Above average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Pine Crest Health And Memory Care during CMS and state inspections, most recent first.
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.
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.
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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 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 | ★★★★★ | 37 | 4 |
| Wausau Manor Health Services | 15 mi | ★★★★★ | 12 | 0 |
| North Central Health Care | 15.9 mi | ★★★★★ | 22 | 0 |
| Tomahawk Health Services | 19.7 mi | ★★★★★ | 15 | 1 |
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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.