Average — CMS composite of the measures below.
A standard survey is most likely before around December 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 View Care Center during CMS and state inspections, most recent first.
A non-employee visitor, the son of a cook, was allowed into the kitchen and was shown in a publicly accessible social media post actively assisting with kitchen duties, including handling beverage pitchers. The facility’s handbook requires employees to complete TB testing, orientation, and personnel file documentation, and specifies that visitors must enter through reception, be directed or escorted, and that employees are responsible for their visitors’ conduct. The Dietary Manager acknowledged the son was not an employee or volunteer and stated visitors were allowed only to visit in the back of the kitchen and were not permitted to touch food, yet the photo evidence confirmed the visitor was performing food service tasks, demonstrating that food and nutrition service functions were not limited to appropriately trained and authorized staff.
A cognitively intact resident with multiple medical conditions, including chronic pain and depression, reported that while receiving a shower from a CNA, another CNA searched through the resident's purse, which had been tucked away in a nightstand, and removed Tylenol and other medications without permission. An RN documented that oxycodone from home was initially found in the purse and later placed in the medication cart, and believed the CNA had removed it from the purse without knowing if permission had been granted. The CNA stated that after a housekeeper found a pill on the floor and gave it to the CNA, a nurse instructed the CNA to search the resident's room, leading to discovery of medications in the purse on the nightstand; the CNA admitted not having permission to go through the resident's belongings. The DON was unaware of the incident but acknowledged that the CNA should not have searched the resident's belongings without consent.
A deficiency occurred when staff did not thoroughly investigate or implement care plan updates and monitoring after a physical altercation between two residents, one cognitively intact and one severely cognitively impaired with multiple comorbidities. During a church service, one resident objected to another playing cards, attempted to remove the cards, and the other resident slapped the resident’s hand away. Although the incident was self-reported and both residents later described it as minor, record review showed no post-incident monitoring, no documentation addressing a resident’s initial fear, and no new interventions or care plan revisions to prevent recurrence, which the DON acknowledged during interview.
A resident admitted after hip replacement surgery, cognitively intact and continent of bladder, had a baseline care plan indicating stand-and-pivot transfers. Shortly after admission, the resident reported that a CNA, unable to locate a bedpan and concerned about pain with transfers, suggested the resident could void in an incontinent brief if unable to wait, which upset the resident. Review of the baseline and comprehensive care plans showed they were not revised to include person-centered, comprehensive interventions following this incident. Staff interviews revealed that CNAs depend on care plans for transfer and toileting instructions, that care plans are expected to be available at admission, and that bedpans are typically stored in a main supply closet, while the DON acknowledged that no immediate care plan interventions were added after the event.
A resident with severe cognitive impairment and multiple comorbidities, including Alzheimer’s dementia and coronary artery disease, had a care plan requiring Hoyer lift transfers with assistance of two staff. However, staff interviews revealed that CNAs and nursing staff routinely used a sit-to-stand mechanical lift for toileting without a corresponding medical order, while the ADL care plan did not specify equipment for toileting. The RN, DON, and a family member all confirmed that the resident was care planned as a Hoyer lift transfer, and the DON acknowledged there was no current order authorizing the use of the sit-to-stand lift, despite its ongoing use for toileting.
A resident admitted with atrial fibrillation, major depressive disorder, and asthma had multiple missed doses of ordered medications, including ASA, bupropion, famotidine, a fluticasone-salmeterol inhaler, amitriptyline, and duloxetine. Facility policy defined unavailable prescribed drugs as medication errors and required completion of a Medication/Treatment Error Administration Report and timely reporting to the DON or administrator, but no such errors were documented on the incident log. Progress notes contained no evidence that the physician was notified that the medications were unavailable, and the NHA reported being unaware of the missed doses, stating the expectation would have been to contact the physician for further orders.
A resident admitted with atrial fibrillation and other conditions had physician orders for Xarelto and Amiodarone but missed multiple scheduled doses of both drugs because they were unavailable. Nursing documentation noted that one of the medications was held due to unavailability, yet there was no evidence that the provider was notified or that a medication error report was completed, despite facility policy defining unavailable medications as medication errors and requiring timely reporting to the DON or administrator. The NHA later stated they were unaware of the missed doses and that the expectation would have been to contact the physician for further orders.
A resident with dementia and severely impaired cognition, care planned for sit-to-stand lift use for all transfers and dependent for transfers and toileting, was observed being transferred from the bathroom to a wheelchair on a sit-to-stand lift by a single CNA, contrary to facility policy and staff expectations that all mechanical lift transfers require two staff. The CNA acknowledged receiving training, knowing that two staff were required for lift use, and understanding that this resident needed two-person assistance, but proceeded alone because the nurse was busy. Other CNAs, an RN, and facility leadership all confirmed that two-person assistance is required for all lift equipment transfers and that the resident’s care plan called for use of the sit-to-stand lift.
