Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pine Crest Health And Memory Care during CMS and state inspections, most recent first.
The facility lacked a policy to provide residents with a written transfer notice that included the reason for transfer, Ombudsman contact information, and appeal rights. During record review, the surveyor found no protocol for these required elements, and the DON stated being unaware that a written transfer notice was required unless a resident was being discharged. The deficiency was identified as affecting all 93 residents.
Failure to Provide Written Transfer Notices: The facility did not provide written transfer notices for multiple residents who were sent to the hospital. Records showed hospital transfers and, in some cases, signed bed hold notices or Ombudsman notification, but no written notice with the reason for transfer, Ombudsman contact information, or appeal rights. The DON and medical records staff stated they were unaware the notice was required for residents or next of kin.
Food items were found stored without required dating and, in some cases, without coverage. An open package of chicken breasts, an opened bag of cauliflower, and an opened bag of chopped celery lacked use-by, expiration, or open dates, and several bowls of lettuce and prepared desserts were uncovered and undated in cooler storage. The DS confirmed the items were not dated and stated that opened or prepared food should be labeled, dated, and covered when stored.
Infection control deficiencies were identified in the facility’s water management and wound care practices. The facility did not document required water temperature monitoring or Legionella testing under its Water Management Program, and staff were unable to locate prior records. During wound care, an RN used undisinfected scissors and the same cleansing wipe across multiple open wounds on a resident with diabetes and bilateral ankle incisions, then palpated a new toe area with a bare finger. In another observation, an RN changed gloves during care for a resident with a pressure ulcer but did not perform hand hygiene between glove changes, and the DON and infection preventionist acknowledged the hand hygiene issue.
Diabetic foot care was not provided in accordance with professional standards for several residents with type 2 DM and diabetic peripheral neuropathy. The facility had no physician orders for daily diabetic foot checks for multiple residents, and the medical record lacked documentation of foot assessments and cares for several of them. During observation, an LPN noted a resident’s toenails were untrimmed and extending under the toes, and the resident stated no one had ever trimmed them. The DON said nurses were expected to provide foot care, including nail trimming, but an RN could not identify a specific staff member assigned to complete diabetic foot assessments and cares.
A facility failed to follow physician orders and care plans for two residents. One resident with chronic lymphedema and a 2,000 mL fluid restriction had inconsistent intake documentation, repeated intake over the ordered limit, and no routine circumference monitoring by nursing, while OT measurements showed a marked increase in leg girth before the resident was sent to the hospital for right thigh pain and hematomas. Another cognitively intact resident with CKD, heart disease, and respiratory failure did not have ordered fluid intake, daily weights, pulses, or physician notification for out-of-range weights consistently documented, and staff reported the process was inconsistent.
Incomplete fall investigations and inadequate supervision for a resident with cognitive impairment. A resident with dementia, hemiplegia/hemiparesis after CVA, moderate cognitive impairment, and a history of falls had repeated unwitnessed falls involving a bed safety device and an electric recliner. The facility repeatedly identified missing care plan interventions or unsupervised recliner use as the root cause, but did not complete staff interviews, competency checks, or a documented review of whether adequate supervision was in place.
Two residents receiving IV therapy through PICC lines did not have required upper arm circumference measurements consistently documented. For one resident, nursing staff recorded check marks but no numeric values, and a nurse stated there was no way to compare changes without prior measurements. For another resident, an ADON hung the IV and attached it to the PICC but did not measure the arm circumference as ordered, and staff gave inconsistent accounts of who was responsible for PICC care and documentation.
A resident with recurrent C-Diff infection did not receive prescribed Vancomycin in a timely manner after the pharmacy reported Fidaxomicin was unavailable. Nursing staff reported ongoing difficulties with pharmacy communication, medication delivery delays, and issues accessing refills, resulting in the resident being hospitalized to receive necessary treatment.
A resident with severe cognitive impairment and a history of trauma was not protected from abuse by another resident who repeatedly entered her room and was found with his hand under her blanket. Despite policies and interventions such as 15-minute checks and direct supervision, staff did not consistently monitor the resident, allowing further unauthorized entries. The affected resident experienced emotional distress, and required staff education on abuse prevention was not completed.
