Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
ADDOLORATA VILLA
WHEELING, IL · 86 certified beds · Last Life Safety survey January 16, 2025
CMS Certification Number 145724 · first certified June 1992
Ownership
Operated by FRANCISCAN COMMUNITIES · Non profit - Church related
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within IL
21 citations — more than 66% of the 666 certified nursing homes in IL. Compared within IL rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 8 citations; the earlier surveys in the window averaged 6.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (December 2025 to February 2026), and past the point by which nine in ten IL facilities have been surveyed. This facility’s last Life Safety survey was January 2025. Facilities in IL are typically surveyed 11–13 months after the last one (median 12), measured over 759 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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2 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
1 of the 21 citations on file is Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
4 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 21 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
How that compares
Compared with the median facility in IL, and nationally. Surveyors differ markedly between states, so the IL figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 21 |
| Median facility in IL | 15 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| February 16, 2023 | 8 |
| March 27, 2024 | 5 |
| January 16, 2025 | 8 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | 2 | 2024-03-27 |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | 2 | 2025-01-16 |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | 2 | 2025-01-16 |
| K-0293 | Have properly located and lighted "Exit" signs. | 1 | 2023-02-16 |
| E-0037 | Establish staff and initial training requirements. | 1 | 2024-03-27 |
| K-0351 | Install an approved automatic sprinkler system. | 1 | 2025-01-16 |
| K-0754 | Provide properly sized and located linen or trash receptacles. | 1 | 2025-01-16 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 1 | 2025-01-16 |
What the citations cover
- Smoke Deficiencies 10
- Miscellaneous Deficiencies 4
- Egress Deficiencies 2
- Gas, Vacuum, and Electrical Systems Deficiencies 2
- Other 3
| Category | Citations |
|---|---|
| Smoke Deficiencies | 10 |
| Miscellaneous Deficiencies | 4 |
| Egress Deficiencies | 2 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 2 |
| Construction Deficiencies | 1 |
| Emergency Preparedness Deficiencies | 1 |
| Services Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
January 16, 2025 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0311 | Have an enclosure around a vertical opening shaft. | Deficient, Provider has date of correction (February 6, 2025) |
| K-0351 | Install an approved automatic sprinkler system. | Waiver has been granted (February 24, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Waiver has been granted (February 24, 2025) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (January 31, 2025) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (February 6, 2025) |
| K-0531 | Have elevators that firefighters can control in the event of a fire. | Deficient, Provider has date of correction (January 24, 2025) |
| K-0754 | Provide properly sized and located linen or trash receptacles. | Deficient, Provider has date of correction (February 6, 2025) |
| K-0929 | Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Deficient, Provider has date of correction (February 6, 2025) |
March 27, 2024 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (April 25, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (March 28, 2024) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (March 28, 2024) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (April 11, 2024) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (April 23, 2024) |
February 16, 2023 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0133 | Install a two-hour-resistant firewall separation. | Deficient, Provider has date of correction (March 16, 2023) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (March 17, 2023) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (March 17, 2023) |
| K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Deficient, Provider has date of correction (March 20, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (March 20, 2023) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (March 17, 2023) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (March 30, 2023) |
| K-0926 | Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Deficient, Provider has date of correction (March 27, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.