A resident with type 2 DM on a prescribed sliding scale insulin lispro regimen did not receive two ordered insulin doses when blood glucose readings required administration. Facility policy required blood sugar monitoring and sliding scale insulin per MD orders. On two separate occasions, blood glucose values fell within the range requiring 2 units of insulin, but no insulin was given. One missed dose occurred when a nurse became occupied with another resident’s fall and forgot to administer insulin, and the other occurred when a med tech failed to report the blood sugar result to the nurse, resulting in the nurse not giving the ordered dose.
A resident with significant care needs was subjected to verbal abuse and rough handling by a CNA, as witnessed and reported by staff. The resident expressed feeling mistreated and fearful, and the incident was reported to facility leadership. However, the CNA was not removed from resident care during the investigation, which was limited in scope and not reported to the State Agency as required.
The facility did not follow its abuse prevention and reporting policies for two residents. In one case, a CNA was reported for yelling and rough handling, but was not removed from care and the incident was not reported to the State Agency. In another case, staff used a stern tone and inappropriate comments during a transfer, causing anxiety for a resident, but the incident was not fully investigated or reported. Both cases lacked thorough investigation and failed to meet required reporting procedures.
The facility did not report two separate allegations of abuse involving two residents to the State Survey Agency or law enforcement as required. In one case, a staff member reported that a CNA was rough and yelled at a resident, and in another, a family member reported staff using an inappropriate and abrupt approach during a transfer, causing distress to a resident with atrial fibrillation and hypertension. Both incidents were acknowledged by facility leadership as allegations of abuse but were not reported according to policy.
Two residents' allegations of abuse were not thoroughly investigated, with incomplete interviews and no evidence of protective measures or timely reporting to the state. In both cases, staff and family reported rough or inappropriate treatment by CNAs, but the facility failed to follow its abuse policy and regulatory requirements.
A resident with a right below the knee amputation, who required a full body mechanical lift for transfers per their care plan, was transferred using a sit-to-stand mechanical lift by a CNA. This action was not in accordance with the resident's care plan or facility policy, which specifies the use of a full body lift for residents unable to bear weight.
Improper Food Handling and Cross-Contamination During Meal Preparation: A staff member was observed wearing single-use gloves while cooking and touching multiple contaminated surfaces, then handling ready-to-eat food with the same gloves. The staff member picked up a sausage link to temp it, returned it to the container, and used the same contaminated gloves to remove eggs from a container and place them into a Robo coupe. The DON and CFM stated this was not appropriate and that clean hands, new gloves, and utensils should have been used.
A resident's advance directive was not properly documented or accessible in the facility's records, despite policy requirements to discuss and record CPR/DNR orders upon admission. Staff interviews confirmed the absence of necessary documentation, and hospital transfer documents indicating DNR status were not placed in an accessible location.
A facility failed to maintain a medication error rate of 5% or less, with a surveyor observing 2 errors out of 27 opportunities, resulting in a 7.41% error rate. A resident received insulin injections from pens that were not primed as per manufacturer's instructions, due to the RN's lack of awareness about the priming requirement. The DON was also unsure about the facility's policy on insulin pen use.
The facility failed to maintain food safety standards by serving potentially hazardous foods at improper temperatures and transporting uncovered food trays through hallways. Pureed lasagna was served at 128 degrees Fahrenheit, below the required 135 degrees, affecting two residents on a pureed diet. Additionally, an LPN delivered uncovered food items to residents' rooms, contrary to facility expectations.
A resident dependent on staff for eating was fed in an undignified manner by a CNA who repeatedly wiped food from the resident's face with a spoon and re-fed it to them. The CNA was unaware that this practice was inappropriate, and the DON confirmed it violated dignity and infection control standards.
A resident with severe cognitive impairment and significant health issues did not receive adequate assistance with meals, leading to poor nutrition. Despite care plan instructions and therapy recommendations, staff provided minimal help and did not offer alternative foods or fluids. Observations and staff interviews revealed inconsistent and inadequate meal assistance.
The facility failed to conduct a comprehensive trauma-informed assessment and develop a care plan for a resident with a significant history of trauma and related diagnoses, despite the facility's policy requiring such assessments.
A resident received 10 units of Insulin Aspart (Humalog) 58 minutes before their meal, contrary to guidelines that recommend administering rapid-acting insulin within 0-15 minutes before a meal or immediately after. The RN acknowledged the mistake, and the DON confirmed the correct protocol.