Surveyors found expired Molnupiravir bottles and an undated, opened multi-use vial of Aplisol in a medication storage room, as well as undated open bottles of Clear Lax and Geri-Lanta on a medication cart. The Aplisol vial was used for nine doses on seven residents after its expiration. Staff confirmed that medications should be dated and expired drugs should not be present in stock.
A resident with severe cognitive impairment and multiple medical conditions developed a skin tear on the lower leg, but the physician was not notified at the time of the initial injury. Despite ongoing wound issues documented in progress notes, staff did not inform the provider or obtain treatment orders until several days later, contrary to facility protocol and the resident's care plan.
Two residents with dementia and cognitive deficits did not receive appropriate assistance or encouragement during meals, despite care plans indicating the need for supervision, set-up, and cuing. Staff observed the residents struggling to eat or not eating at all but did not provide the necessary help, resulting in inadequate intake and failure to meet assessed ADL needs.
A resident with a history of pain and recent falls repeatedly expressed significant pain and requested medication during care, but the CNA continued care tasks without stopping to notify a nurse. The resident's pain was not assessed or treated until nearly two hours later, and a comprehensive pain assessment was delayed by four hours, despite facility policy requiring immediate reporting and intervention. Staff interviews confirmed that the expected protocol for pain management was not followed.
Staff failed to consistently use required PPE and perform hand hygiene during care of residents on contact and enhanced barrier precautions. A resident with MRSA did not receive care with proper gown and glove use, and staff showed confusion about PPE requirements. During catheter care and medication administration, hand hygiene was not performed as required, with staff unaware of or forgetting proper procedures.
The facility did not consistently post or update daily nurse staffing information at the beginning of each shift, failing to reflect changes in staffing levels or resident census, especially on weekends and during staff absences. This deficiency was confirmed through observation, record review, and staff interviews, affecting all residents in the facility.
A resident with specific dietary preferences and restrictions did not consistently receive meals that adhered to their stated dislikes, such as sausage and gravy, despite these being clearly noted on their meal ticket. The resident, who has intact cognition, reported the issue to the kitchen through an aide but expressed ongoing frustration with the situation. Interviews with staff revealed that while meal tickets are intended to guide meal preparation, errors in adhering to these instructions occurred frequently.
The facility failed to develop comprehensive care plans for residents involved in altercations. A resident with severe cognitive impairment was involved in an altercation with another resident, but their care plan lacked interventions to prevent recurrence. Another resident, who is non-verbal and dependent on staff, was involved in an incident with a third resident, yet their care plan did not address this or include protective measures. The Nursing Home Administrator acknowledged the oversight.
Missing Written Transfer Notice Requirements
Penalty
Summary
The facility did not have policies in place to provide residents with a written notice of transfer that included the reason for the transfer, Ombudsman contact information, and appeal rights. During record review on 06/03/26, the surveyor requested the facility's transfer notice policy and found that it did not include a protocol for giving residents a written transfer notice with those required elements. On 06/03/26 at 2:51 PM, the surveyor interviewed DON B about written transfer notices, and DON B stated being unaware that a written notice of transfer was required for residents unless they were being discharged. The deficiency was identified as affecting all 93 residents.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility did not provide a written notice of transfer for 10 of 10 residents reviewed who were transferred to the hospital. The missing notices were to include the reason for transfer, Ombudsman contact information, and appeal rights. Residents identified in the report included R7, R17, R8, R14, R99, R6, R83, R3, R96, and R101, all of whom had hospital transfers documented in their records without a corresponding written transfer notice. For R7, the record showed a transfer to the local hospital on 03/26/26, but no written notice of transfer was documented. During interview, the DON stated being unaware that a written notice of transfer was required unless the resident was discharged. For R17, R8, and R3, the records showed hospital transfers and signed bed hold notices, but no written transfer notices were found. The DON stated the facility did not provide written notices of transfer and was not aware this was required prior to transfers or discharges. Other residents had similar findings. R14, R6, R83, R96, R99, and R101 each had hospital transfers documented in the record, along with diagnoses such as hyponatremia, hypocalcemia, hypomagnesemia, osteoporosis, stroke history, CHF, diabetes, paraplegia, osteomyelitis, and dementia, but no written transfer notice was found. In one case, the facility did provide evidence that the Ombudsman was notified of R101's discharge, but still did not provide written notice to the resident or resident's representative. Medical records staff stated they did not know a written transfer notice was required for the resident or next of kin.
