Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
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 Marina Health And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that the facility failed to follow required abuse reporting procedures for two residents. One resident with multiple serious medical conditions and total dependence for care was found with a large unexplained rib bruise, but the final misconduct incident report was not submitted to the State Agency within the required 5 business days. Another cognitively intact resident with Lewy Body dementia and other diagnoses reported that an RN attempted sexual contact, yet this allegation was not reported to the State Agency within 2 hours and no 5‑day misconduct report was submitted. Facility leadership acknowledged that both incidents should have been reported promptly in accordance with policy and regulatory timeframes.
A resident with multiple neurologic and cognitive diagnoses, but assessed as cognitively intact, reported that an RN offered sex. Review of the grievance file, investigation, and the resident’s EHR showed the facility did not notify the resident’s physician of the allegation, did not remove the accused RN from the building or schedule during the investigation, and did not provide follow-up abuse education to staff, despite facility policy requiring physician notification, immediate removal of accused staff, and ongoing training on abuse, neglect, and exploitation.
Food was not prepared and served according to professional standards for all residents. A dietary staff member was observed serving food with only one glove, touching counters, utensils, clean bowls, dishes, and equipment, wiping surfaces with a dish cloth, handling muffins and eggs, and returning to food service without hand hygiene or changing gloves after contamination. The staff member also coughed into an ungloved hand and touched a resident before going back to food prep and service. The DM stated staff should wear gloves on both hands and perform hand hygiene whenever touching anything other than food or dishes.
Staff failed to follow infection control practices during multiple observed care activities. An CNA did not perform hand hygiene while passing water and collecting used cups for several residents, an LPN did not maintain a clean field during wound care for a resident with CVA-related hemiplegia, DM, and weakness, and another LPN contaminated a new Lactulose bottle during medication administration by puncturing the foil seal with a thumbnail without repeating hand hygiene.
Failure to provide required transfer, bedhold, and Ombudsman notifications for three residents. Two residents received a Notice of Transfer when discharged home, but the Ombudsman was not notified, and one resident transferred to the hospital for a change in condition declined a bedhold but did not receive a Notice of Transfer. The NHA and SSD could not provide supporting documentation during interview.
The facility failed to follow professional standards for food service safety by not consistently taking and recording food temperatures. A staff member served food without checking temperatures, and the Dietary Manager confirmed that temperatures for anytime menu items were generally not taken. Additionally, beverage temperatures were not monitored. A review of records showed multiple instances of missing temperature documentation, potentially affecting all residents.
The facility did not have a flow diagram in its Water Management Plan to identify areas where Legionella could grow, as required. Maintenance staff and the NHA confirmed the absence of such a diagram, which could affect all 70 residents.
The facility failed to maintain confidentiality of resident medical records during medication administration and treatment procedures. An RN and an LPN left medication and treatment carts unattended with open electronic health records facing the hallway, allowing potential unauthorized access to sensitive information. Both staff members acknowledged the oversight, which violated the facility's HIPAA compliance policies.
The facility did not perform a required Wisconsin background check for a CNA who had direct contact with residents, as mandated by their policy. The CNA, who commuted from a nearby state, only had a background check from Minnesota. The HRD admitted to missing this requirement, and the NHA confirmed the expectation for proper checks to ensure resident safety.
A resident with multiple health issues did not receive adequate ADL care, including oral hygiene and washing, as observed by a surveyor. The resident confirmed the lack of a bed bath and oral care, and visible signs of neglect were noted. The DON acknowledged the expectation for daily partial bed baths and oral care, which were not met.
A facility failed to ensure proper treatment for a resident with a G-tube by not verifying tube placement before administering nutrition. An LPN did not check the G-tube placement due to the absence of a physician order, contrary to the facility's expectations and current standards of practice. The resident had diagnoses including dysphasia and quadriplegic cerebral palsy.
The facility failed to properly label and timely destroy controlled medications. Two residents' Lorazepam bottles lacked open date labels, contrary to policy, risking the use of expired drugs. Additionally, a resident's medication was not destroyed within the required 72-hour period after their passing, indicating a lapse in procedure adherence.
