Deficiency Index

Aria at Villa Pines

Friendship, Wisconsin · CCN 525351

22 surveys since 2011, 4 of them producing a finding at harm level or worse.

Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.

Citations on record
87
Surveys
22
Harm or worse
4
Immediate jeopardy
3
The record, 2011–2026
’11’15’20’25’26
No harm recordedHarm or worseNot surveyed
Immediate jeopardy3

Findings at the most serious level CMS records.

Beyond CMS’s monthly file18/22

Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.

The facility

Certified beds
50
Ownership
For profit - Individual
Chain
Independent
County
Adams · rural
Medicare-certified since
1984

CMS ratings

Overall
3
Health inspection
3
Staffing
4
Quality measures
3

CMS’s own Five-Star ratings.

Compared with similar facilities

Not shown for this facility: too few citations in window (n=15, floor 20).

Last survey on record

Apr 22, 2026

201 days ago.

Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.

Staffing

MeasureThis facilityPeer median
Nurse hours per resident day4.453.73
Registered-nurse hours per resident day1.48—
Annual nurse turnover45.7%45.7%

As reported by the facility to CMS, beside the peer-group median.

Enforcement

No fines, payment denials or special-focus designation on the current CMS record.

Severity of recent findings

Citations by CMS scope and severity. Rows are harm level, columns are how widespread the finding was.
SeverityIsolatedPatternWidespread
Immediate jeopardyJ—K—L—
Actual harmG—H—I—
No harm, potential for more than minimalD1173.3%E—F320.0%
No harm, potential for minimalA—B—C16.7%
CMS’s current file: 15 of the 87 citations on record.

Most frequently cited here

In CMS’s current monthly file.

  • F6892×

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  • F8122×

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  • F8802×

    Provide and implement an infection prevention and control program.

  • F5801×

    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

  • F5851×

    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

In the surveyor’s words

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

  • No harm, potential for more than minimal, widespreadF812Apr 22, 2026

    Based on observation, interview, and record review, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 33 residents who reside in the facility.Surveyor observed the stove hood to have dust directly above the food preparation area and attached to the light fixtures, the sprinklers, the 5-foot shelving, and a metal box.Surveyor observed the facility's stand mixer to be stored with a plastic covering. When staff removed the plastic covering, Surveyor observed food particles on the undercarriage. Surveyor observed one dented can in circulation.Evidenced by:Example 1Facility policy, titled Cleaning Instructions: Hoods and Filters, includes: . […]

  • No harm, potential for more than minimal, widespreadF880Apr 22, 2026

    Number of residents sampled:Number of residents cited:Based on observation, interview and record review, the facility did no establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and help prevent the development and transmission of communicable diseases and infection. This has potential to affect the census of 33 residents. The facility did not add the residents with COVID infection during an outbreak to the January infection Control Rates. […]

  • No harm, potential for more than minimal, widespreadF812Feb 19, 2024

    Based on observation, interview, and record review, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect all 26 residents. Surveyor observed Cook J use single use alcohol pads multiple times. Cook J did not allow thermometer to air dry before using it in different dishes. Surveyor observed 3 utensils to have pieces missing from them and in circulation. Surveyor observed food to be removed from original container, undated, and not closed properly in freezer. Surveyor observed food in refrigerator past the use by date. […]

  • No harm, potential for more than minimal, isolatedF580Apr 22, 2026

    Based on interview and record review, the facility did not immediately notify and consult with a resident's physician when there was a change in condition. This occurred for 1 of 15 Residents (R16) reviewed for notification of change in condition.R16 had weight gains or losses greater than three pounds in one day and a physician was not notified as ordered.This is evidenced by: The facility's policy, titled Change of Condition Process, effective 3/1/21, states in part: Policy Statement: The purpose of this policy is to promptly implement a system for a resident having a change in condition. A change in condition is defined as an improvement or decline in their physical, mental, or psychosocial status. Procedure: Change of Condition: 1. […]

  • No harm, potential for more than minimal, isolatedF609Apr 22, 2026

    Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, are reported immediately to the administrator of the facility and to other officials, including the State Survey Agency, in accordance with State law through established procedures for 1 of 3 incidents reviewed, affecting 1 of 2 residents (R34).R34 had a potential allegation of abuse and the facility did not submit a report to the State Agency (SA).Evidenced by:The facility's Abuse Prevention Program, undated, states, in part: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. […]

Read 23 findings in full →The most serious and the most recent: 23 of 87 on record.

Every survey on record

FindingsAt actual harm or above

  • Apr 22, 2026Standard and complaint9 findings
  • Sep 16, 2025Complaint1 finding
  • Aug 5, 2025Complaint1 finding
  • Feb 19, 2024Standard4 findings
  • Aug 6, 2020Complaint1 finding · 1 harm
  • Jun 30, 2020Infection control1 finding
  • Aug 15, 2019Standard and complaint5 findings
  • May 24, 2018Standard and complaint3 findings
Show the 14 earlier surveys
  • Jun 1, 2017Complaint1 finding
  • Mar 9, 2017Standard and complaint6 findings
  • Nov 3, 2016Complaint1 finding
  • Jun 22, 2016Complaint1 finding
  • Apr 12, 2016Complaint2 findings
  • Dec 17, 2015Standard and complaint13 findings
  • Oct 28, 2015Complaint4 findings
  • Aug 24, 2015Complaint4 findings · 1 harm
  • Dec 3, 2014Standard7 findings
  • Jul 24, 2014Complaint1 finding · 1 harm
  • May 19, 2014Complaint1 finding
  • Sep 12, 2013—7 findings
  • Jul 24, 2012—7 findings · 1 harm
  • May 4, 2011—7 findings

Surveys that found no deficiencies are not in CMS’s files and do not appear here.

Comparable facilities

The nearest facilities to this one in the same peer group, by weighted findings.

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