Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
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 Pigeon Falls Hcc during CMS and state inspections, most recent first.
A Food Service Worker was observed on multiple occasions serving and handling food with his moustache uncovered due to improper use of a facial hair cover, contrary to facility policy requiring all facial hair to be restrained. This resulted in food not being distributed under sanitary conditions.
A resident with multiple diagnoses, including anxiety disorder and dementia, received PRN Hydroxyzine for anxiety on several occasions without a documented rationale for extended use or a specified duration. Surveyors found no supporting documentation in the medical record, and the DON confirmed the absence of a facility policy specific to PRN psychotropic medication use.
A resident did not receive care and treatment in accordance with physician orders and their stated preferences and goals, as observed and documented by surveyors.
A resident did not receive appropriate care for existing pressure ulcers, and the facility did not take effective steps to prevent new ulcers from developing. Surveyors found that established protocols for pressure ulcer management and prevention were not consistently followed.
A resident with multiple medical conditions had their Foley catheter changed on a routine monthly basis without documented clinical indications, contrary to CDC/HICPAC guidelines and facility policy. The DON confirmed there was no physician rationale for the scheduled changes.
A resident with an open leg wound did not have enhanced barrier precautions implemented as required, and a nurse failed to wear a gown during wound care. Additionally, an activity aide did not follow proper hand hygiene procedures, using a t-shirt to dry hands and turning off the faucet with bare hands, contrary to facility policy. The DON confirmed these lapses in infection control and hand hygiene practices.
Failure to Ensure Proper Facial Hair Restraint During Food Service
Penalty
Summary
A deficiency was identified when a Food Service Worker (FSW) was repeatedly observed serving and handling food with a facial hair cover positioned below the level of his lips, leaving his moustache uncovered. This occurred on multiple occasions over two days, including while plating food for multiple residents, retrieving food, and transporting food on a cart. The facility's Uniform Dress Code policy, last revised on 01/24/25, requires all associates working with food to wear approved hair restraints and to restrain all facial hair with a beard net or restraint. An interview with another dietary staff member confirmed that dietary staff are expected to wear hair and beard nets while working with food. These observations indicated that food was not distributed under sanitary conditions as required by facility policy.
Lack of Documentation for PRN Psychotropic Medication Use
Penalty
Summary
A resident with a history of anxiety disorder, vascular dementia, cerebral infarct, depressive disorder, dysphagia, and aphasia was prescribed PRN Hydroxyzine for anxiety without a documented rationale for extended use or a specific duration for its administration. The physician's order allowed for Hydroxyzine 25mg as needed twice daily, and the medication was administered on multiple occasions over a period of weeks. Upon review, surveyors were unable to locate any documentation in the resident's medical record that justified the ongoing use of the PRN psychotropic medication or specified how long it should be used. The Director of Nursing confirmed that there was no additional information available regarding the medication's use and that the facility did not have a specific policy or procedure for PRN psychotropic medications, instead referring to regulatory guidelines.
Failure to Follow Treatment Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. This deficiency was identified through surveyor observation and review of records, which showed that care provided did not align with the documented orders or the expressed wishes and care goals of the resident involved.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that residents were not consistently receiving the necessary interventions to manage existing pressure ulcers or to prevent new ones from forming. The report specifically notes a lack of adherence to established protocols for pressure ulcer care and prevention.
Routine Catheter Changes Without Clinical Indication
Penalty
Summary
A deficiency was identified when a resident with an indwelling Foley catheter did not receive care and treatment consistent with professional standards of practice to prevent complications or urinary tract infections. The resident's Foley catheter was changed on a routine monthly basis without documented clinical indications, contrary to the Centers for Disease Control and Prevention (CDC) and Healthcare Infection Control Practices Advisory Committee (HICPAC) guidelines, which recommend changing catheters only based on clinical indications such as infection, obstruction, or compromise of the closed system. The facility's own policy also states that catheters should not be routinely changed, but rather changed according to physician orders or as needed. Record review showed that the physician order for the resident specified a catheter change every four weeks, but there was no documented physician rationale or clinical indication for this routine schedule. The Director of Nursing (DON) confirmed that the policy is to change catheters as needed or per physician order, but was unable to provide a clinical rationale for the monthly catheter changes. The resident had multiple diagnoses, including vascular dementia, congestive heart failure, peripheral vascular disease, urinary retention, benign prostatic hyperplasia, rheumatoid arthritis, and cognitive communication deficit.
Failure to Implement Infection Control Precautions and Proper Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by multiple lapses in following established protocols. A resident with a non-pressure chronic ulcer of the left lower leg, who was admitted with a diagnosis that included long-term use of anticoagulants, developed an open wound. Despite facility policy requiring enhanced barrier precautions (EBP) for residents with wounds, staff did not implement these precautions for the resident. During wound care, a registered nurse sanitized hands and donned gloves but did not wear a gown as required, and there was no EBP signage outside the resident's room. The Director of Nursing confirmed that EBP should have been in place for this resident and acknowledged the absence of appropriate signage and PPE use during wound care. Additionally, the facility did not ensure proper hand hygiene practices among staff. An activity aide was observed washing hands but then turned off the faucet with bare hands and dried hands on a t-shirt, contrary to facility policy, which requires using a disposable paper towel for both drying hands and turning off the faucet. The Director of Nursing confirmed that the observed hand hygiene practice did not comply with facility policy and acknowledged the need for staff education in this area.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Nursing homes near Pigeon Falls
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Trempealeau Cty Hcc Imd | 6.7 mi | ★★★★★ | 2 | 0 |
| Grand View Care Ctr | 9.2 mi | ★★★★★ | 0 | 0 |
| Dove Healthcare - Osseo | 11.3 mi | ★★★★★ | 6 | 0 |
| Augusta Health And Rehabilitation | 18.7 mi | ★★★★★ | 0 | 0 |
| Meadowbrook At Black River Falls | 19.2 mi | ★★★★★ | 14 | 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.