Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Aria At Villa Pines during CMS and state inspections, most recent first.
Surveyors found multiple sanitation failures in the kitchen, including a stove hood with accumulated dust on filters, sprinklers, light fixtures, shelving, and a metal box directly over the food prep area, which staff acknowledged had not been properly cleaned by Maintenance. A dented can was observed in active dry storage, despite staff stating such cans should be removed and returned to the supplier. In addition, a stand mixer stored under plastic covering was found to have hardened food particles on its undercarriage, contrary to facility policy requiring small appliances to be cleaned and sanitized after each use.
The facility failed to maintain an effective infection prevention and control program by omitting 11 COVID-positive residents from the January infection control record, despite policies requiring complete outbreak tracking logs and accurate monthly infection rate analysis. Additionally, a CNA was observed performing pericare and indwelling catheter care for a resident, then, without removing gloves or performing hand hygiene, adjusting the resident’s bedding, repositioning the catheter drainage bag, and assisting with clean undergarments, contrary to facility policies on standard precautions, perineal care, and catheter care. The DON and CNA both acknowledged that pericare/catheter care is a dirty task and that gloves are contaminated afterward, requiring hand hygiene and glove changes before handling clean items.
The deficiency concerns the facility’s failure to consistently notify a physician of significant daily weight changes for a resident with pulmonary hypertension, acute respiratory failure with hypercapnia, and stage 3 CKD who was on a loop diuretic and ordered for daily weights with MD notification for changes over 3 lbs in a day or 5 lbs in a week. Medication and weight records showed multiple instances of weight gains and losses exceeding 3 lbs in a 24‑hour period without documented physician notification, even though staff used a secure messaging app to communicate changes and acknowledged that only some weight issues were reported. Review of the messaging history and records confirmed that on several days with qualifying weight fluctuations, no MD notification occurred, contrary to the physician’s order and the facility’s change‑of‑condition policy.
A resident with multiple chronic conditions, cognitive communication deficits, and impaired decision-making requested a suppository for constipation. During the procedure, the resident screamed for staff to stop, stating the staff member was elbowing them. Facility policy requires immediate reporting of all alleged abuse, neglect, exploitation, or mistreatment to the administrator and State Survey Agency, and the DON acknowledged such an event should be reported, especially when a nurse is involved. The NHA stated they were present, spoke with staff and the resident, but there was no documentation of interviews and no report was submitted to the State Agency, resulting in a failure to report a potential abuse allegation as required.
A resident with COPD, chronic heart failure, muscle wasting, weakness, cognitive communication deficit, and moderate decision-making impairment cried out "stop, stop you are elbowing me" while an RN and CNA were repositioning the resident and inserting a suppository for constipation. Facility policy requires that all abuse allegations be investigated, including interviews with the reporter, anyone with direct knowledge, the resident if possible, and other residents and staff who regularly receive care from or work with the accused. Although the RN reported the concern to the DON and the NHA spoke with the involved CNA and the resident, no interviews were conducted with other residents or staff, and there was no documentation of interviews or a complete investigation, resulting in a failure to follow the facility’s Abuse Prevention Program.
A resident with dementia, anxiety, depression, and severe cognitive impairment was assessed as at risk for elopement, with a plan for a WanderGuard device and a physician order to check its function and placement every shift. Facility policy required at-risk residents to have elopement precautions such as a WanderGuard, with regular testing and documentation. Although the resident was observed wearing a WanderGuard, review of the Treatment Administration Record showed a gap of several months with no WanderGuard check order or documentation. An RN and the DON both stated that WanderGuard checks should be documented in the TAR every shift but were unable to locate any such documentation for this resident, and the DON acknowledged entering the physician order with an incorrect future start date, resulting in the lack of ongoing monitoring records.
A resident with CHF, interstitial lung disease, and chronic respiratory failure was receiving O2 via nasal cannula with humidification at 3 LPM. Facility policy required routine changes of oxygen delivery devices, and the MD order specified weekly changes of oxygen tubing and related supplies with staff to initial and date them. During observation, the surveyor noted the tubing tag showed a change date several weeks earlier, and a CNA confirmed this date despite stating tubing is changed weekly. The DON later acknowledged that the tubing should be changed weekly and that the facility missed changing this resident’s oxygen tubing as ordered.