A facility failed to secure a medication cart, leaving it unlocked and unattended in a hallway during a medication pass. An RN prepared medications for a resident and left the cart facing a common area, allowing potential unauthorized access. The RN was away from the cart for seven minutes, contrary to the facility's policy requiring carts to be locked unless the nurse is present. The DON confirmed the expectation for carts to be locked when out of sight.
The facility failed to report two incidents of potential misconduct to the State's OCQ. One incident involved a narcotic diversion by an LPN, and the other was a resident-to-resident altercation resulting in injury. Despite investigations and internal actions, the facility did not notify the Department of Health Services or the police, as required by policy.
Failure to Timely Report Alleged Abuse and Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to timely report and complete required investigations for alleged abuse and injuries of unknown origin for two residents. For one resident (R1), who had respiratory failure, heart failure, bone cancer, and pleural effusion and was dependent on staff for eating, bed mobility, transfers, and toileting, staff discovered a large dark purple bruise on the left ribs extending from the armpit into the ribcage. This injury of unknown origin was considered a potential abuse situation that required reporting to the State Agency within two hours and submission of a final misconduct incident report with investigation findings within five business days. The self-report showed the final report was not submitted until several months later, well beyond the 5‑day requirement. The facility’s own policy required immediate reporting of any suspicion of abuse, neglect, exploitation, misappropriation, or suspicious bruising to the Administrator or designee to ensure all alleged violations, including injuries of unknown source, were reported. The facility also failed to report an allegation of sexual abuse involving another resident (R2), who had pneumonia, stroke, Lewy Body dementia, hallucinations, amnesia, and cognitive communication deficit but was cognitively intact per MDS and largely independent or needing only supervision for mobility and toileting. R2 accused an RN of trying to have sex with them, and this allegation was documented in the facility’s grievance records. However, surveyor review found no evidence that this allegation was reported to the State Agency within two hours or at all, and no misconduct incident report with investigation findings was submitted within five business days. During interviews, the social worker stated they believed reporting was unnecessary because the investigation was completed quickly, the resident had Lewy Body dementia, and the police did not substantiate the allegation. The Nursing Home Administrator confirmed that both incidents should have been reported within two hours with final reports submitted within five days and acknowledged that one report was extremely late and the other was never reported.
Failure to Thoroughly Investigate and Manage Allegation of Staff Sexual Misconduct
Penalty
Summary
The facility failed to thoroughly investigate an allegation of sexual misconduct, maintain documentation of a complete investigation, and prevent further potential abuse, neglect, exploitation, or mistreatment during the investigation for one resident. The resident had diagnoses including pneumonia, stroke, Lewy Body Dementia, hallucinations, amnesia, and cognitive communication deficit, and was assessed as cognitively intact with a BIMS score of 14/15, being independent with eating and bed mobility and requiring supervision for transfers and toileting. The facility’s abuse-prevention policy required the DON or designee to contact the resident’s physician when an allegation arose and to immediately remove any accused staff member from the facility and schedule pending the outcome of the investigation, as well as to provide ongoing staff training on abuse, neglect, exploitation, and related topics. Surveyors reviewed the facility’s grievance records and the investigation of an incident in which the resident accused an RN of offering sex. Review of the investigation and the resident’s electronic health record showed no evidence that the resident’s physician was notified of the allegation, no evidence that the accused RN was suspended or removed from the facility during the investigation, and no evidence of ongoing abuse-related education provided to staff following the incident. During interview, the DON confirmed that the physician had not been updated, that the RN remained punched in and in the building during the investigation, and that there was no documentation to prove the RN had no resident contact during that time. The DON also confirmed that staff were not re-educated regarding abuse/misconduct policies and procedures after the allegation.
