the wheelchair. The facility's policy on fall prevention and management emphasizes the need for adequate supervision based on individual resident needs. However, the supervision provided to R120 was insufficient, as evidenced by the lack of staff presence in the common area at the time of her fall. Interviews with staff, including the Director of Nursing, confirmed that the facility's protocol for monitoring residents in the common area was not followed, leading to the deficiency in preventing R120's fall.
Failure to Provide Bed Hold Notifications
Penalty
Summary
The facility failed to provide bed hold notifications to residents and/or their family members when residents were discharged to a local hospital. This deficiency was identified during interviews and record reviews, affecting five residents out of a sample of 38. The residents involved had various medical conditions, including pneumonia, sepsis, dysphagia, acute kidney failure, Pick's disease, hemiplegia, hemiparesis, Alzheimer's disease, and fractures. Despite being transferred to a hospital, there was no documentation of bed hold notifications for these residents, indicating a lapse in the facility's adherence to its own policy. The facility's Administrator and Director of Nursing acknowledged the oversight, stating that the bed hold policy had not been followed throughout the facility. The Director of Nursing admitted unfamiliarity with the policy and mentioned that communication with families was limited to informing them about the discharge and follow-up with the hospital. The facility's policy, effective since 2019, requires informing residents and their representatives about the duration of the bed hold and the payment policy. However, this procedure was not implemented, and the staff was not adequately trained or informed about the policy, leading to the deficiency.
Deficiencies in Food Handling and Hygiene Practices
Penalty
Summary
The facility failed to adhere to proper food storage and handling practices, as well as maintaining appropriate dishwasher temperatures, which could lead to food-borne illnesses. During a kitchen tour, it was observed that three 50-pound bags of carrots were placed directly on the floor, and containers of flour, salt, sugar, and navy beans were not labeled with open and used by dates. The Director of Dining Services acknowledged these issues, stating that staff are expected to follow facility policy regarding food labeling and storage. Additionally, the facility's dishwasher was not maintaining the required final rinse temperature. The surveyor noted that the final rinse temperature was below the expected range of 180F to 190F, with readings of 174F and 175F. The Director of Dining Services indicated that a local company was contacted to address the issue, as one of the dishwasher's elements was not functioning, and parts were ordered for repair. Furthermore, improper hand hygiene practices were observed in the dining room. A dietary server was seen handling food with the same gloves used to open a refrigerator, without performing hand hygiene in between tasks. The Director of Nursing and the Infection Preventionist confirmed that staff are expected to wash their hands or use hand sanitizer before and after care, after removing gloves, and when changing tasks. The facility's policies emphasize the importance of hand hygiene and proper glove use to prevent contamination and infection.
Failure to Implement STAT X-ray Order and Document Fall
Penalty
Summary
The facility failed to implement a physician's order for a STAT X-ray after a resident sustained an unwitnessed fall and complained of pain in the right hip area. The resident, who had a history of dementia, chronic obstructive pulmonary disease, and hypertension, was found on the floor by a Certified Nurse Assistant after his roommate pulled the call light. Despite the resident's complaint of hip pain, the nurse assessed the resident and moved him to a wheelchair without conducting a full assessment or calling 911. The physician was contacted and ordered a STAT X-ray, but the X-ray was not performed as the portable X-ray company did not arrive, and the nurse failed to notify the physician of this delay. The resident was transferred to a local emergency room ten hours after the fall, where he was diagnosed with a right hip fracture. The Director of Nursing confirmed that there was no documentation in the resident's medical record regarding the fall, which was against the facility's expectations. The resident's care plan indicated a high risk for falls, and the resident was unable to use the call light due to cognitive impairment. The facility's staff did not follow the standard protocol for neurological checks after an unwitnessed fall, and there was a lack of communication with the physician regarding the unfulfilled X-ray order. The report highlights several failures in the facility's response to the resident's fall, including inadequate documentation, failure to perform necessary medical assessments, and lack of communication with the physician. The facility did not have policies in place for neurological checks or carrying out doctors' orders, contributing to the deficiency. The resident's condition worsened, leading to a diagnosis of acute and chronic respiratory failure with hypoxia, and a fracture was confirmed through an X-ray at the hospital.
Failure to Prevent Resident-to-Resident Aggression
Penalty
Summary
The facility failed to prevent an incident of resident-to-resident physical aggression, which resulted in one resident kicking another, causing a 7 cm skin tear. The incident occurred in the common area when a resident with dementia and severe impairment, who is known for speaking loudly due to being hard of hearing, was addressing another resident who was shaking a table. A second resident, also with dementia and poor impulse control, became frustrated with the loud speaking and kicked the first resident in the leg. The incident was witnessed by staff members who were present in the common area and nearby nurse's station. The nurse on duty was alerted by a shout and found the injured resident bleeding from the leg. The resident was immediately treated for the skin tear, and the two involved residents were separated to prevent further aggression. The staff did not anticipate the aggressive behavior from the second resident, who had a history of verbal aggression but not physical aggression. The facility's investigation revealed that both residents involved have dementia and exhibit behaviors such as poor impulse control and difficulty interpreting their environment. The facility's policy affirms the right of residents to be free from abuse, including physical abuse by other residents. Despite this policy, the staff did not foresee the physical aggression, which led to the deficiency in protecting residents from abuse.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that a resident received her medications as ordered upon admission. The resident, identified as R5, was admitted to the facility, and her Medication Administration Record indicated that she was prescribed several medications, including Allegra, Amlodipine, Cefpodoxime Proxetil, Januvia, Telmisartin, Bisoprolol Fumarate, and Preservision. However, none of these medications were signed out as administered. The Pharmacy Manifest Document revealed that the medications were not delivered until the following day, indicating a delay in medication administration. Interviews with facility staff highlighted communication issues and procedural lapses. An RN, V23, explained the process of obtaining and verifying medication orders, while another RN, V22, mentioned that the family had their own stock of medications and was informed about the delay in pharmacy delivery. V22 expressed difficulty in communicating with the resident due to her sarcastic demeanor, which complicated the situation further. The facility's policy on medication administration mandates that medications be administered according to the prescriber's written orders, which was not adhered to in this instance.
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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 Wheeling
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Warren Barr Buffalo Grove | 1 mi | ★★★★★ | 1 | 0 |
| Greek American Rehab Care Ctr | 1.5 mi | ★★★★★ | 18 | 0 |
| Bella Terra Wheeling | 1.5 mi | ★★★★★ | 0 | 0 |
| Elevate Care Riverwoods | 2 mi | ★★★★★ | 1 | 0 |
| Radford Green | 2.7 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.