Cycle 1
Health 2025-01-16 · Fire 2025-01-16
7 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Wheeling, IL
Addolorata Villa
5-star overall rating with 3-star inspections with $128,018 in total fines with 7 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
555 Mchenry Road, Wheeling, IL
(847) 537-2900
Overall
5 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
86
Certified beds
Average residents
65
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Franciscan Communities
Operator or chain grouping
Approved since
1992-06-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
6 facilities
Chain averages 4 overall / 4 health / 4 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.48
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.32
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
3.28
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
5.08
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.80
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
4.57
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
1.01
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
1.48
CMS adjusted RN staffing hours
Adjusted total hours
5.11
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
32%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
21%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,158
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
59.37
Composite VBP score used to determine payment impact.
Payment multiplier
1.0146
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.98
Baseline 18.00% · Performance 19.59% · Measure score 3.98 · Achievement 3.98 · Improvement 0
Healthcare-associated infections
3.76
Baseline 7.16% · Performance 6.71% · Measure score 3.76 · Achievement 3.76 · Improvement 1.56
Total nurse turnover
10
Baseline 55.10% · Performance 22.50% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
6
Baseline 4.64 hours · Performance 4.79 hours · Measure score 6 · Achievement 6 · Improvement 0.74
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.46% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 155 · Observed rate 8.39% · Lower 95% interval 7.23% |
| Discharge to community | 47.26% |
50.57%
3.3 pts worse
|
No Different than the National Rate · Eligible stays 147 · Observed rate 41.5% · Lower 95% interval 39.41% |
| Medicare spending per beneficiary | 1.02 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 95.24% |
95.27%
About the same
|
Numerator 80 · Denominator 84 |
| Falls with major injury | 1.19% |
0.77%
0.4 pts worse
|
Numerator 1 · Denominator 84 |
| Discharge self-care score | 70.97% |
53.69%
17.3 pts better
|
Numerator 44 · Denominator 62 |
| Discharge mobility score | 53.23% |
50.94%
2.3 pts better
|
Numerator 33 · Denominator 62 |
| Pressure ulcers or injuries, new or worsened | 2.38% |
2.29%
0.1 pts worse
|
Numerator 2 · Denominator 84 · Adjusted rate 1.87% |
| Healthcare-associated infections requiring hospitalization | 6.71% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 94 · Observed rate 4.26% · Lower 95% interval 3.69% |
| Staff COVID-19 vaccination coverage | 0.63% |
8.2%
7.6 pts worse
|
Numerator 1 · Denominator 160 |
| Staff flu vaccination coverage | 75.76% |
42%
33.8 pts better
|
Numerator 125 · Denominator 165 |
| Discharge function score | 69.35% |
56.45%
12.9 pts better
|
Numerator 43 · Denominator 62 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 37 · Denominator 37 |
| Resident COVID-19 vaccinations up to date | 43.75% |
25.2%
18.6 pts better
|
Numerator 21 · Denominator 48 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
2.0
0.6 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.4 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
2.3
1.5 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.7 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
89.6%
10.4 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
91.6%
8.4 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.9% |
3.3%
2.4 pts better
|
3.3%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 15.1% |
50.3%
35.2 pts better
|
11.4%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 17.9% · Q3 16.7% · Q4 11.5% · 4Q avg 15.1% |
| Percentage of long-stay residents who lose too much weight | 9.1% |
6.5%
2.6 pts worse
|
5.4%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 15.2% · Q3 6.7% · Q4 7.7% · 4Q avg 9.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.5% |
18.5%
1 pts worse
|
19.6%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 17.0% · Q3 21.7% · Q4 19.2% · 4Q avg 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.5% |
22.8%
8.3 pts better
|
16.7%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.9% · Q2 15.8% · Q3 13.6% · Q4 14.0% · 4Q avg 14.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 15.1% |
17.2%
2.1 pts better
|
16.3%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 15.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.4% |
15.0%
8.6 pts better
|
14.9%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.2% · Q2 2.4% · Q3 10.3% · Q4 2.3% · 4Q avg 6.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.1%
1.1 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
1.7%
1.2 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.4% |
21.3%
4.9 pts better
|
19.8%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.0% · Q2 22.1% · Q3 13.6% · Q4 12.7% · 4Q avg 16.4% |
| Percentage of long-stay residents with pressure ulcers | 2.5% |
5.2%
2.7 pts better
|
5.1%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 3.6% · Q3 1.9% · Q4 1.4% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.7% |
68.8%
23.9 pts better
|
81.7%
11 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.2% · Q2 93.1% · Q3 93.8% · Q4 87.7% · 4Q avg 92.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.3% |
14.0%
4.7 pts better
|
12.0%
2.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.3% · Observed 8.7% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.3%
2.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.5% |
63.0%
33.5 pts better
|
79.7%
16.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.1% |
26.2%
2.1 pts better
|
23.9%
0.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.1% · Observed 21.7% · Expected 21.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-27 · Fire 2024-03-27
9 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-02-16 · Fire 2023-02-16
11 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
8 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-24
E · Potential for more than minimal harm
2025-01-16
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2025-02-06
E · Potential for more than minimal harm
2025-01-16
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-02-24
E · Potential for more than minimal harm
2025-01-16
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-01-31
E · Potential for more than minimal harm
2025-01-16
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-02-06
E · Potential for more than minimal harm
2025-01-16
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2025-01-24
E · Potential for more than minimal harm
2025-01-16
K754 · Miscellaneous Deficiencies
Fire Safety
Provide properly sized and located linen or trash receptacles.