Food Handling and Hand Hygiene Lapses During Meal Service
Penalty
Summary
Food was not prepared, distributed, and served in accordance with professional food service standards for 64 of 64 residents. During observation on 09/16/2025, Dietary [NAME] (DC) H was seen distributing food with a glove on the right hand only while the left hand remained ungloved. DC H touched utensils, clean bowls, kitchen counter surfaces, and other kitchen equipment during food distribution, then returned to serving food without removing the contaminated glove, performing hand hygiene, or putting on new gloves. DC H also wiped surrounding kitchen surfaces with a dish cloth while wearing the same glove, used both hands while wiping, touched clean dishes, and grabbed muffins with an ungloved hand to place them on plates. The observation further showed DC H coughing into an ungloved hand and then continuing to serve food without hand hygiene or new gloves. DC H also left the food distribution area, handled a pan of potatoes and opened an oven door, cracked eggs into a frying pan, and later removed the glove to go into the dining area and touch a resident on the shoulders before returning to the kitchen without hand hygiene or new gloves. On 09/17/2025, the Dietary Manager (DM) I stated staff should always perform hand hygiene and wear gloves on both hands when prepping and serving foods, and that gloves should be changed and hand hygiene performed if any surface other than the food or dishes is touched.
Infection Prevention and Control Failures During Water Pass, Wound Care, and Medication Administration
Penalty
Summary
The facility did not maintain an infection prevention and control program designed to provide a safe and sanitary environment to prevent the transmission of communicable disease and infection. Surveyors observed staff failing to perform hand hygiene during water pass activities for 7 residents, including after touching used water cups and before handling clean cups or moving from one resident room to the next. CNA G delivered fresh water cups and removed used cups in multiple resident rooms without sanitizing hands between residents, and later stated she usually performs hand hygiene but forgot after working 5 days in a row. RN C stated the expectation was hand hygiene after touching used cups, before touching clean cups, and after entering one resident room before going to the next. During wound care for a resident with diagnoses including hemiplegia and hemiparesis following cerebral infarction, type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene, unspecified fall, and generalized muscle weakness, staff did not maintain a clean environment. The resident’s wound care orders included daily care to the right knee and three-times-weekly care to the left second toe. Surveyors observed an LPN apply ointment with a tongue blade that was not kept in a clean environment and not wrapped, place the hand sanitizer bottle and wound cleanser bottle directly on the floor, and then continue wound care while touching those bottles with clean gloves. The infection preventionist stated the floor was an unclean surface and that a clean environment should be maintained during wound care. During medication administration for another resident, an LPN opened a new Lactulose bottle with a foil seal and attempted to remove the seal with fingers. When unsuccessful, the LPN used her thumbnail to puncture the foil seal without repeating hand hygiene. The LPN’s thumbnail extended about one-half inch beyond the nailbed and entered partway into the bottle, touching the remaining foil seal and rim before the medication was poured into a cup and administered. The facility’s infection preventionist stated that if a foil seal could not be removed by hand, bandage scissors wiped with alcohol and allowed to air dry should be used, followed by hand hygiene before removing any remaining foil while avoiding contact with the bottle rim.
Failure to Provide Required Transfer, Bedhold, and Ombudsman Notifications
Penalty
Summary
The facility failed to provide required Notice of Bedhold, Notice of Transfer, and/or Ombudsman notification for 3 of 4 residents reviewed. Record review and interview showed that the facility used a one-page blank Notice of Transfer or Discharge form for residents or resident representatives upon transfer or discharge, but did not provide supporting documentation that the Ombudsman was notified for R76 and R11 after each resident was discharged home. R76 was admitted on 05/15/25 and later discharged home, and R11 was admitted on 08/04/25 and later discharged home; both received a Notice of Transfer, but the Ombudsman was not notified of the discharge. For R4, who was admitted on 08/20/25 and transferred to the hospital for a change in condition, the record showed the resident declined a bedhold, but did not receive a Notice of Transfer. During interview, the NHA and SSD were unable to provide supportive documentation or information for the required notices and stated that transfer/discharge information was being sent to the Ombudsman at that time.
Failure to Adhere to Food Temperature Protocols
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by not consistently taking and recording food temperatures, which is a critical component of ensuring food safety. During an observation, a surveyor noted that a staff member, identified as [NAME] L, served hamburgers and macaroni and cheese to residents without checking their temperatures. This oversight was confirmed by the Dietary Manager, who admitted that temperatures for items on the anytime menu, such as hamburgers, were generally not taken, despite the facility's policy requiring it. Additionally, the facility did not take temperatures of beverages like juice, which were simply cooled before serving. The surveyor's review of the Food Temperature Record for July 2024 revealed multiple instances where temperatures were not recorded for various meals, including breakfast, lunch, and supper on specific dates. This lack of documentation indicates a systemic issue in maintaining food safety standards, potentially affecting all 70 residents. The Nursing Home Administrator acknowledged the importance of checking food temperatures to ensure safety, highlighting a gap between policy and practice within the facility.