Untrained Visitor Allowed to Perform Kitchen Duties and Handle Beverages
Penalty
Summary
The deficiency involves the facility’s failure to ensure that dietary staff had appropriate competencies and that only qualified personnel carried out food and nutrition service functions. A cook’s son, who was not an employee or volunteer of the facility, was observed in a social media post assisting with kitchen duties, including handling beverage pitchers on a counter in the kitchen. The post, which remained publicly visible, included a caption from the cook thanking her son for coming to work with her to help her out. The Division of Quality Assurance received concerns about this situation and obtained photo evidence dated 03/30/26, showing the non-employee son in the facility kitchen handling beverages. Review of the facility’s employee handbook showed that employees are required to undergo a two-stage TB test upon hire, have a 6‑month orientation period, and have a personnel file with identifying information, health and training records, and reference checks. The handbook also states that all visitors should enter through reception, receive directions or be escorted, and that employees are responsible for the conduct and safety of their visitors. The Dietary Manager confirmed that the cook’s children were not employed or volunteering in the kitchen and stated that while the son sometimes visited his mother and was allowed in the back of the kitchen if wearing a hair net and staying near the exit door, visitors were not allowed to touch any food. The surveyor verified the kitchen location from the photo and confirmed with leadership that the social media posting showed the non-employee son actively working in the kitchen, which did not align with facility policies or competency and staffing requirements for food and nutrition services.
Unauthorized Search of Resident Belongings and Removal of Medications
Penalty
Summary
The deficiency involves a failure to honor a resident's right to be treated with respect and dignity and to retain and use personal possessions when a CNA searched through and removed items from a resident's purse without permission. The resident, who was cognitively intact with a BIMS score of 15/15, had diagnoses including aftercare following joint replacement surgery, hypertension, major depressive disorder, chronic pain syndrome, edema, and attention-deficit hyperactivity disorder. The resident reported that while receiving a shower from one CNA, another CNA went through the resident's purse, which had been tucked away in the nightstand, and removed Tylenol and other medications without authorization. The resident stated that the CNA had no business being in the purse and did not know if any other items were taken. Subsequent interviews and record review showed that an RN documented that oxycodone was initially found in the resident's purse and that residents could not have narcotics on their person in the building. The RN stated that the oxycodone prescription bottle from home was retrieved from the resident and placed in the medication cart and believed that the CNA had removed it from the resident's purse but did not know if the CNA had permission or where the purse was located. The CNA later stated that a housekeeper had found a pill on the floor and given it to the CNA, who then showed it to a nurse and was told to look through the resident's room to find its source; the CNA reported finding medications in the resident's purse on the nightstand and acknowledged not having permission to go through the resident's belongings. The DON was unaware of the events and acknowledged that the CNA should not have gone through the resident's belongings without permission.
Failure to Investigate and Care Plan After Resident-to-Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and respond to an alleged resident-to-resident physical altercation and to implement care plan updates and monitoring for two residents. Facility policy states that all alleged violations will be thoroughly investigated and that, when cause or probable cause is determined, the resident care plan will be revised to ensure a corrective plan is in place to prevent recurrence. An incident occurred in which one resident, who is cognitively intact with a BIMS score of 14/15 and diagnoses including right femur fracture, type 2 diabetes mellitus, muscle weakness, and history of falls, was playing cards during a televised church service. Another resident, who has severe cognitive impairment with a BIMS score of 6/15 and diagnoses including atrial fibrillation, Parkinson’s disease, major depressive disorder, anxiety, chronic kidney disease, and history of falls, believed this was disrespectful, attempted to remove the cards, and the first resident slapped or cuffed the other resident’s hand away. The facility self-reported the incident and documented that the residents agreed to distance themselves and that there was no injury or ill effect, with the cognitively impaired resident later describing the event as a “silly little thing” and a “little slap” that did not leave marks. However, the surveyor’s review of the electronic health record showed no monitoring in place related to the incident or to the cognitively impaired resident’s statement to the Director of Social Services about initially being scared. Care plan reviews for both residents showed no updates or added interventions to prevent recurrence following the altercation. Interviews with both residents confirmed that no one had spoken with the cognitively intact resident about how to prevent a similar incident, and the DON acknowledged that no interventions or care plan updates were implemented after the event.
