Above average — CMS composite of the measures below.
The next survey window likely opens around January 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 Villa Maria Health And Rehab Ctr during CMS and state inspections, most recent first.
Infection control failures were observed when the DON of Laundry Services transported clean linens through the facility uncovered, despite staff stating that clean linens should be covered during hallway transport. Surveyors also observed a CNA provide care to a resident on droplet precautions and then immediately assist the roommate without doffing PPE, changing gloves, or sanitizing hands between residents. The resident on precautions had a hoarse voice, occasional non-productive cough, and was identified as having a common cold.
A resident with multiple chronic conditions and ongoing pain did not receive consistent individualized pain assessment and monitoring. The MAR showed PRN morphine was often given without documented pain location or pain scale, and surveyors found no documentation of pain characteristics, cause, effective pain tool, or acceptable pain level. During observation, the resident reported severe butt pain, cried, and could not activate the call light, while staff offered medication but did not provide repositioning or other comfort measures before leaving the room.
A resident with severe cognitive impairment was left alone with a visitor after a CNA witnessed sexual conduct between them. The CNA left the room to report the incident, leaving the resident at risk for further abuse. The resident had not been assessed for capacity to consent prior to the incident, and staff did not immediately ensure the resident's protection as required by policy.
A resident with severe cognitive impairment was found with a lab draw needle left on her bed, posing a potential risk of injury. The ADON had performed a blood draw earlier but failed to dispose of the needle properly. The DON confirmed that the needle should have been disposed of immediately to ensure the resident's safety.
Infection Control Failures With Uncovered Linen Transport and PPE/Hygiene Lapses
Penalty
Summary
The facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. Surveyors observed the Director of Laundry Services transporting clean linens through the hallway uncovered on 02/24/26 at 7:00 AM and again at 12:58 PM while taking clean linens from a closed room near the nurse's station and moving them down the hall past the kitchen uncovered. The Director of Laundry Services stated that only dirty linens are covered, not clean linens. The Laundry Aide stated that all linens, clean or dirty, should be covered when transported in the hallways, and the DON stated the expectation was that clean or dirty linens are covered during transport. Surveyors also observed CNA C on 02/24/2026 at 7:45 AM sanitize hands, don gown, mask, and gloves, and deliver breakfast to R37, who had been placed on droplet precautions after developing a hoarse voice and occasional non-productive cough and being identified as having a common cold. After assisting R37 with the wheelchair transfer setup, CNA C went directly to roommate R16 and set up the breakfast tray, combed hair, and applied glasses without changing PPE, doffing gloves, or sanitizing hands between the two residents. CNA C stated they were not sure whether PPE and hand hygiene were needed before assisting the roommate and acknowledged they did not do that. The DON stated the expectation was that CNAs would doff PPE, remove gloves, sanitize hands, and don new PPE before caring for the roommate, with hand hygiene between resident contact and the environment regardless of precautions.
Inconsistent Pain Assessment and Monitoring for Resident Receiving PRN Opioids
Penalty
Summary
The facility did not ensure safe, appropriate pain management for a resident with rheumatoid arthritis, osteoarthritis, chronic kidney disease, peripheral vascular disease, abnormal posture, dysphagia, age-related cognitive decline, adult failure to thrive, and pain in an unspecified joint. The resident’s care plan identified altered comfort related to pain from impaired mobility and arthritis, with a goal of attaining comfort through medication or comfort measures and the resident stating relief of pain or resting quietly. Physician orders included PRN morphine for pain/discomfort related to comfort care status, a fentanyl patch every 72 hours, and PRN acetaminophen suppositories. Record review showed pain assessments were not consistently completed before PRN morphine administration. The MAR documented no pain assessment prior to any of the 14 morphine doses given in December 2025. In January 2026, pain location and pain scale were documented before morphine only 4 of 10 times, and in February 2026 pain scale, but not location, was documented only 1 of 6 times. Survey review also found no documentation of individualized pain assessments to monitor, assess, and evaluate chronic pain, including pain characteristics, underlying cause, an effective pain tool, or the resident’s acceptable level of pain. During observation, the resident was found in bed reporting butt pain rated 10/10 and crying, stating, “It hurts,” and asking for oil to be applied because it helped. The resident had a soft-touch call light paddle by the elbow but was unable to activate it after repeated attempts, even when trying with the elbow. CNA H stated the resident usually let staff know about pain by yelling out or using the call light, and RN G stated the resident usually used the call light with the elbow. When staff responded, they asked the resident to rate pain and offered pain medication, but neither RN G nor CNA H repositioned the resident or provided other comfort measures before leaving the room. The DON later stated the facility used the quarterly MDS pain assessment and staff knowledge of the resident rather than tracking or documenting pain assessments well, and said pain medication decisions were based on nursing judgment and prior doses.