Inadequate Water Management Plan for Legionella Prevention
Penalty
Summary
The facility failed to adequately describe its building water systems using a flow diagram to identify areas where Legionella and other opportunistic waterborne pathogens could grow and spread. This deficiency was identified during a surveyor's review of the facility's Water Management Plan (WMP), which lacked records of maintenance, inspections, or flushing of areas of concern that required such actions. The facility's policy on water management indicated a commitment to preventing, detecting, and controlling water-borne contaminants, including Legionella, but did not include a flow diagram or a plan identifying high-risk areas for Legionella growth. During interviews, the Maintenance Staff (MS) was unable to provide a diagram showing quality control measures for stagnation or hot spots throughout the facility. The Maintenance Director confirmed the absence of such a diagram. The Nursing Home Administrator (NHA) also acknowledged the lack of a diagram and was unaware of the requirement to have one in place. This oversight has the potential to affect all 70 residents in the facility, as it does not adequately address the risk of Legionella growth and spread.
Failure to Maintain Confidentiality of Resident Medical Records
Penalty
Summary
The facility failed to maintain the confidentiality of resident medical records for four residents during medication administration and treatment procedures. The surveyor observed that the medication cart, which contained open electronic health records, was left unattended and facing the hallway, allowing unauthorized individuals to potentially view sensitive information. This occurred during the administration of medications to residents by a registered nurse (RN) and during an enteral feeding procedure performed by a licensed practical nurse (LPN). The RN was observed preparing medications for three residents and leaving the medication cart with the computer screen open, displaying the residents' medical records. Similarly, the LPN left the treatment cart with a resident's medical information open while performing a procedure in the resident's room. Both the RN and LPN acknowledged the failure to minimize or exit the electronic health records when leaving the carts, which was against the facility's policy and training requirements for maintaining HIPAA compliance.
Failure to Conduct Required Background Check
Penalty
Summary
The facility failed to adhere to its own policies and procedures designed to prevent abuse, neglect, and exploitation of residents by not conducting a required Wisconsin background check for a staff member. The policy, dated 10/15/17, mandates that all potential employees undergo a criminal conviction history check through the Wisconsin State Police Department and other applicable sources before employment and every four years thereafter. However, during a record review on 07/23/24, it was discovered that one of the eight employees investigated, a Certified Nursing Assistant (CNA) identified as N, did not have a Wisconsin Department of Justice (DOJ) or Integrated Background Information System (IBIS) check. The only background information available for CNA N was from the state of Minnesota. The Human Resources Director (HRD) P was interviewed and admitted to not completing the necessary Wisconsin DOJ and IBIS checks for CNA N, as the staff member commuted from a nearby state and did not reside in Wisconsin. HRD P acknowledged that similar checks had been performed for other employees in comparable situations but was uncertain if it was required for CNA N due to their home location. This oversight was confirmed during an interview with the Nursing Home Administrator (NHA) A, who stated that they expected all proper background checks, including the Wisconsin DOJ and IBIS letter, to be completed to ensure resident safety.
Failure to Provide Adequate ADL Care for a Resident
Penalty
Summary
The facility failed to ensure that activities of daily living (ADL) such as grooming, personal hygiene, and oral hygiene were provided for a resident, identified as R425. The resident was admitted with multiple diagnoses, including a left femur fracture, diabetes, pressure ulcers, chronic leukemia, and severe kidney disease with an ileostomy. The care plan for R425 required substantial assistance for bathing, morning and bedtime care, repositioning, and oral care. However, during an observation, it was noted that the CNAs did not provide oral care or wash the resident before dressing him. The surveyor interviewed the resident, who confirmed that a bed bath was not completed that morning and could not recall when his dentures were last brushed. The surveyor observed crusty light brown matter in the resident's mustache and on his chin, as well as moderate eye drainage. The Director of Nursing stated that the expectation for morning care includes a partial bed bath, oral care, and shaving, which were not provided to the resident, leading to the deficiency.