A resident receiving hospice services for chronic pain and post-stroke hemiplegia/hemiparesis had PRN morphine sulfate oral solution (20 mg/mL) with a documented expiration date that remained in the medication cart and was administered after it had expired. Facility policy required nurses to check expiration dates before administration and to remove and destroy all expired medications, but the expired morphine remained on the cart with multiple prefilled syringes and was given on several documented occasions. The expiration date was also recorded in the narcotic count binder, yet staff did not remove or discard the medication as required.
Surveyors found that the facility exceeded the acceptable medication error rate when a med tech crushed two different extended-release (ER) medications and administered them in applesauce to two residents, despite facility policy prohibiting crushing long-acting or enteric-coated drugs. One resident received Isosorbide Mononitrate ER for essential HTN in crushed form, and another received Metoprolol Succinate ER for ventricular rate control in A-fib in crushed form. The med tech later acknowledged knowing ER medications should not be crushed, and the DON confirmed that staff are expected not to crush ER medications.
A resident with chronic pain and other medical conditions reported concerns about a nurse administering unfamiliar medication and not following her preferences for medication delivery. The facility's investigation lacked documentation of staff interviews and did not provide the resident with written follow-up or obtain her signature on the grievance resolution, as required by policy. Leadership confirmed that Tylenol was offered instead of the prescribed hydrocodone-acetaminophen, despite no order for Tylenol, and no further staff or resident interviews were conducted.
Two residents reported receiving cold food, and a test tray confirmed that hot foods were served below required temperatures and cold foods above safe limits. The issue was attributed to delays in the tray line, partly due to a new staff member in training, resulting in unpalatable and improperly held food.
Unsanitary Kitchen Hood, Equipment, and Food Storage Practices
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for food preparation, storage, and distribution, with the potential to affect all 33 residents. During an observation of the kitchen, the surveyor and the Dietary Manager noted that the stove hood above the food preparation area had visible dust on the filter, sprinklers, light fixtures, a metal box, and a 5-foot shelf. The Dietary Manager acknowledged that the hood needed cleaning, that Maintenance was responsible for this task, and that there was potential for dust to dislodge and fall into food being prepared underneath. A subsequent observation with another staff member showed that the metal box on the hood remained covered with dust, and this staff member confirmed that the Maintenance worker was supposed to clean it but had missed that section, again acknowledging the potential for dust to fall into food. Additional unsanitary conditions were identified in food storage and equipment cleaning. In the dry storage area, the surveyor observed a dented can on the shelf in circulation, and the Dietary Manager stated that such cans should be removed and returned to the supplier for credit. The facility’s policy on food preparation appliances required that small appliances such as mixers be cleaned and sanitized after each use. However, when the surveyor asked the Dietary Manager to remove the plastic covering from the stand mixer that was reported to be clean, hardened food particles were observed on the undercarriage. The Dietary Manager acknowledged that the mixer had not been thoroughly cleaned before being stored, contrary to facility policy.
Failure to Maintain Accurate Infection Surveillance and Adhere to Standard Precautions During Catheter and Perineal Care
Penalty
Summary
The deficiency involves the facility’s failure to establish and maintain an effective infection prevention and control program as required by its own policies. During a COVID-19 outbreak, the facility’s January 2026 resident line list showed 11 residents with COVID-19, but the January 2026 monthly infection control record only documented 3 residents with lower respiratory infections and did not include the 11 COVID-positive residents. Facility policies on management of COVID-19, influenza, and other acute respiratory infection outbreaks, as well as infection surveillance, required the Infection Preventionist or designee to initiate tracking logs/line lists, complete all sections of the log, and complete the monthly rate and analysis for the month. The DON/IP confirmed that all infections, including COVID-19, should be included on the monthly infection control record and acknowledged that omitting the 11 residents meant the January infection control rates would not be accurate. The deficiency also includes a breach in infection control practices during direct resident care. A CNA was observed performing perineal care and indwelling catheter care for a resident after donning a gown and gloves, cleansing, rinsing, and drying the perineal area and catheter tubing. Without removing gloves or performing hand hygiene, the CNA then adjusted the resident’s bedding, repositioned the catheter drainage bag, and assisted the resident with application of clean undergarments. This practice conflicted with the facility’s policies on standard and transmission-based precautions, perineal care, and indwelling catheter care, which require glove removal and hand hygiene when moving from dirty to clean tasks. In interviews, both the CNA and the DON acknowledged that pericare/catheter care is considered a dirty task, that gloves are contaminated afterward, and that hand hygiene and glove changes are required before touching clean bedding and clothing.
