Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

VILLA MARIA HEALTH AND REHAB CTR

HURLEY, WI · 70 certified beds · Last Life Safety survey February 25, 2026

CMS Certification Number 525540 · first certified June 1994

Ownership

Independently operated (no chain recorded by CMS) · For profit - Partnership

No change of ownership on CMS record since January 1, 2016, when the records begin.

15
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
3
Tags cited more than once
Across separate surveys
8
Inspection & testing records
Of the citations on file

Position within WI

15 citations — more than 38% of the 323 certified nursing homes in WI. Compared within WI rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Improvingfewer citations at the latest survey than at its earlier surveys in the window.

The latest survey found 0 citations; the earlier surveys in the window averaged 7.5. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

The window opens April 2027 — about 6 months from now. This facility’s last Life Safety survey was February 2026. Facilities in WI are typically surveyed 13–15 months after the last one (median 14), measured over 516 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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Which alerts

2 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

1 of the 15 citations on file is Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

3 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 15 Life Safety citations above. The Physical Environment Index

  • F-0880 Provide and implement an infection prevention and control program.
  • F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

How that compares

Citations on file over three years

Compared with the median facility in WI, and nationally. Surveyors differ markedly between states, so the WI figure is the meaningful one.

This facility15WI median17National median11
Citations on file over three years, compared
MeasureCitations
This facility15
Median facility in WI17
Median facility nationally11

Survey history

Citations at each Life Safety survey
82023-1172024-1202026-02
Citations at each Life Safety survey
Survey dateCitations
November 8, 20238
December 11, 20247
February 25, 20260

Most-cited tags

Most-cited tags at this facility
K-02112K-03452K-09182E-00251K-09141K-07531K-05211K-07121
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0211Keep aisles, corridors, and exits free of obstruction in case of emergency.22024-12-11
K-0345Have approved installation, maintenance and testing program for fire alarm systems.22024-12-11
K-0918Have generator or other power source capable of supplying service within 10 seconds.22024-12-11
E-0025Create arrangements with other facilities to receive patients.12024-12-11
K-0914Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.12023-11-08
K-0753Have restrictions on the use of highly flammable decorations.12024-12-11
K-0521Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.12023-11-08
K-0712Have simulated fire drills held at unexpected times.12023-11-08

What the citations cover

Citations by CMS category
  • Egress Deficiencies 4
  • Smoke Deficiencies 4
  • Gas, Vacuum, and Electrical Systems Deficiencies 3
  • Miscellaneous Deficiencies 2
  • Other 2
Citations by CMS category
CategoryCitations
Egress Deficiencies4
Smoke Deficiencies4
Gas, Vacuum, and Electrical Systems Deficiencies3
Miscellaneous Deficiencies2
Services Deficiencies1
Emergency Preparedness Deficiencies1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

December 11, 2024 — 7 citations

Citations issued on December 11, 2024
TagWhat the surveyor checksStatus
E-0025Create arrangements with other facilities to receive patients.Deficient, Provider has date of correction (February 10, 2025)
K-0211Keep aisles, corridors, and exits free of obstruction in case of emergency.Deficient, Provider has date of correction (February 10, 2025)
K-0271Have exits that are accessible at all times.Deficient, Provider has date of correction (February 10, 2025)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (February 10, 2025)
K-0363Install corridor and hallway doors that block smoke.Deficient, Provider has date of correction (February 10, 2025)
K-0753Have restrictions on the use of highly flammable decorations.Deficient, Provider has date of correction (February 10, 2025)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (February 10, 2025)

November 8, 2023 — 8 citations

Citations issued on November 8, 2023
TagWhat the surveyor checksStatus
K-0211Keep aisles, corridors, and exits free of obstruction in case of emergency.Deficient, Provider has date of correction (December 1, 2023)
K-0291Install emergency lighting that can last at least 1 1/2 hours.Deficient, Provider has date of correction (December 1, 2023)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (December 1, 2023)
K-0346Follow proper procedures when the fire alarm was out of service for more than 4 hours.Deficient, Provider has date of correction (December 1, 2023)
K-0521Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.Deficient, Provider has date of correction (December 1, 2023)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (December 1, 2023)
K-0914Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.Deficient, Provider has date of correction (December 1, 2023)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (December 1, 2023)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.