Failure to Revise Care Plan With Person-Centered Interventions After Toileting Incident
Penalty
Summary
The deficiency involves the facility’s failure to revise and update a resident’s comprehensive care plan with person-centered, comprehensive interventions following a reported incident. The resident was admitted after a hip replacement with diagnoses including hypertension, major depressive disorder, chronic pain syndrome, edema, and attention-deficit hyperactivity disorder, and had a BIMS score of 15/15 indicating no cognitive impairment. The baseline care plan dated 04/02/26 indicated the resident was a stand and pivot transfer and was continent of bladder. On 04/03/26, the resident reported that a CNA told the resident to use the incontinent product instead of being assisted to the bathroom because the CNA could not find a bedpan and was concerned about the resident’s pain with transfer. The resident refused to void in the brief and was ultimately assisted to the bathroom but was upset by the situation. Surveyor review of the resident’s baseline and comprehensive care plans showed that no new or revised interventions were added immediately after the reported incident. Staff interviews indicated that care plans and CNA care cards are expected to be created and available at admission, including transfer and bowel/bladder information, and that CNAs rely on these care plans for transfer instructions. One CNA involved in the incident stated there was no care plan ready and no bedpans available, and that the CNA had not received report on how the resident should transfer. Another CNA reported that bedpans are usually kept in the main supply closet and that some staff assume there are none if they are not in the closer, smaller closet. The DON acknowledged that no immediate interventions were placed in the resident’s care plan following the incident.
Improper Use of Sit-to-Stand Lift Contrary to Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received adequate supervision and appropriate assistive devices for transfers as outlined in the resident’s care plan. The facility’s policy on the Resident Assessment Instrument and person-centered care planning requires the IDT to develop and modify care plans to provide appropriate care and services. The resident, admitted with diagnoses including Alzheimer’s dementia, coronary artery disease, hypertension, and peripheral vascular disease, had a Minimum Data Set showing a BIMS score of 3/15, indicating severe cognitive impairment. The ADL care plan, dated 11/11/25, specified that the resident was to transfer via Hoyer lift with assistance of two staff, and toileting required assistance of two, though the toileting section did not specify the transfer equipment to be used. Despite the care plan indicating Hoyer lift transfers, staff interviews revealed that CNAs and nursing staff were using a sit-to-stand mechanical lift for toileting. The resident was unable to provide information about transfers due to impaired cognition. A family member reported believing staff used the sit-to-stand lift for toileting and stated that staff should be using what is ordered, but was not aware of improper transfers. An RN confirmed that the resident was supposed to be a Hoyer lift for all transfers but acknowledged that staff used the sit-to-stand lift for toileting and that they were in discussions with Hospice about obtaining an order for this, which had not yet been obtained. A CNA stated it was their understanding that the sit-to-stand use for toileting was ordered by Hospice. The DON confirmed that the care plan listed the resident as a Hoyer lift and acknowledged there was no current order authorizing the use of the sit-to-stand lift for any transfers, even though staff were using it for toileting.
Failure to Ensure Availability and Administration of Ordered Medications and Physician Notification
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate acquiring, receiving, dispensing, and administration of prescribed medications for a resident, and failure to notify the physician when medications were unavailable. The facility’s own Medication/Treatment Administration Error Policy, revised in April 2025, defines a facility medication error as occurring when a prescribed medication is not available to be administered and requires that, upon discovery of a medication error, the nurse complete a Medication/Treatment Error Administration Report and submit it to the DON or administrator within 24 hours. Despite this policy, the facility’s incident logs contained no identified medication errors related to this situation, and there was no documentation that the physician was notified that medications were unavailable. The resident was admitted with diagnoses including atrial fibrillation, major depressive disorder, and asthma, and had physician orders for multiple medications: aspirin 81 mg daily, bupropion HCl ER 300 mg daily, famotidine 40 mg daily, fluticasone-salmeterol inhaler twice daily, amitriptyline 25 mg daily, and duloxetine 60 mg daily. Review of the admission medication record showed the resident missed 3 doses of aspirin, 2 doses of bupropion, 3 doses of famotidine, 11 doses of the fluticasone-salmeterol inhaler, 3 doses of amitriptyline, and 3 doses of duloxetine. Progress notes did not show any physician notification regarding the unavailability of these medications. During interview, the NHA stated they were not aware the resident had not received the ordered medications and indicated the expectation would have been that the physician be contacted for further direction or orders.
Failure to Administer and Report Unavailable Cardiac Medications
Penalty
Summary
The facility failed to ensure accurate acquiring, receiving, dispensing, and administration of medications for one resident, resulting in multiple missed doses of significant medications without appropriate follow-up. The facility’s own Medication/Treatment Administration Error Policy defines a medication error as occurring when a prescribed medication is not available to be administered and requires completion of a Medication/Treatment Error Administration Report and submission to the DON or administrator within 24 hours of discovery. For this resident, who was admitted with diagnoses including atrial fibrillation, major depressive disorder, and asthma, physician orders included Xarelto 20 mg every evening and Amiodarone 200 mg three times a day. Review of the admission medication record showed the resident did not receive five scheduled doses of Xarelto and eight scheduled doses of Amiodarone. Nursing progress notes documented that Xarelto was held because it was unavailable, but there was no documentation that the physician was notified that Xarelto or Amiodarone were not available for administration. Review of the facility’s incident logs revealed no recorded medication errors related to these missed doses, despite the policy requiring such reporting when medications are unavailable. Further review of the resident’s progress notes did not show any physician notification regarding the unavailability of the medications. During an interview, the NHA stated they were not aware that the resident had not received the medications and indicated that the expectation would have been for the physician to be contacted for further direction or orders.
