Villa Maria Health And Rehab Ctr
VILLA MARIA HEALTH AND REHAB CTR in HURLEY, WI — inspection on February 25, 2026.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Surveyor the pain was 10 out of 10 on pain scale. R49 stated if the staff put oil on it, it helps. R49
call paddle, unsuccessfully, then tried to use her elbow to press call light and again was unsuccessful
not respond to offer and asked for oil to be put on her butt and stated R49 is in pain. CNA did not reposition and went to get nurse.On 2/24/2026 at 9:16 AM, Surveyor interviewed CNA H and asked how does R49 let them know if she is having pain. CNA H stated R49 would tell them by yelling out or putting on her call light.
Surveyor asked CNA H how does R49 use her call light. CNA H stated R49 is usually able to hit it.
Surveyor reported to CNA H that R49 was not able to turn on call light after several attempts. On 2/24/2026 at 9:18 AM, Registered Nurse (RN) G asked R49 to rate pain. R49 responded it hurts and asked for oil. RN G offered pain medication.
Neither RN G nor CNA H repositioned or provided other comfort measures to R49 before leaving R49's room.On 2/24/2026 at 9:24 AM, R49 asked Surveyor to reposition her onto her stomach.
Surveyor encouraged R49 to put call light on. R49 attempted to press it with her right elbow and was not able to.
Surveyor located staff who came into R49's room and repositioned R49 on to her left side.On 2/24/2026 at 9:57 AM, Surveyor interviewed RN G and asked how does R49 let staff know R49 has pain. RN G stated R49 can put on the call light or tell the CNAs.
Surveyor asked RN G if R49 is able to press call light. RN G stated R49 usually does with her elbow.
Surveyor informed RN G of the observation made by Surveyor which indicated R49 was not able to do so.
Surveyor asked RN G if they try non-pharmacological interventions prior to giving medications. RN G reported they will sometimes try to reposition or redirect R49. On 2/24/2026 at 10:10 AM, Director of Nursing (DON) B went into R49's room and asked R49 to rate pain and asked if R49 wanted to get out of bed to take a shower. R49 said pain is 10/10.
DON B asked R49 if she wanted DON B to call the doctor to get more pain medication. DON B did not ask R49 where pain was located. On 2/24/2026 at 10:24 AM, Surveyor interviewed DON B asking if she assessed where R49's pain is. DON B stated DON B didn't know.
Surveyor asked DON B if R49 was asked where R49's pain was located, and DON B stated, I don't know.On 2/24/2026 at 11:36 AM, Surveyor interviewed RN G about R49's pain monitoring. RN G stated every 2-hour pain monitoring had just been implemented for R49.
Surveyor asked RN G if scheduled pain monitoring was in place before today, and RN stated it was not. On 2/25/26 at10:46 AM, Surveyor interviewed DON B.
Surveyor asked what pain assessment tool is used to monitor R49's pain. DON B stated the assessment they use is the quarterly pain assessment in the MDS and the facility staff knows R49 well, that is why they don't track or document R49's pain assessments well.
Surveyor asked DON B how the nurses know how much PRN morphine to give R49 if they don't assess and track pain regularly. DON B stated it is based on nursing judgement. R49 has been on pain meds for a long period of time, and the nurses look to see what she had been given previously. DON B stated the facility could probably improve their charting and frequency of the pain assessments.
droplet precautions that required hand hygiene, gloves, gown, and masks prior to entering the room.
glasses.
Surveyor noted that CNA C did not change PPE and perform hand hygiene between the two residents that were assisted.
On 02/24/2026 at 7:59 AM, Surveyor asked CNA C, When you assisted [R37], did you have to physically assist her into her wheelchair? CNA C replied, No, but moved [R37's] wheelchair next to the bed for [R37] to self-transfer.
Surveyor asked, Do you need to change PPE, gloves, and sanitize hands before assisting roommate? CNA C replied, I wasn't sure.
Surveyor asked, Did you? CNA C stated, No, I didn't know I could do that in the room. I moved [R37's] wheelchair but did not touch her and then assisted [R16] with glasses and hair without changing gloves, PPE, and sanitizing hands. I guess I should have done that.
On 02/24/2026 at 1:37 PM, Surveyor interviewed DON B and asked what the expectation would be for CNAs that provide care to a resident on droplet precautions then assist with roommate right afterwards. DON B informed Surveyor they would expect the CNAs to doff PPE, gloves, sanitize hands, and don new PPE prior to caring for roommate, and there should always be hand hygiene between resident contact and environment regardless of precautions.
525540 02/25/2026
Villa Maria Health and Rehab Ctr 300 Villa Dr Hurley, WI 54534