Corrected 2025-02-06
E · Potential for more than minimal harm
2025-01-16
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2025-02-06
F · Potential for more than minimal harm
2024-03-27
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-04-25
F · Potential for more than minimal harm
2024-03-27
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-03-28
F · Potential for more than minimal harm
2024-03-27
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-04-23
E · Potential for more than minimal harm
2024-03-27
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-03-28
E · Potential for more than minimal harm
2024-03-27
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-04-11
F · Potential for more than minimal harm
2023-02-16
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-03-30
F · Potential for more than minimal harm
2023-02-16
K926 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2023-03-27
E · Potential for more than minimal harm
2023-02-16
K133 · Construction Deficiencies
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2023-03-16
E · Potential for more than minimal harm
2023-02-16
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-03-17
E · Potential for more than minimal harm
2023-02-16
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-03-17
E · Potential for more than minimal harm
2023-02-16
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2023-03-20
E · Potential for more than minimal harm
2023-02-16
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-03-20
C · Minimal harm
2023-02-16
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-03-17
Inspection history
Recent health citations
G · Actual harm
2025-12-07
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-12-23
D · Potential for more than minimal harm
2025-08-14
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-08-29
D · Potential for more than minimal harm
2025-08-14
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-08-29
G · Actual harm
2025-01-16
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-02-04
G · Actual harm
2025-01-16
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-02-04
F · Potential for more than minimal harm
2025-01-16
F625 · Resident Rights Deficiencies
Health
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.
Corrected 2025-02-04
F · Potential for more than minimal harm
2025-01-16
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-02-04
D · Potential for more than minimal harm
2024-12-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-10
D · Potential for more than minimal harm
2024-09-29
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-10-14
D · Potential for more than minimal harm
2024-07-19
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-08-02
G · Actual harm
2024-03-27
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-04-17
F · Potential for more than minimal harm
2024-03-27
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-04-17
E · Potential for more than minimal harm
2024-03-27
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-04-17
D · Potential for more than minimal harm
2024-03-27
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-04-17
D · Potential for more than minimal harm
2024-03-27
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-04-17
D · Potential for more than minimal harm
2024-03-27
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-04-17
D · Potential for more than minimal harm
2024-02-24
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-03-04
G · Actual harm
2024-02-08
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-03-04
G · Actual harm
2023-08-25
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-09-18
D · Potential for more than minimal harm
2023-07-13
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-08-03
G · Actual harm
2023-02-16
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-03-08
G · Actual harm
2023-02-16
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-03-08
F · Potential for more than minimal harm
2023-02-16
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-03-08
F · Potential for more than minimal harm
2023-02-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-02
E · Potential for more than minimal harm
2023-02-16
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2023-03-08
D · Potential for more than minimal harm
2023-02-16
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-03-08
D · Potential for more than minimal harm
2023-02-16
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-03-08
Penalties and ownership
What sits behind the stars
$26,481
2025-01-16
Fine
Fine · fine $26,481
Fine
$63,544
2024-03-27
Fine
Fine · fine $63,544
Fine
$26,813
2024-02-08
Fine
Fine · fine $26,813
Fine
$11,180
2023-08-25
Fine
Fine · fine $11,180
Fine
Ownership
Amiano, Judy
Corporate Director · Individual
Amiano, Judy
Corporate Officer · Individual
Cohn, Dawn
Operational/Managerial Control · Individual
Cohn, Dawn
W-2 Managing Employee · Individual
Duren, Andrew
Corporate Director · Individual
Duren, Andrew
Corporate Officer · Individual
Noonan, Daniel
Corporate Director · Individual
Noonan, Daniel
Corporate Officer · Individual
Radke, Francis
Corporate Director · Individual
Radke, Francis
Corporate Officer · Individual
Stark, James
Corporate Director · Individual
Stark, James
Corporate Officer · Individual
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#3
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