Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pembilier Nursing Center during CMS and state inspections, most recent first.
A dietary staff member tested a premixed sanitizing solution with test strips that had expired in October 2025. Surveyors observed the use of the expired strips during a kitchen observation, and the staff member later stated that staff should not use expired test strips.
Staff failed to follow infection control practices during multiple resident care tasks, including perineal care, ostomy care, dressing changes, insulin administration, and blood glucose monitoring. CNAs and an RN were observed removing soiled gloves and continuing care without hand hygiene, handling clean supplies without establishing a clean field, administering insulin without gloves, and disposing of contaminated items with a bare hand. These lapses occurred during care for several residents and during EBP care.
A nurse left a medication cart unattended with prepared insulin while taking a resident to a private area for medication administration, but did not lock the cart or computer screen. During that time, two visitors walked by and the eMAR was clearly visible. An admin staff member confirmed staff are expected to lock the computer screen and medication cart when unattended.
Improper Labeling and Reuse of Single-Use Eye Drops: A nurse administered preservative-free single-use eye drops to a resident, then capped the vial and placed it back in the med cart for reuse. Surveyors found the pharmacy label did not match the physician order, and an admin staff member confirmed single-use vials should be discarded and labels should match orders.
Expired Sanitizer Test Strips Used in Kitchen
Penalty
Summary
The facility failed to maintain a sanitary kitchen environment in 1 of 1 facility kitchen areas when a dietary staff member tested the concentration of a premixed sanitizing solution using test strips that had expired in October 2025. During the kitchen observation on 04/27/26 at 11:13 a.m., surveyors observed the staff member using the expired test strips to check the sanitizer concentration. During an interview on 04/27/26 at 11:25 a.m., the dietary staff member stated that staff should not use expired test strips.
Infection Control Failures During Resident Care and Procedures
Penalty
Summary
The facility failed to follow infection control standards for hand hygiene and glove use during resident care and procedures for Residents #3, #4, #18, and #20, as well as for supplemental Resident #8. The report cites facility policies for hand hygiene, clean dressing changes, insulin pen use, and blood glucose monitoring, all of which required hand hygiene at specified points and, for certain procedures, the use of gloves and a clean field. An administrative staff member stated that staff were expected to follow infection prevention policies and procedures related to infection control. During care for Resident #4, two CNAs performed hand hygiene, applied gloves, and assisted the resident with a mechanical sit-to-stand lift. One CNA completed perineal care, then placed a clean brief on the resident without removing soiled gloves or performing hand hygiene. After removing the soiled gloves, the CNA repositioned the resident's pants and transferred the resident into the wheelchair without performing hand hygiene. For Resident #3, two CNAs in enhanced barrier precautions transferred the resident with a mechanical body lift, removed a soiled brief, and provided perineal care. One CNA removed soiled gloves and placed a clean brief without hand hygiene or clean gloves, while the other CNA assisted with the clean brief while still wearing soiled gloves. The same CNA later positioned heel boots and blankets without applying clean gloves. A nurse performing a colostomy change for Resident #18 placed supplies on the overbed table without establishing a clean field, removed the soiled bag, and changed gloves multiple times without performing hand hygiene between glove changes or before sanitizing the scissors and overbed table. For Resident #20, a nurse performed a dressing change by moving items on the overbed table aside and placing clean dressing supplies on the table without sanitizing it or using a barrier. The same nurse also performed blood glucose monitoring for Resident #20, placed the soiled lancet on the bedside table, and disposed of the lancet and test strip in a sharps container with a bare hand after removing gloves. For Resident #8, a nurse administered insulin without gloves and then returned to the medication cart and prepared medication for another resident without performing hand hygiene.
Unattended Medication Cart Left eMAR Visible
Penalty
Summary
The facility failed to promote privacy and confidentiality of the electronic medication administration record (eMAR) on 1 of 1 medication cart. Review of the facility policy titled Safeguarding of Resident Identifiable Information stated that resident identifiable information must be protected and that computer screens showing clinical record information may not be left unattended and readily observable or accessible by other residents or visitors. During observation on 04/28/26 at 11:41 a.m., a nurse left the medication cart with prepared insulin and took Resident #8 from the dining room to administer medication in a private area down the hallway, but the nurse did not lock the unattended cart or computer screen. While the cart was unattended, two visitors walked in front of it and the computer screen with the eMAR was clearly visible. An administrative staff member later confirmed that staff are expected to lock the computer screen and medication cart when unattended.
Improper Labeling and Reuse of Single-Use Eye Drops
Penalty
Summary
The facility failed to ensure accurate labeling and storage of eye drops for one resident observed receiving Systane Ultra Preservative-Free single-use vials. Surveyors observed a nurse administer one drop in each eye to the resident and then cap the single-use vial, place it in the medication cart, and state that there was enough medication left for another use. Review of the product information stated that Systane Ultra PF single-use vials must be discarded after each use and that contamination risk increases after opening. Review of the eMAR showed the medication ordered as one drop into both eyes two times daily, while the pharmacy label stated to give it 2-4 times a day as needed. An administrative staff member confirmed that single-use medication vials should be discarded and that medication labels should match physician orders.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Walhalla
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wedgewood Manor | 15.8 mi | ★★★★★ | 0 | 0 |
| Maple Manor Care Center | 23.6 mi | ★★★★★ | 9 | 0 |
| Good Samaritan Society - Park River | 39.2 mi | ★★★★★ | 20 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.