Food Items Stored Without Required Dating and Coverage
Penalty
Summary
The facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an initial kitchen tour, the surveyor observed an opened bag of cauliflower and an opened bag of chopped celery in the walk-in freezer without a date showing an open date, expiration date, or use-by date. The surveyor also observed several individual bowls of lettuce in the snack cooler without a date identifying when they were prepared, and several uncovered prepared desserts in the dessert cooler without a date identifying when they were prepared. In the walk-in freezer, an open package of chicken breasts was also found out of the original box without a use-by or expiration date. The Dietary Supervisor verified that the opened packages did not have dates on them and stated that opened or prepared food should be labeled and dated and prepared foods should be covered when stored for later use.
Infection Control Program Deficiencies in Water Monitoring and Wound Care
Penalty
Summary
The facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. The report states that the facility’s measures to prevent the growth of Legionella and other opportunistic waterborne pathogens in the building water systems were not being performed based on nationally accepted standards and were not being monitored in accordance with the facility’s Water Management Program. The Water Management Program dated 3/6/2023 required daily temperature monitoring at specific points and quarterly Legionella testing at 3 locations, but water flushing logs only showed housekeeping flushing vacant rooms twice a week, and the facility had no documentation of temperature monitoring or Legionella testing. During wound care for a resident with type 2 diabetes mellitus with diabetic neuropathy and displaced bimalleolar fractures of both lower legs, RN L removed bandage scissors from a uniform pocket and placed them on the bedside table without disinfecting them, then used the scissors to cut dressings for multiple open incisional wounds on both ankles. RN L used the same saline wipe to cleanse both the medial and lateral open incisional wounds on the left ankle, then applied dressings cut with the undisinfected scissors to the left and right ankle wound sites. After removing gloves, RN L palpated a new scabbed area below the resident’s anterior great toe with a bare finger. RN L told the surveyor that there was a lack of hand-based alcohol rubs and wound care supplies in the room and acknowledged personal faults in infection control compliance. For another resident with a pressure ulcer of the right buttock stage II and orders for coccyx and heel dressings, RN C was observed providing care and changing gloves multiple times without performing hand hygiene between glove changes. RN C cleaned both heels, changed gloves without hand hygiene, applied new heel dressings, then continued perineal and coccyx care, again removing gloves and putting on clean gloves without hand hygiene. RN C later told the surveyor that she normally carried a small hand sanitizer but did not have it that day. The DON stated RN C should have performed hand hygiene when removing gloves and when putting on clean gloves, and the infection preventionist acknowledged that the facility had removed hand sanitizer stations from residents’ rooms, changing staff process.
Diabetic Foot Care Not Provided or Documented
Penalty
Summary
Diabetic foot care was not provided in accordance with professional standards of practice for six residents with type 2 diabetes mellitus and diabetic peripheral neuropathy. The facility did not have physician orders for daily diabetic foot checks for R3, R4, R22, R56, R80, and R83, and the medical records did not contain documentation of diabetic foot assessments and/or cares for R3, R4, R22, R80, and R83. The facility policy, titled Skin Integrity Foot Care, stated the facility was to ensure residents received proper treatment and care within professional standards of practice to maintain mobility and good foot health. During observation, R3’s toenails on both feet were noted to be untrimmed and stretched over the top of the nail bed, extending underneath the toes. When asked, R3 stated no one had ever trimmed his toenails and he was not aware of the toenails extending underneath his toes because of diabetic neuropathy and lack of sensation to the feet. The LPN performing wound care to R3’s lower legs stated the wound care was provided to both feet at least every 2 days, sometimes daily, and nurses had visual access to the toenails, but had not noticed them before. The DON stated all nurses were expected to perform foot care, including nail trimming, for diabetic residents, while an RN could not identify a specific staff member designated to complete diabetic foot assessments and cares.