Failure to Protect Resident from Sexual Abuse by Visitor
Penalty
Summary
The facility failed to protect a resident from abuse, specifically sexual abuse, by a visitor. A Certified Nursing Assistant (CNA) witnessed a resident and a visitor engaging in sexual conduct in the resident's bathroom. The CNA left the resident alone with the visitor for approximately 30 seconds to report the incident, leaving the resident at risk for further abuse during that time. This action did not ensure the immediate protection of the resident as required by facility policy. The resident involved had a history of traumatic brain injury, expressive aphasia, and hemiplegia following a stroke, with a Brief Interview for Mental Status (BIMS) score indicating severe cognitive impairment. The resident was able to communicate with one-word answers or gestures and had an activated Power of Attorney. There was no sexual intimacy assessment completed for the resident on admission or prior to the incident. The facility's policies required immediate protection and assessment of capacity to consent, but the resident was only evaluated for capacity after the incident, and it was determined that the resident was unable to consent. Staff interviews and record reviews confirmed that the CNA left the resident alone with the visitor after witnessing the sexual conduct, and that the visitor was not immediately removed from the resident's presence. The facility's failure to immediately protect the resident from further potential harm constituted a deficiency in safeguarding residents from abuse, as required by both facility policy and regulatory standards.
Removal Plan
- Educate all staff on abuse and ensuring residents are protected from further abuse.
- Conduct staff and resident interviews.
- Contact law enforcement and ensure Visitor G is removed from the facility.
- Request emergency guardianship.
- Provide immediate education to all staff on Abuse, Capacity to Consent, and Visitor Restriction.
- Place pictures of Visitor G in shift report books for staff identification.
- Interview residents to identify concerns.
- Interview staff to identify concerns.
- Review incident at ad hoc Quality Assurance and Performance Improvement (QAPI) meeting.
- Conduct monthly QAPI and review monitoring of R1, changes, and interventions.
- Update R1's care plan based on monthly QAPI reviews.
Improper Disposal of Needle Poses Risk to Resident
Penalty
Summary
The facility failed to identify and eliminate a known accident hazard in the environment of a resident with severe cognitive impairment. The resident, who had a BIMS score of 3 out of 15 indicating severe cognitive impairment and diagnoses including dementia and sleep disorder, was found with a lab draw needle left on her bed. This incident was observed by a surveyor on the morning of December 9, 2024. The presence of the needle posed a potential risk of injury or accident to the resident. Upon inquiry, the Certified Nursing Assistant (CNA) was unaware of any scheduled lab work for the resident, and the Registered Nurse (RN) confirmed that they had not drawn the resident's blood. It was later determined that the Assistant Director of Nursing (ADON) had performed the blood draw earlier that morning but had failed to dispose of the needle properly. The ADON acknowledged the oversight when questioned by the surveyor, despite typically being meticulous about such procedures. The Director of Nursing (DON) confirmed that the needle should have been disposed of immediately after the blood draw to ensure the resident's safety.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 10 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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Hurley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sky View Nursing Center | 0.3 mi | ★★★★★ | 5 | 0 |
| Westgate Nursing & Rehabilitation Community | 1.6 mi | ★★★★★ | 5 | 0 |
| Gogebic Medical Care Facility | 10.7 mi | ★★★★★ | 0 | 0 |
| Ashland Health Services | 34.6 mi | ★★★★★ | 0 | 0 |
| Court Manor Health Services | 35 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Villa Maria Health And Rehab Ctr.
100% money-back within 48 hours.
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.