Failure to Notify Physician of Significant Daily Weight Changes
Penalty
Summary
The deficiency involves the facility’s failure to immediately notify and consult with a resident’s physician when there was a change in condition, specifically significant daily weight fluctuations, as required by physician orders and facility policy. The facility’s “Change of Condition Process” policy states that when a change from baseline is observed, such as weight loss or gain, the licensed nurse must evaluate the resident and notify the physician. One resident, admitted with pulmonary hypertension, acute respiratory failure with hypercapnia, and stage 3 chronic kidney disease, had an order for daily weights with instructions to call the MD if there was a 3‑pound change overnight or a 5‑pound change in a week. Medication records showed multiple instances of weight changes greater than three pounds in a single day, including losses and gains of 3.5 to 7.9 pounds, without corresponding physician notification. Surveyor interviews and record reviews confirmed that the facility used a secure messaging app (Hucu) to notify physicians of changes, and that some general notifications about weight were sent on certain dates. However, there was no documentation that the physician was notified on specific dates when the resident’s weight changed by more than three pounds in one day, despite the standing order to do so. Staff, including an RN, the DON, and the ADON, acknowledged that notifications were sent only on some occasions and that factors such as timing of weights and resident refusals might affect whether a physician was contacted. Review of the Hucu message history and other documentation showed gaps in physician notification on multiple dates with qualifying weight changes, demonstrating that the physician order and facility policy for change‑in‑condition notification were not consistently followed.
Failure to Report Alleged Abuse Incident to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to immediately report an alleged incident of potential abuse to the administrator and the State Survey Agency as required by its Abuse Prevention Program and state/federal regulations. The facility’s policy states that it prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment, and that it will prevent such occurrences in part by filing accurate and timely investigative reports. One resident, admitted with multiple chronic conditions including COPD, chronic combined systolic and diastolic heart failure, muscle wasting and atrophy, weakness, a cognitive communication deficit, and a need for assistance with personal care, was documented as rarely/never understood and unable to complete the BIMS, with moderately impaired decision-making. This resident requested a suppository for constipation, and during the procedure, while being repositioned on the left side and having the suppository inserted, the resident screamed loudly, “stop, stop you are elbowing me.” The Director of Nursing stated that in a situation where a resident says, “Stop, stop you’re elbowing me,” staff should stop, apologize, get another person to assist, and report to the nurse, and further acknowledged that if a nurse is involved, the incident should be reported. Review of the resident’s progress note documenting the event showed no evidence that the incident was treated as a reportable allegation. The DON did not recall the situation but stated she felt she would have followed up and updated the Nursing Home Administrator to start an investigation. The Nursing Home Administrator reported being present at the time of the incident and speaking with both staff and the resident, but confirmed there was no documentation of interviews and that the incident was not reported to the State Agency. As a result, the facility did not submit a required report to the State Agency for this potential allegation of abuse.
Failure to Thoroughly Investigate Allegation of Abuse During Personal Care
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough investigation into an allegation of abuse involving one resident. The facility’s Abuse Prevention Program requires that all incidents or allegations involving abuse, neglect, exploitation, mistreatment, or misappropriation of resident property result in an investigation, including interviews with the person who reported the incident, anyone likely to have direct knowledge, the resident if interviewable, and other residents and employees with whom the accused regularly works. Despite this policy, when an allegation arose that a resident was being elbowed during care, the facility did not follow all required investigative steps, including interviewing other residents and staff who might have relevant information. The resident involved had multiple medical conditions, including COPD, chronic combined systolic and diastolic heart failure, muscle wasting and atrophy, weakness, a cognitive communication deficit, and a need for assistance with personal care. A progress note documented that the resident was rarely or never understood, had memory problems, and was moderately impaired in decision-making, though could identify the current season and recognize being in a nursing home or hospital. On the day of the incident, a nurse and a CNA repositioned the resident on the left side to insert a suppository for constipation, and during the procedure the resident screamed loudly, “stop, stop you are elbowing me.” Staff interviews confirmed awareness that when a resident says “stop,” staff are expected to stop and ensure safety, and that such an event involving a nurse should be reported and investigated. The RN involved stated that the resident called out frequently and that the family had a camera in the room and might think abuse was occurring, and reported being certain the DON was informed because it could sound abusive. The NHA recalled being told that the resident said staff were elbowing them, spoke with the CNA and the resident, and was told there was no elbowing and nothing was wrong. However, the NHA acknowledged that no interviews were conducted with other residents under the care of the involved staff, no documentation of interviews with the RN, CNA, or resident existed, and there was no complete investigation of the incident as required by the facility’s Abuse Prevention Program.