Failure to Follow Orders for Fluid Restriction, Weights, and Lymphedema Monitoring
Penalty
Summary
The facility did not ensure treatment and care were provided according to physician orders and the residents’ comprehensive plans of care for two residents. One resident had chronic lymphedema and a 2,000 mL daily fluid restriction, but nursing did not routinely assess the lymphedema with measurements and did not consistently monitor or document daily fluid intake. The resident’s care plan did not include interventions to monitor lymphedema with measurements, and nursing staff stated that therapy completed the measurements rather than nursing. For the resident with lymphedema, the intake record showed multiple days when fluid intake exceeded the 2,000 mL restriction, and several shifts had no documentation of intake. No additional assessment or provider notification was documented on days when intake exceeded the ordered limit. OT notes documented total active girth measurements of the right lower extremity, including a 24 cm increase over a short period, and the resident later reported increased right thigh pain. The resident was transferred to the hospital for evaluation, where CT findings showed multiple hematomas in the right thigh. The second resident had diagnoses including hypertensive heart disease, chronic kidney disease stage 4, candidal endocarditis, and chronic respiratory failure, and was cognitively intact. The resident’s care plan included a fluid restriction and monitoring/documentation/reporting of weight gain over 2 pounds in a day and increased heart rate, but the facility did not document fluid intake every shift as ordered, did not perform and document daily weights and pulses as ordered, and did not notify the physician for weights outside ordered parameters. Facility staff and the DON stated that fluid intake documentation was inconsistent, that weights were not obtained as expected, and that no care plan interventions or risk/benefit education were in place for the resident’s refusal-related issues.
Incomplete fall investigations and inadequate supervision for a resident with cognitive impairment
Penalty
Summary
The facility did not ensure falls were investigated thoroughly to determine root cause, implement new safety interventions, and ensure adequate supervision for one resident with dementia, hemiplegia and hemiparesis following cerebral infarction, memory deficit following cerebral infarction, and a BIMS score of 10/15 indicating moderate cognitive impairment. The resident had a history of falls, including falls with injury, and had a durable power of attorney for healthcare due to incapacitation. The resident’s care plan identified fall risk related to CVA with left hemiparesis, dementia, weakness, balance deficit, seizure disorder, medications, recent falls, and decreased safety awareness, and included use of an electric recliner with supervision because the resident was unable to use it safely independently. After an unwitnessed fall in the resident’s room, the facility determined the root cause was that staff did not place the pool noodle on the bed. The investigation documented re-education for staff on placing the pool noodle and following the care plan, but no additional safety interventions were implemented. No staff interviews were completed and no staff competency evaluations were completed. After another unwitnessed fall that resulted in an abrasion to the left eyebrow, the facility again determined the pool noodle was not in place, but did not complete staff interviews, staff competency evaluations, or additional skin assessments beyond what was documented. The resident later had two additional unwitnessed falls involving the electric recliner. In one event, the resident fell out of the recliner, and the facility determined the resident was resting in the recliner unsupervised; in the other, the resident was found on the floor next to the recliner and the facility determined the resident had been sleeping in the recliner. In both investigations, the facility did not document review of whether adequate supervision was in place, did not complete staff interviews, and did not complete staff competency evaluations. During interview, the ADON stated that staff interviews, care plan audit, and review of staff involved should have been completed, that staff competency was not reviewed, and that audits or reviews of adequate supervision for the electric recliner were not completed.
Incomplete PICC Monitoring and Documentation for IV Therapy
Penalty
Summary
The facility failed to provide care and services for the administration of parenteral medications consistent with professional standards of nursing practice for two residents receiving IV therapy through PICC lines. For one resident with Charcot-Marie-Tooth disease, right foot osteomyelitis, and right hip septic arthritis, the care plan and physician orders required daily measurement of the upper arm circumference above the PICC insertion site. Although nursing staff placed check marks and initials on the TAR, there were no numerical arm circumference values documented in the medical record for comparison, and the nurse who performed the measurement stated there was no place on the TAR to document a number and that there was no way to determine changes without prior measurements. During interview, the nurse initially gave an incorrect arm circumference measurement for that resident and then corrected it after checking the measuring tape, stating unfamiliarity with IVs and that documented measurements would make it easier to identify inaccurate measurements and possible infiltrations. The DON confirmed the TAR did not contain numerical values or narrative charting for the arm circumference measurements. The resident was cognitively intact with a BIMS score of 15/15 and was aware of the PICC placement and IV medication administration. For the second resident, who had a stage 4 sacral pressure ulcer, colostomy, paraplegia, osteomyelitis, and spina bifida, the care plan and physician orders also required daily measurement of the upper arm circumference above the PICC insertion site. On observation, an ADON mixed the IV, primed the tubing, set up the pump, and attached the IV to the PICC line, but did not measure the resident’s arm circumference as ordered. Interviews with the ADON, an LPN, and the DON showed inconsistent understanding of who was responsible for PICC-related tasks, and the DON later stated the facility could not find progress notes with the required measurements, with only one measurement found on the June TAR.