Failure to Use Required Two-Person Assist for Mechanical Lift Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure the environment remained as free of accident hazards as possible by not following its own policy requiring two staff members for all mechanical lift transfers. The facility’s Body Mechanics - Transfer Training policy, reviewed in 11/2024, specifies that two CNAs, licensed nurses, or therapists are required for mechanical sit-to-stand and full-body lift use. The resident involved, R3, was admitted with dementia and had a BIMS score of 00, indicating cognition not intact. R3’s most recent MDS documented a need for substantial/maximal assistance with bed mobility and dependent assistance with toileting hygiene, sit-to-stand, chair/bed transfers, and toilet transfers. R3’s care plan required use of a sit-to-stand lift for all transfers and documented toileting assistance of one. During observation, the surveyor saw that R3 was transferred from the bathroom to a wheelchair using a sit-to-stand lift by one CNA (CNA D) without a second staff member present. CNA D confirmed she had been trained on safe transfer techniques and knew that two staff were required for lift equipment transfers, and she stated she was aware R3 needed two staff for use of the lift machine but proceeded alone because the nurse was busy and R3 needed to be transferred. Other staff interviewed, including another CNA and an RN, stated that the expectation was that two staff are required for all lift transfers, and review of R3’s care plan by staff confirmed that a sit-to-stand lift was required for transfers, which they understood to mean two staff assistance. Facility leadership also acknowledged that the expectation is for two staff to assist with resident transfers using lift equipment and that this was a concern given repeated staff education on resident safety with lift transfers.
Missed Sliding Scale Insulin Doses for Diabetic Resident
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors related to insulin administration. Facility policy on diabetic blood sugar monitoring, last reviewed in 11/2022, requires that blood sugars be measured and recorded per physician orders and that sliding scale insulin be given as ordered. The resident, admitted with type 2 diabetes mellitus without complications, had a physician order for insulin lispro on a sliding scale four times daily, with specific unit doses tied to blood glucose ranges and an instruction to call the physician for readings over 400. Review of the medication administration record showed that on 02/28/26 the resident’s morning blood sugar was 154, which required administration of 2 units of insulin lispro per the sliding scale order, but no insulin was given. Further review showed that on 03/15/26 the resident’s lunchtime blood sugar was 192, again requiring 2 units of insulin lispro per the physician’s sliding scale order, and no insulin was administered. During an interview on 03/23/26, the Clinical Services Consultant explained that every other weekend a med tech obtains diabetic blood sugars and informs the nurse of the results so the nurse can administer insulin. On 02/28/26, another resident experienced a fall, and the nurse became busy and forgot to administer the ordered insulin dose. On 03/15/26, the med tech did not inform the nurse of the resident’s blood sugar result, and the nurse did not administer the lunchtime insulin dose. The Clinical Services Consultant confirmed that these missed doses constituted medication errors and that insulin should have been administered on both occasions.
Failure to Protect Resident from Verbal Abuse and Rough Handling by CNA
Penalty
Summary
A deficiency occurred when a Certified Nursing Assistant (CNA) engaged in verbal abuse and rough handling of a resident who required extensive assistance with activities of daily living due to diagnoses including renal cancer, urine retention, and hydronephrosis. The resident reported feeling like an animal during care and expressed fear of staff, stating that staff were rough and used inappropriate language. The resident also indicated that they had reported these concerns to facility leadership. Multiple staff interviews confirmed that the CNA was observed swearing at the resident and handling them roughly during care. A housekeeper witnessed the CNA cursing at the resident and placing their legs harshly on wheelchair pedals, and reported hearing the CNA yelling from down the hall. The housekeeper reported the incident to a Registered Nurse (RN), who in turn reported it to the Nursing Home Administrator (NHA). However, neither the housekeeper nor the RN intervened to remove the resident from the situation or to have the CNA leave the room at the time of the incident. Despite the allegations and reports, the CNA was not removed from resident care during the investigation. The facility's investigation was limited, consisting of only three handwritten staff interviews without times or signatures, and did not include interviews with other staff or residents. The incident was not reported to the State Agency as required, and the NHA acknowledged that the event constituted an allegation of abuse but did not take further investigative or protective actions.
