Aria at Villa Pines: Wrong Medication Given to Resident - WI
They weren't hers.
The resident, identified in inspection records as R2, had been prescribed hydrocodone-acetaminophen 10/325mg for pain. The nurse, according to the facility's own administrator, had decided to substitute plain Tylenol because the scheduled medication wasn't available from the regular supply. R2 had no order for Tylenol. Neither the nursing home administrator nor the director of nursing could confirm that during their interviews with the inspector on September 16. Both said they would have to check.
The nurse went back to the medication cart and returned with the correct medication. R2 reported the incident to the facility's social services director.
What followed was an investigation that the facility's own administrator acknowledged was incomplete. No one interviewed the nurse about why she had substituted a medication without an order. No one interviewed other residents to find out whether the same nurse had given anyone else the wrong drugs. The administrator said she had come in on a night shift to observe the nurse and had spoken with a nursing assistant about a separate grievance, but there were no staff interviews specific to R2's complaint.
The social services director told the inspector that the facility follows up with residents verbally and that staff sign off on the grievance form. Residents are not asked to sign anything indicating whether they agree or disagree with the resolution. R2 told the inspector that nobody had followed up with her at all. The social services director said she had spoken with R2 the following day and told her the nurse had been educated.
R2 said that conversation never happened.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Aria At Villa Pines from 2025-09-16 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
Aria at Villa Pines in Friendship, WI was cited for violations during a health inspection on September 16, 2025.
The resident, identified in inspection records as R2, had been prescribed hydrocodone-acetaminophen 10/325mg for pain.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.