Failure to Verify G-Tube Placement Before Feeding
Penalty
Summary
The facility failed to ensure that a resident with a Gastrostomy (G) tube received treatment based on current standards of practice. Specifically, the staff did not verify the proper placement of the G-tube before administering nutrition and treatment to the resident. The facility's policy on administering medications through an enteral tube lacked a revision date and did not align with the recommended practices for verifying tube placement. The American Association of Critical Care Nurses advises checking tube location at regular intervals to prevent dislocation during use, which was not adhered to in this case. The deficiency was observed when an LPN did not check the placement of the G-tube before flushing it with water and starting the enteral feeding. The LPN indicated that there was no physician order for checking placement, and therefore, it was not performed. The Director of Nursing confirmed that the expectation was to auscultate and check placement, even without a physician order. The facility's policy did not provide guidance consistent with current standards of practice, contributing to the oversight in care for the resident, who had diagnoses including dysphasia and quadriplegic cerebral palsy.
Improper Medication Labeling and Destruction
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, as evidenced by the improper labeling and destruction of controlled medications. During a survey, it was observed that the medication room contained bottles of Lorazepam without open date labels, which is against the facility's policy. Specifically, two residents' medications were involved: one bottle for a resident was received from the pharmacy but lacked an open date, and another bottle for a different resident also lacked an open date. This oversight in labeling could lead to the use of expired medications, as staff would rely on the pharmacy receipt date instead of the actual open date. Additionally, the facility did not ensure the timely destruction of controlled medications after a resident passed away. The Lorazepam bottle for a resident who had passed away remained in the medication room refrigerator beyond the 72-hour window for destruction, as per the facility's policy. The Director of Nursing (DON) and a Registered Nurse (RN) eventually destroyed the medication, but this action was delayed, indicating a lapse in following the established procedures for medication disposal. This deficiency highlights the facility's failure to adhere to its own policies regarding the handling and destruction of controlled substances.
Medication Cart Security Breach
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored and labeled according to accepted professional principles, and did not restrict access to medication carts to authorized personnel only. This deficiency was observed during a medication administration by a Registered Nurse (RN) identified as RN C. During the medication pass, RN C prepared medications for a resident, referred to as R70, and left the medication cart unlocked and unattended in the hallway. The cart was positioned facing the common area, allowing potential unauthorized access while RN C was inside R70's room administering medications. The surveyor noted that RN C was away from the medication cart for approximately seven minutes, during which time the cart remained unlocked and unsupervised. Upon questioning, RN C acknowledged the expectation to keep the medication cart locked when not directly beside it. The Director of Nursing (DON) confirmed that the facility's policy required medication carts to be locked unless the nurse was present. The incident highlighted a lapse in adherence to the facility's medication security policy, as RN C did not lock the cart when it was out of sight and down the hall.
Failure to Report Misconduct and Abuse Incidents
Penalty
Summary
The facility failed to report two incidents of potential misconduct to the State's Office of Caregiver Quality (OCQ) via the State's Misconduct Incident Reporting (MIR) system in a timely manner. The first incident involved a narcotic diversion by an LPN who took 26 Lorazepam tablets from a resident's medication blister pack. Despite conducting an investigation and notifying law enforcement and the State Board of Nursing, the facility did not report the incident to the Department of Health Services, as the Nursing Home Administrator believed it was not necessary under state regulations. The second incident involved a resident-to-resident altercation where one resident punched another, resulting in a bruise that developed and spread over time. Although the facility provided emotional support and monitored the injury, they failed to notify the police as required by their policy. The decision not to report was influenced by the resident and their family's preference. Both incidents highlight the facility's failure to adhere to their own policies and state regulations regarding the reporting of misconduct and abuse.
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What surveyors actually found near you
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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.
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Nursing homes near Superior
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Twin Ports Health Services | 1.3 mi | ★★★★★ | 4 | 0 |
| Franciscan Health Center | 2.6 mi | ★★★★★ | 20 | 0 |
| Dove Healthcare - Superior | 2.7 mi | ★★★★★ | 3 | 0 |
| Bayshore Residence And Rehabilitation Center | 4.3 mi | ★★★★★ | 2 | 0 |
| The North Shore Estates Llc | 5.6 mi | ★★★★★ | 16 | 0 |
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