Failure to Implement Abuse Prevention and Reporting Policies
Penalty
Summary
The facility failed to implement its policies and procedures prohibiting abuse, neglect, and mistreatment for two residents. In the first instance, a housekeeper reported to a registered nurse that a certified nursing assistant (CNA) was yelling, swearing, and handling a resident roughly during care. The registered nurse reported the incident to the nursing home administrator, but the CNA was not removed from resident care during the investigation. The facility's investigation was incomplete, consisting only of three unsigned, undated handwritten interviews, and no additional interviews with other staff or residents were conducted. The incident was not reported to the State Agency as required by facility policy. In the second case, a family member raised concerns about staff approach and communication during a transfer of another resident who had recently transitioned to using an EZ stand. The family member reported that staff were abrupt, used a stern voice, and made inappropriate comments, causing the resident to become anxious and confused. The staff told the resident she could remain in the chair and go to the bathroom there, then left the room without assisting further. The family member reported the incident to the social worker, who documented it as a grievance. The social worker and administrator both acknowledged the incident could be considered abuse, but the incident was not reported to the State Agency, and a full investigation was not completed. Both incidents demonstrate that the facility did not follow its own abuse policy, which requires immediate safeguarding of residents, thorough investigation of all allegations, and timely reporting to the State Agency. In both cases, the facility failed to remove the alleged perpetrator from resident care during the investigation, did not conduct comprehensive interviews, and did not report the allegations as required by policy and regulation.
Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately to the facility administrator and to the State Survey Agency, as well as to law enforcement, as required by both facility policy and state law. In two separate cases, allegations of abuse were not reported to the appropriate authorities. In the first case, a staff member reported that a CNA was yelling at and being rough with a resident. The Nursing Home Administrator (NHA) acknowledged receiving the report and initiating an investigation but did not report the incident to the State Agency or law enforcement. Documentation of the investigation was incomplete, consisting only of three unsigned, undated handwritten interviews, with no additional interviews from other staff or residents. In the second case, a family member raised concerns about the manner in which staff transferred a resident using an EZ stand, describing the staff's approach as abrupt and inappropriate. The family member reported that staff made negative comments about the resident, such as calling her non-compliant and unmotivated, and told her she could remain in her chair or fall on the floor. The resident became emotional, tearful, and confused as a result. The incident was reported to the facility's social worker and documented as a grievance. Both the social worker and the NHA acknowledged that the incident constituted an allegation of abuse and that it should have been reported to the State Agency within two hours, but no such report was made to the State Agency or law enforcement. The residents involved included one with diagnoses of atrial fibrillation and hypertension, who was newly admitted and unfamiliar with the EZ stand transfer device. The failure to report these allegations of abuse as required by policy and regulation represents a deficiency in the facility's abuse reporting procedures. The events were substantiated through interviews with staff, the NHA, the social worker, and the family member, as well as review of grievance documentation.
Failure to Thoroughly Investigate and Protect Residents Following Abuse Allegations
Penalty
Summary
The facility failed to ensure that allegations of abuse involving two residents were thoroughly investigated, as required by its own policies and federal regulations. In the first instance, a staff member reported that a certified nursing assistant (CNA) was rough and yelled at a resident during a transfer, with the resident's pant leg becoming stuck in the wheelchair. The facility's investigation consisted only of three handwritten interviews lacking interview times and signatures, and did not include interviews with other staff or residents. The nursing home administrator confirmed that no additional interviews were conducted and that the CNA was not suspended or removed from patient care during the investigation. There was also no evidence that protective measures were put in place to prevent further potential abuse during the investigation process. In the second instance, a family member reported concerns about the approach staff used while transferring another resident with an EZ stand, describing the staff as abrupt and communicating inappropriately. The family member stated that staff made negative comments about the resident's motivation and compliance, and told the resident she could remain in the chair. The facility provided interviews with the resident, the family member, and two CNAs (only one of whom was present during the incident). Although the facility provided documentation of staff education on resident approach and abuse policy, the nursing home administrator acknowledged that a full investigation was not completed and that the incident was not reported to the state as required. Both cases demonstrate that the facility did not follow its own abuse policy, which mandates immediate safeguarding of residents, thorough investigation of all alleged violations, and reporting to the state agency within specified timeframes. The lack of comprehensive investigations and failure to implement protective measures for the residents involved resulted in noncompliance with regulatory requirements for responding to allegations of abuse.