Delayed Medication Delivery for C-Diff Treatment
Penalty
Summary
The facility failed to provide timely pharmaceutical services to meet the needs of a resident diagnosed with recurrent Clostridium difficile (C-Diff) infection. The resident was admitted with a physician's order for Fidaxomicin, which the pharmacy reported as unavailable. The physician then ordered Vancomycin HCL capsules to be administered every six hours until Fidaxomicin became available. Despite the order, the Vancomycin was not delivered as scheduled, and by the following day, the medication had still not arrived. As a result, the resident was hospitalized to receive the necessary medication for C-Diff management. Interviews with nursing staff revealed ongoing difficulties in obtaining medications from the pharmacy in a timely manner. Staff reported issues such as delayed deliveries, problems with pharmacy communication regarding faxed orders, and challenges with the pharmacy's computer program, which hindered their ability to access and refill medications. These issues directly contributed to the delay in providing essential medication to the resident.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident's right to be free from abuse by another resident. One resident with severe cognitive impairment and a history of trauma was found in her room with another resident, also severely cognitively impaired, whose hand was under the blanket on her bed. Staff observations and interviews confirmed that the male resident had previously made inappropriate comments and attempted to enter the female resident's room on multiple occasions. Both residents were assessed as unable to consent to sexual activity, and the incident was reported to the State Agency. Despite facility policies requiring protection from abuse and interventions for residents with wandering or aggressive behaviors, the male resident was not adequately supervised. The facility's interventions included 15-minute checks and direct supervision, but surveyors observed that these checks were not consistently performed. After the initial incident, the male resident was able to enter the female resident's room on at least four additional occasions, and staff could not always verify whether the female resident was present during these times. Staff interviews revealed that the male resident continued to attempt to access the female resident's room, and that staff were sometimes too busy to prevent these occurrences. The facility did not complete all required staff education following the incident, and there was no documentation to confirm that additional abuse prevention training had been provided. Interviews with staff and family indicated that the female resident experienced emotional distress, including fearfulness and crying, following the incident. The facility's failure to implement and maintain effective supervision and monitoring allowed repeated access by the male resident to the female resident's room, resulting in a failure to protect her from potential further abuse.
Expired and Undated Medications Found in Medication Storage and Carts
Penalty
Summary
Surveyors identified that drugs and biologicals in one of three medication storage rooms/carts were not stored and labeled according to accepted professional standards. Expired medications, specifically two bottles of Molnupiravir 200 mg, were found among resident stock medications in the north storage medication room. The Assistant Director of Nursing (ADON) confirmed these expired medications should not have been present and indicated that pharmacy staff are responsible for inspecting and removing expired stock. Additionally, an opened multi-use vial of Aplisol (Tuberculin Purified Protein Derivative, Diluted) was found in the medication fridge without an open date on either the box or the vial, contrary to facility expectations that both should be dated and used within 28 days of opening. Further inspection of the medication cart on the north wing revealed an open bottle of Clear Lax and Geri-Lanta, both undated, with the LPN unable to identify when the Geri-Lanta was opened. Record review showed that the Aplisol vial had been opened on 2/14/25 and was used for nine doses on seven residents after its expiration date of 3/14/25. The Director of Nursing (DON) confirmed that multi-use vials are expected to be dated and disposed of within 28 days, and expired medications should not be in stock. The north wing medication room serves as the main stock supply for the facility, but the expired PPD solution was only used for residents on the north wing.
