Aria At Villa Pines
Inspection Findings
F-Tag F0585
F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
meds be handed to her and not given directly from med cup.When she looked at the 3 medications in her cup, she recognized 2 of the medications but one of them looked different. When the resident questioned
the nurse, [Nurse's Name] took the medications to the hall where the med cart was and returned within a reasonable amount of time with the correct medication. It is important to note that the grievance investigation does not have documentation of staff or resident interviews, other than SSD C's interview with Resident R2. Additionally, the facility does not have documentation that the resolution of the grievance was communicated, in writing, with the resident. On 9/16/25 at 12:22 PM, Surveyor interviewed Resident R2. Surveyor asked Resident R2 to explain the incident, Resident R2 reported that the nurse came into her room to administer her medications and attempted to pour the medications into her mouth, instead of handing them to her. Resident R2 stated that she requested the medications to be placed into her hand and then realized that she did not have the correct medications, stating that she has taken these medications for 15 years and knows what
they look like. Resident R2 reported that the nurse then went back to the med cart and brought in the correct medications. Surveyor asked Resident R2 who she reported her concerns to, Resident R2 stated SSD C. Surveyor asked Resident R2 if
the facility followed up with her regarding a resolution, Resident R2 stated no. On 9/16/25 at 12:30 PM, Surveyor interviewed SSD C. Surveyor asked SSD C what the process is once a resident expresses a grievance, SSD C stated that the facility initiates an investigation. Surveyor asked SSD C if facility staff follow- up with residents to discuss the resolution once the grievance has been fully investigated, SSD C stated that they follow- up with residents or their representatives verbally and it is signed off on the bottom of the grievance form by facility staff. Surveyor asked SSD C if they obtain a signature from the resident or their representative indicating that they agree or disagree with the resolution, SSD C stated no. Surveyor asked SSD C if they met with Resident R2 to discuss the outcome of her grievance, SSD C stated that she met with Resident R2 the following day and gave her a verbal update, indicating to Resident R2 that facility staff identified that the nurse was attempting to give her Tylenol, and that the nurse was educated.It is important to note that Resident R2 did not have
an order for Tylenol/ acetaminophen. On 9/16/25 at 1:25 PM, Surveyor interviewed NHA A (Nursing Home Administrator). Surveyor asked NHA A if they asked the nurse why she was attempting to give Resident R2 Tylenol instead of her scheduled hydrocodone- acetaminophen 10/325mg, NHA A reported that the nurse needed to get the medication from their contingency (back-up) supply, but the nurse decided to administer the Tylenol instead. Surveyor asked NHA A if Resident R2 had an order for Tylenol, NHA A stated that she would have to look. Surveyor asked NHA A if they interviewed other residents about not getting the correct medications, NHA A stated no. NHA A reported that she did come in on a night shift to make observations of the nurse and spoke with the CNA (Certified Nursing Assistant) regarding another grievance but did not have any staff interviews regarding Resident R2's grievance. On 9/16/25 at 2:25 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if she asked the nurse why she was attempting to give Resident R2 Tylenol instead of her scheduled pain medication, DON B stated that the nurse reported that Resident R2's scheduled pain medication was not available, so she attempted to administer the Tylenol. Surveyor asked DON B if Resident R2 had
an order for Tylenol, DON B stated that she would have to check. The facility failed to conduct a complete investigation into Resident R2's grievance and provide adequate follow- up with Resident R2 regarding the resolution of the grievance.
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Aria at Villa Pines in Friendship, WI inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Friendship, WI, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Aria at Villa Pines or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.