Improper Transfer Method Used for Resident with Amputation
Penalty
Summary
A deficiency occurred when a resident with a right below the knee amputation, who was care planned for transfer with a full body mechanical lift and assistance of two staff, was instead transferred using a sit-to-stand mechanical lift. The facility's policy specifies that residents who cannot sit, stand, or bear weight should not be lifted manually and require a mechanical assist. Despite this, a Certified Nursing Assistant (CNA) used a sit-to-stand lift for the transfer, contrary to the resident's care plan and facility policy. This action was confirmed through interviews with the CNA and the Nursing Home Administrator, as well as review of the resident's care plan and facility policy.
Improper Food Handling and Cross-Contamination During Meal Preparation
Penalty
Summary
The facility did not follow proper food handling practices to prevent foodborne illness. During observation, staff were seen touching ready-to-eat foods with contaminated gloves. The report states that the facility policy on personal hygiene and cross contamination prevention prohibited bare hand contact with ready-to-eat foods and required use of approved alternatives such as tongs, serving utensils, waxed paper squares, or clean gloves. On 09/16/2025 at 7:39 AM, a staff member identified as [NAME] C was observed wearing single-use gloves while cooking and touching multiple potentially contaminated surfaces with those gloves, including the serving tabletop, aluminum foil box, ladle, spatula, microwave, and Robo coupe puree machine. [NAME] C then picked up a sausage link with the contaminated gloved hand, inserted a thermometer probe into the sausage, and returned the sausage link to the container. [NAME] C also used the contaminated gloved hand to remove eggs from a container and place them into the Robo coupe. The DON and CFM later stated that this was not appropriate and that clean hands, new gloves, and utensils such as tongs, a spoon, or a ladle should have been used.
Failure to Maintain Advance Directive for Resident
Penalty
Summary
The facility failed to formulate and maintain an advance directive for Resident 185, which is a requirement to honor the resident's right to request, refuse, and/or discontinue treatment. Upon admission, the facility's policy mandates that a licensed nurse or social worker discuss options such as Cardiopulmonary Resuscitation (CPR) or Do-Not-Resuscitate (DNR) orders with the resident or their legal representative and obtain the corresponding physician orders. However, during the survey, it was found that Resident 185 did not have any orders for CPR or DNR on file, nor was there a Provider Orders for Scope of Treatment (POST) form available in the resident's hard charts or electronic records. Interviews with facility staff, including a Registered Nurse and a Quality Consultant, revealed that the usual process for determining a resident's CPR or DNR status involved checking the most recent signed orders in the hard charts. Despite this, no such orders were found for Resident 185, and the staff acknowledged that the necessary documentation was not accessible. Although there were hospital transfer documents indicating the resident's DNR status, these were not placed in a location where staff would typically look during an emergency. The Quality Consultant confirmed that the DNR orders were not in the expected location and took steps to contact the hospital for the necessary documentation.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or less, as observed during a medication administration task. The surveyor noted 2 errors out of 27 medication opportunities, resulting in an error rate of 7.41%. This deficiency affected one resident, who received two insulin injections using injectable pens that were not properly primed according to the manufacturer's instructions. The insulin pens used were Basaglar Kwikpen (insulin glargine) and Insulin Aspart, both requiring priming to ensure accurate dosing. During the observation, a registered nurse (RN) did not prime the insulin pens before administering the doses to the resident. The RN was unaware of the need to prime the pens, indicating a lack of training or knowledge regarding the proper procedure. The Director of Nursing (DON) was also uncertain about the facility's policy on insulin pen use and whether priming was necessary, although they later acknowledged the manufacturer's instructions were not followed. This oversight in medication administration procedures led to the identified deficiency.
Deficiencies in Food Safety and Handling Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, specifically in the storage, preparation, distribution, and serving of food. Surveyors observed that potentially hazardous foods were not served at appropriate temperatures, which could increase the risk of illness for residents. During the survey, it was noted that food items such as pureed lasagna were served at temperatures below the required 135 degrees Fahrenheit. The Dietary Aide recorded a temperature of 128 degrees Fahrenheit for the pureed lasagna, which was not reheated before being served to residents on a pureed diet. This oversight affected two residents who were served the pureed meal without the necessary temperature adjustments. Additionally, the facility did not cover food items while transporting room trays through hallways and past resident rooms. Observations included uncovered bowls of cereal, juice, and coffee being delivered to residents' rooms by an LPN, who walked significant distances with the exposed food. This practice was contrary to the facility's expectations, as stated by the Dietary Manager, who acknowledged that food should be covered when transported outside of the holding cart. These deficiencies in food handling and transportation practices were identified during the survey, highlighting lapses in maintaining food safety standards.