Failure to Notify Physician of New Skin Wound
Penalty
Summary
A deficiency occurred when the facility failed to notify the physician of a new skin wound for a resident with multiple complex medical conditions, including congestive heart failure, cellulitis, MRSA infection, dementia, and muscle weakness. The resident, who was severely cognitively impaired and required maximum assistance, was at risk for pressure injuries and had a care plan in place for potential skin breakdown. Despite documentation of a skin tear on the resident's lower left leg, which was treated with steri strips, there was no notification to the physician at the time of the initial injury. Subsequent progress notes indicated ongoing issues with the wound, including the scab reopening and the presence of purulent drainage, but the physician was not notified until several days after the initial incident, at which point orders for wound culture were obtained. Interviews with facility staff confirmed that the expected protocol was to notify the physician and obtain orders when a new open area or skin tear was identified. The Director of Nursing acknowledged that the provider should have been notified when the open area first occurred. The lack of timely physician notification and failure to obtain treatment orders as required by the resident's care plan and facility policy led to the identified deficiency.
Failure to Provide ADL Assistance During Meals for Residents with Cognitive Impairment
Penalty
Summary
The facility failed to recognize and assess the inability of two residents to perform Activities of Daily Living (ADLs), specifically related to eating, and did not implement appropriate interventions according to their assessed needs. Both residents had cognitive impairments, including dementia and severe cognitive deficits, and were identified as being at nutritional risk. Care plans for both residents indicated the need for supervision, set-up assistance, and cuing during meals, as well as adherence to standard ADL and nutrition protocols. Despite these documented needs, observations revealed that staff did not provide adequate assistance or encouragement during mealtimes. One resident was repeatedly observed struggling to eat independently, using her fingers to pick up food from the table, and consuming less than 25% of her meals without staff intervention. Staff members, including RNs, LPNs, and CNAs, were present but did not offer the necessary assistance, such as moving the resident closer to the table, providing encouragement, or helping with feeding. Similar issues were observed with the second resident, who did not attempt to eat and was not provided with timely or effective assistance, despite staff being aware of her needs for set-up and cuing. Interviews with staff confirmed that they relied on the care plan or Kardex to determine the level of assistance required but did not consistently act when residents were observed not eating or having difficulty. The lack of proactive assessment and intervention resulted in both residents not receiving the care and assistance needed to perform ADLs, specifically eating, as outlined in their care plans and facility protocols.
Failure to Promptly Assess and Manage Resident Pain
Penalty
Summary
A deficiency occurred when a resident, who was cognitively intact and enrolled in hospice care, expressed significant pain during personal care. The resident, with a history of pain, dementia, pneumonia, urinary tract infection, and recent falls, repeatedly verbalized pain and requested medication while being assisted by a CNA. Despite the resident's clear and repeated expressions of pain, the CNA continued with care tasks, including transfers and hygiene, without stopping to summon a nurse for assessment or pain management. The facility's pain management policy and standard pain protocol required CNAs to report any signs or symptoms of pain to a nurse immediately, and for nursing staff to assess and manage pain promptly. However, the CNA delayed notifying the nurse, only informing the medication technician after completing care and transferring the resident back to a recliner. The resident's pain assessment and administration of scheduled acetaminophen did not occur until nearly two hours after the initial complaint, and a comprehensive pain assessment by a nurse was not initiated until four hours after the resident first expressed pain. Interviews with facility staff, including the LPN, nurse manager, and DON, confirmed that the expected protocol was not followed. Staff acknowledged that care should have been stopped and a nurse notified immediately for assessment and intervention. The delay in both assessment and administration of pain medication resulted in the resident experiencing prolonged, unaddressed pain, contrary to facility policy and physician orders.