Failure to Ensure WanderGuard Monitoring and Documentation for Elopement-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate elopement prevention interventions and documentation for a resident assessed as at risk for elopement. The facility’s Elopement Prevention and Missing Resident Policy required that residents at risk for elopement be provided with safety precautions such as a WanderGuard device, with all devices tested and documented as part of the preventive maintenance program. The resident, admitted with dementia, anxiety disorder, and depression, had a Minimum Data Set showing a BIMS score of 3, indicating severe cognitive impairment. An elopement risk assessment concluded the resident was at risk for elopement, with a plan for a WanderGuard to be in place. A physician order directed staff to check the WanderGuard’s function and placement every shift, but the start date was incorrectly entered as a future year. Record review of the Treatment Administration Record (TAR) showed that from admission through a specified date, the WanderGuard checks were ordered and documented, but from that date until several months later there was no order in the TAR for checking the WanderGuard. During observation, the resident was seen wearing a WanderGuard on the left wrist. In interviews, an RN described the process for WanderGuard use, including activation, awareness of expiration dates, and documenting checks each shift in the TAR, and confirmed that documentation should be in the TAR. However, the RN was unable to locate any WanderGuard documentation for this resident in the TAR. The DON similarly stated that WanderGuard documentation should be in the TAR every shift but could not find any such documentation for the resident and acknowledged that the physician order had been entered with the wrong start year. This combination of an incorrect order start date and lack of TAR documentation demonstrated that the facility did not ensure the resident’s WanderGuard was checked and documented each shift as required by policy and physician order.
Failure to Change Oxygen Tubing per Physician Order and Policy
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory care consistent with professional standards and physician orders for a resident receiving oxygen therapy. The facility’s policy on oxygen tubing changes states that oxygen delivery devices, including tubing and cannulas, are to be changed routinely, with tubing changed every 14 days when humidification is in use. The resident had physician orders specifying that oxygen tubing and supplies, including cannula, tubing, humidifier bottles, and concentrator filter washing, were to be changed weekly on Fridays, with staff to initial and date the supplies. The resident was admitted with diagnoses including acute on chronic diastolic congestive heart failure, interstitial pulmonary disease, and chronic respiratory failure, and was receiving oxygen via nasal cannula from a concentrator with humidification at 3 LPM. During observation, the surveyor noted that the resident’s oxygen tubing had a green tag labeled with a change date of 3/31, indicating it had not been changed as ordered by the time of the surveyor’s visit on 4/20. When interviewed, a CNA stated that oxygen tubing is changed weekly and, upon checking the label on the resident’s tubing, confirmed the date of 3/31. In a subsequent interview, the DON stated that oxygen tubing needs to be changed weekly and acknowledged that the facility had missed changing the tubing for this resident. This sequence of observations and interviews shows that the resident’s oxygen tubing was not changed according to the weekly physician order or the facility’s stated practice.
Expired Morphine Sulfate Administered and Stored on Medication Cart
Penalty
Summary
The deficiency involves the facility’s failure to ensure pharmaceutical services were provided in accordance with its own medication storage policy, resulting in the administration and continued availability of expired morphine sulfate oral solution for a resident. The facility’s policy required that outdated medications be immediately removed from inventory, that nurses check expiration dates before administration, and that no expired medications be administered. Despite this, a morphine sulfate oral solution (20 mg/mL) prescribed as needed for dyspnea and moderate to severe pain for a resident with hemiplegia, hemiparesis following cerebral infarction, and chronic pain remained in the medication cart after its printed expiration date of 12/28/25. During a medication cart observation, an RN and the surveyor identified that five prefilled syringes of this medication with the expired date were still present in the cart, and the RN expressed surprise that they remained there. Record review showed that the expired morphine sulfate oral solution was administered to the resident on multiple occasions after the expiration date. The MAR documented administrations on specific dates in February and April, confirming that nursing staff had given the expired medication despite the policy requirement to verify expiration dates before each administration and to discard expired medications. The expiration date was also documented in the narcotic count binder, indicating that the information was available but not acted upon. During interview, the DON stated that medication carts should be checked frequently for expired medications and acknowledged the expectation that the morphine sulfate should have been discarded and not used past its expiration date.