Resident Fed in Undignified Manner
Penalty
Summary
The facility did not assist one resident with eating in a dignified manner. The resident, who is dependent on staff for eating, was observed being fed by a Certified Nursing Assistant (CNA) who repeatedly wiped food from the resident's lower lip and chin with a spoon and then fed the food back to the resident. This practice was observed during both lunch and breakfast on separate days. The CNA indicated that she was not aware that using a spoon to wipe food from a resident's face and refeeding it to them was undignified and had not been instructed otherwise. The Director of Nursing (DON) confirmed that it is inappropriate for staff to wipe residents' chins or lips with a spoon and re-feed them due to dignity and infection control reasons. The facility's policy on Meal Service Standards, which emphasizes serving residents in a dignified and courteous manner, was not followed in this instance. The DON indicated that staff reeducation would be initiated to address this issue.
Failure to Provide Adequate Assistance with Meals for Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to ensure that a resident with severe cognitive impairment received the necessary assistance with meals to maintain good nutrition. The resident, who has Alzheimer's disease and other significant health issues, was observed struggling to eat independently during multiple meal times. Despite the resident's care plan and speech therapy recommendations indicating the need for verbal cues and physical assistance during meals, staff provided minimal assistance and did not offer alternative foods or fluids when the resident did not consume the provided meal. During lunch, the resident was observed eating only a small portion of the meal and engaging in inappropriate eating behaviors, such as pouring juice over the meal and attempting to drink milk with a spoon. Staff made only one attempt to assist the resident and did not offer any alternative foods or fluids. Similarly, during breakfast, the resident was left unattended for extended periods, and staff did not provide timely assistance or offer alternative foods. The resident consumed very little of the meal and was not given additional fluids or finger foods despite the care plan's instructions. Interviews with staff revealed a lack of consistent and adequate assistance for the resident during meals. The Certified Dietary Manager was unaware of the specific issues observed and stated that finger foods and double breakfasts were provided, but these were not observed during the survey. The Registered Dietitian and Speech Therapist confirmed the resident's need for assistance and direction during meals. The Director of Nursing and a Registered Nurse acknowledged the deficiency and indicated plans to educate staff and address the issue immediately.
Failure to Conduct Trauma-Informed Assessment and Care Planning
Penalty
Summary
The facility failed to comprehensively assess a resident (R31) for trauma-informed care and develop care plan approaches to mitigate any triggers to prevent re-traumatization. The facility's policy on providing culturally competent and trauma-informed care requires a multi-faceted approach to identifying resident history of trauma and cultural preferences, including the use of various assessment tools. However, the surveyor found that no trauma-informed assessment was conducted for R31, who is a military veteran with diagnoses including PTSD, alcohol dependence in remission, bipolar disorder, and other mood disorders. R31 reported no recollection of any facility staff discussing his history or potential stress triggers with him. The Assistant Nursing Home Administrator (ANHA) confirmed that a comprehensive trauma-informed assessment was not completed for R31, and thus no care plan was developed to address potential triggers. Although the ANHA mentioned having a conversation with R31 about his diagnosis and potential triggers, there was no documentation of this discussion in R31's record. The lack of a comprehensive assessment and care plan for R31, despite his significant history of trauma and related diagnoses, constitutes a deficiency in providing trauma-informed care as per the facility's policy.
Improper Timing of Insulin Administration
Penalty
Summary
The facility did not provide pharmaceutical services to meet the needs of a resident reviewed for insulin administration. Specifically, a registered nurse (RN) administered 10 units of Insulin Aspart (Humalog) to the resident's right arm at 6:59 AM, but the resident did not begin eating their meal until 7:57 AM, which was 58 minutes after the insulin was given. This timing is inconsistent with guidelines that rapid-acting insulins should be administered within 0-15 minutes before a meal or immediately following a meal to optimize blood sugar control. During an interview, the RN acknowledged that she thought the meal would be served around 7:30 AM and admitted that she should have ensured the insulin was administered closer to the meal time. The Director of Nursing (DON) confirmed that the expectation is for rapid-acting insulin to be administered within 5-10 minutes of a meal or right after. The surveyor explained the observation to the DON, who stated that she would address the issue with education.
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 24 citations issued within 25 miles in the last 12 months — 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 Black River Falls
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Meadowbrook At Black River Falls | 0.4 mi | ★★★★★ | 14 | 0 |
| Grand View Care Ctr | 18.6 mi | ★★★★★ | 0 | 0 |
| Pigeon Falls Hcc | 19.5 mi | ★★★★★ | 0 | 0 |
| Trempealeau Cty Hcc Imd | 23.3 mi | ★★★★★ | 2 | 0 |
| Rolling Hills Rehab Ctr | 23.7 mi | ★★★★★ | 8 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.