Failure to Adhere to Infection Control Practices and Hand Hygiene
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in the use of personal protective equipment (PPE) and hand hygiene for four residents. One resident with a history of MRSA and severe cognitive impairment was on contact precautions, but staff did not consistently wear the required gown and gloves when providing care. Observations showed that staff entered the resident's room and performed personal care and medication application without donning the appropriate PPE, despite signage indicating contact precautions. Staff interviews revealed confusion and inconsistent understanding regarding when to use gowns and gloves for contact precautions. Hand hygiene practices were also deficient during catheter care and medication administration. In one instance, a staff member providing catheter care to a resident on Enhanced Barrier Precautions failed to perform hand hygiene after removing gloves and before donning new gloves, as well as after completing care. The staff member was unaware of the requirement to use hand hygiene immediately after glove removal and before touching other surfaces. This failure was observed during the process of assisting the resident with toileting and catheter care. Additionally, during medication administration, a nurse was observed preparing and administering medications to two residents without performing hand hygiene at any point between residents or after handling medication cups and other surfaces. The nurse acknowledged forgetting to perform hand hygiene and was reminded of the expectation to do so before and after entering residents' rooms and after providing care. These observed failures demonstrate a lack of adherence to established infection control policies and procedures.
Failure to Post and Update Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that daily nurse staffing information was posted at the beginning of each shift, as required by both facility policy and federal regulations. Observations revealed that the staffing posting in the lobby was outdated, displaying information from several days prior and an incorrect resident census. Interviews with the Administrative Assistant (AA) confirmed that the posting was not updated daily, particularly on weekends, and that changes in staffing due to absences or callouts were not reflected in the postings. The process relied on the AA receiving emails from schedulers and manually updating the form, but this was not consistently done, especially when the AA was not present. Further review of staff schedules and postings over a two-week period showed no updates were made to reflect staff absences. The Director of Nursing (DON) was unable to provide a clear process for ensuring postings were current and accurate, particularly regarding updates for staffing changes or weekend coverage. As a result, the facility did not maintain accurate and timely nurse staffing information in a location accessible to residents and visitors, potentially affecting all 73 residents in the building.
Failure to Accommodate Resident Dietary Preferences
Penalty
Summary
The facility failed to ensure that a resident received meals that accommodated their dietary preferences and restrictions. The resident, who has intact cognition and requires assistance for certain activities, reported receiving food items that were explicitly listed as dislikes on their meal ticket, such as sausage and gravy. Despite notifying the kitchen through an aide, the resident expressed frustration over the recurring issue of receiving incorrect meals. The dietary note for the resident clearly stated their preferences, including no fish, cow, or pork sausage, yet these preferences were not consistently honored. Interviews with facility staff, including a CNA and the Director of Nursing, revealed that meal tickets are supposed to indicate allergies, likes, dislikes, and any special dietary needs. However, there were instances where the dietary staff failed to adhere to these instructions, resulting in residents receiving incorrect meals. The CNA acknowledged that errors in meal preparation and delivery occurred in waves, with periods of accuracy followed by frequent mistakes. The Director of Nursing confirmed that it is expected for kitchen staff to provide meals according to doctor orders and resident preferences, and for staff passing trays to verify the accuracy of meals against the tickets.
Failure to Address Resident-to-Resident Altercations in Care Plans
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for three residents involved in resident-to-resident altercations. Resident 2, who has severe cognitive impairment, was involved in an altercation with Resident 1, but the care plan did not address this incident or include interventions to prevent recurrence. Similarly, Resident 1, who also has severe cognitive impairment and relies on staff for all activities of daily living, had a care plan that noted episodes of verbal and physical behaviors but did not mention the altercation with Resident 2 or include protective measures against Resident 2's behavior. Resident 3, who is non-verbal and dependent on staff for mobility, was involved in an incident where Resident 1 made contact with their head using a rolled-up magazine. However, Resident 3's care plan, dated nearly two years prior, did not address this altercation or include interventions to protect against Resident 1's behavior. Additionally, Resident 1's care plan did not address the altercation with Resident 3 or include measures to prevent recurrence. The Nursing Home Administrator acknowledged the oversight in addressing these incidents in the care plans and behavior monitoring records.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 64 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Merrill
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wood Aven Health And Rehabilitation | 13.6 mi | ★★★★★ | 14 | 0 |
| Amethyst Health Of Wausau | 14.9 mi | ★★★★★ | 7 | 4 |
| Wausau Manor Health Services | 15 mi | ★★★★★ | 10 | 0 |
| North Central Health Care | 15.9 mi | ★★★★★ | 1 | 0 |
| Tomahawk Health Services | 19.7 mi | ★★★★★ | 15 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Pine Crest Health And Memory Care.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.