Crushing of Extended-Release Medications Resulting in Elevated Med Error Rate
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 2 errors out of 25 opportunities, resulting in an 8% error rate. Facility policy titled "Medication Administration-General Guidelines" dated December 2019 states that long-acting or enteric-coated dosage forms should not be crushed and that an alternative should be sought. Despite this policy, on 4/21/26 at 7:31 AM, a medication technician (MT H) was observed administering two tablets of Isosorbide Mononitrate ER 30 mg, ordered as a total of 60 mg once daily for essential hypertension, crushed in applesauce to Resident 21. The physician’s order and the MAR both specified Isosorbide Mononitrate ER 24-hour extended-release tablets, but they were not administered intact as ordered. In a second example, Resident 15 had a physician’s order and corresponding MAR entry for Metoprolol Succinate ER 24-hour 25 mg, with instructions to give 0.5 tablet by mouth once daily for ventricular rate control in atrial fibrillation. On 4/21/26 at 7:50 AM, MT H was observed crushing the Metoprolol Succinate ER tablet and administering it in applesauce, contrary to the extended-release instructions. During an interview on 4/22/26 at 7:23 AM, MT H acknowledged knowing that extended-release medications should not be crushed and admitted to crushing both the Isosorbide ER and Metoprolol ER during the observed med pass. In a separate interview at 10:00 AM, the DON confirmed that extended-release medications should not be crushed and stated an expectation that staff would not crush such medications.
Failure to Promptly Investigate and Resolve Resident Grievance Regarding Medication Administration
Penalty
Summary
A resident with a history of left pubic fracture, type 2 diabetes mellitus, major depressive disorder, and chronic pain, who was cognitively intact, reported a grievance regarding medication administration. The resident expressed concerns that a nurse attempted to administer medications in a manner she was uncomfortable with and that one of the medications appeared unfamiliar. Upon questioning, the nurse took the medications back to the med cart and returned with the correct ones. The resident reported this incident to the Social Services Director (SSD), who initiated a grievance process. The facility's grievance policy requires that grievances be routed to the appropriate department head, investigated thoroughly, and that the resident be provided with a verbal follow-up including details of the investigation and its resolution. However, the investigation into the resident's grievance lacked documentation of interviews with staff or other residents, aside from the SSD's interview with the complainant. There was also no written communication of the grievance resolution provided to the resident, and the facility did not obtain a signature from the resident or representative indicating agreement or disagreement with the outcome. Interviews with facility leadership revealed that the nurse attempted to administer Tylenol instead of the resident's scheduled hydrocodone-acetaminophen due to the unavailability of the prescribed medication, despite the resident not having an order for Tylenol. The facility did not conduct interviews with other staff or residents regarding the incident, and there was no comprehensive documentation of the investigation or follow-up with the resident as required by policy.
Failure to Serve Food at Safe and Palatable Temperatures
Penalty
Summary
Surveyors identified that the facility failed to ensure food and drink were served at palatable and safe temperatures for two of seven sampled residents. An anonymous complaint was received regarding food temperatures, and both residents interviewed expressed concerns about receiving cold food. During observation, a test tray was requested after all residents on the 200 wing had been served lunch. The test tray revealed that the Chicken Tetrazzini was served at 128.7°F, the cauliflower/broccoli at 130.5°F, and the milk at 50.5°F, all of which were outside the facility's policy requirements for safe food temperatures. Additionally, the cauliflower/broccoli was noted to be mushy and not palatable. Interviews with the residents confirmed ongoing issues with food temperature, with one resident stating that her eggs were often cold and another stating that the food was not always hot enough. The Dietary Manager acknowledged that the tray line was running late due to a new staff member in training, which may have contributed to the delay and subsequent drop in food temperatures. The Dietary Manager also confirmed that the temperatures recorded by the surveyor were below the required standards and that the food was not palatable due to temperature and texture issues.
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Illustrative
What surveyors actually found near you
We read the 19 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
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Illustrative
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Nursing homes near Friendship
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fair View Nursing And Rehabilitation Center | 18.1 mi | ★★★★★ | 10 | 0 |
| Crest View Nursing Home | 18.5 mi | ★★★★★ | 3 | 0 |
| Wisconsin Dells Health Services | 24.7 mi | ★★★★★ | 6 | 0 |
| Edgewater Haven Nursing Home | 26.6 mi | ★★★★★ | 10 | 0 |
| Elroy Health Services | 27.1 mi | ★★★★★ | 15 | 1 |
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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.