Addolorata Villa

In the surveyor’s words

From the most serious findings on record at Addolorata Villa, in the surveyor’s own words.

• Actual harm, isolatedF689May 28, 2026

  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. […]

• Actual harm, isolatedF689Mar 27, 2026

  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. […]

• Actual harm, isolatedF656Dec 7, 2025

  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. […]

• Actual harm, isolatedF686Jan 16, 2025

  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. […]

• Actual harm, isolatedF689Jan 16, 2025

  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. […]