Pine Valley Community Village

Inspectors wroteBased on interview and record review, the facility failed to employ a full-time Director of Food and Nutrition Services with the appropriate certifications. This has the potential to affect all 64 residents in the facility. The facility's Dietary Manager (DM C) is not a Certified Dietary Manager or a Certified Food Service Manager and has no food service or hospitality specific education.

Inspectors wroteBased on observation, interview, and record review, the facility did not maintain a safe and sanitary environment in which food is prepared, stored and distributed. This has the potential to affect all 64 residents who reside in the facility. Food items were observed to have incorrect or no dating. The facility was not manually checking the internal temperature of their dishwasher. Food items were observed to be improperly stored.

Inspectors wroteBased on observation, record review, and interview the facility did not establish a system of records of receipt and disposition of all controlled drugs, and did not ensure drug records are in order and have an account of all controlled drugs for 1 of 3 sampled residents (R1). R1 does not have a controlled drug receipt/record/disposition form for her hydrocodone/acetaminophen tab (a controlled drug, narcotic). This is evidenced by:The facility's policy Medication Administration, dated 6/6/25, includes: Medications will be provided by Contracted Pharmacy. Upon receipt of medications from pharmacy, both pharmacy and a licensed nurse will sign the controlled administration sheets provided by pharmacy. Narcotic Accounting: All controlled medications will be accounted for each shift by the oncoming and outgoing nurse. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide basic life support, including CPR (Cardiopulmonary Resuscitation), to a resident requiring emergency care and failed to immediately notify emergency medical personnel for 1 of 4 total sampled residents (R1). R1 was found pulseless and not breathing on [DATE]. R1's Physician Orders, Care Plan, CNA (Certified Nursing Assistant) Kardex, EHR (Electronic Health Record) banner, and MAR (Medication Administration Record) indicated R1 was a full code. Staff failed to immediately initiate CPR and immediately contact emergency medical personnel. Facility failure to immediately begin cardiopulmonary resuscitation and immediately summon emergency medical personnel created a finding of immediate jeopardy that began on [DATE]. Surveyor notified NHA A (Nursing Home Administrator) of the immediate jeopardy on [DATE] at 12:00 PM. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide regular in-service education for 5 of 5 staff reviewed for education. This has the potential to affect the total census of 70 residents. CNA G (Certified Nursing Assistant), CNA H, CNA I, CNA J, and CNA K did not have regular in-service education completed every 12 months. This is evidenced by:In Wisconsin, CNAs (Certified Nursing Assistants) are required to complete 12 hours of continuing education annually. This requirement is part of maintaining active status on the Wisconsin Nurse Aide Registry. On 7/22/25 at 9:45 AM, Surveyor requested education documentation for CNA G, CNA H, CNA I, CNA J, and CNA K.CNA G was hired on 9/20/22. CNA G did not have 12 hours of continuing education. CNA H was hired on 8/21/17. CNA H did not have 12 hours of continuing education. CNA I was hired on 6/2/23. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that 5 of 5 staff reviewed for education received mandatory education in effective communication. This has the potential to affect the total census of 70 residents. CNA G (Certified Nursing Assistant), CNA H, CNA I, CNA J, and CNA K did not receive their mandatory education in effective communication. This is evidenced by:On 7/22/25 at 9:45 AM, Surveyor requested evidence of effective communication education for the following staff: CNA G, CNA H, CNA I, CNA J, and CNA [NAME] 7/22/25 at 11:23 AM, NHA A indicated she was unable to provide Surveyor with evidence that effective communication education was provided to CNA G, CNA H, CNA I, CNA J, and CNA K. Surveyor interviewed NHA A regarding CNA education. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that 5 of 5 staff reviewed for education received training regarding the elements and goals of the facility's QAPI program. This has the potential to affect the total census of 70 residents. CNA G (Certified Nursing Assistant), CNA H, CNA I, CNA J, and CNA K did not receive their mandatory QAPI education. This is evidenced by:On 7/22/25 at 9:45 AM, Surveyor requested evidence of QAPI education for the following staff: CNA G, CNA H, CNA I, CNA J, and CNA [NAME] 7/22/25 at 11:23 AM, NHA A was unable to provide Surveyor with evidence that QAPI education was provided to CNA G, CNA H, CNA I, CNA J, and CNA K. Surveyor interviewed NHA A regarding CNA education. NHA indicated CNA G, CNA H, CNA I, CNA J, and CNA K should have received QAPI education but did not receive it.

Inspectors wroteBased on interview and record review, the facility did not ensure that 4 of 5 staff reviewed for education received mandatory training on infection control standards, policies and the overall program. This has the potential to affect the total census of 70 residents. CNA H (Certified Nursing Assistant), CNA I, CNA J, and CNA K did not receive their mandatory infection control education. This is evidenced by:On 7/22/25 at 9:45 AM, Surveyor requested evidence of infection control education for the following staff: CNA H, CNA I, CNA J, and CNA K.On 7/22/25 at 11:23 AM, NHA A was unable to provide Surveyor with evidence that infection control education was provided to CNA H, CNA I, CNA J, and CNA K. Surveyor interviewed NHA A regarding CNA education. NHA indicated CNA H, CNA I, CNA J, and CNA K should have received infection control education but did not receive it.

Inspectors wroteBased on interview and record review, the facility did not ensure that 5 of 5 staff reviewed for education received training on compliance and ethics. This has the potential to affect the total census of 70 residents. CNA G (Certified Nursing Assistant), CNA H, CNA I, CNA J, and CNA K did not receive their training on compliance and ethics. This is evidenced by:On 7/22/25 at 9:45 AM, Surveyor requested evidence of training on compliance and ethics for the following staff: CNA G, CNA H, CNA I, CNA J, and CNA [NAME] 7/22/25 at 11:23 AM, NHA A was unable to provide Surveyor with evidence that compliance and ethics training was provided to CNA G, CNA H, CNA I, CNA J, and CNA K. Surveyor interviewed NHA A regarding CNA education. NHA indicated CNA G, CNA H, CNA I, CNA J, and CNA K should have received compliance and ethics training but did not receive it.

Inspectors wroteBased on interview and record review, the facility did not ensure that residents are free of any significant medication errors for 1 of 3 residents (R1) reviewed for medication errors. R1 was given medications for R4 which made her blood pressure low. R1 required intravenous fluids and calcium gluconate intervention in the ER (Emergency Room). This is evidenced by:The facility's policy, Medication Administration, reviewed 6/2/25, documents, in part, as follows: . The nurse will confirm resident using photo identification located in Electronic Medical record (EMAR), as needed. Medication Administration Safety: Preparing and administering medications requires accuracy and the full attention of the nurse. The five rights, is a traditional checklist to promote accuracy in drug administration. The five rights are as follows: a. Right Drug, b. Right Dose, c. Right Resident, d. Right Route, e. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect all 68 Residents. Surveyor observed 2 opened bags of chicken patties in the walk-in freezer to be unsealed and without a use by or opened date. The temperatures of the kitchenette high temperature dishwashers were below the minimum recommendations on several days for washing.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that all residents are clinically appropriate to self-administer medications for 2 of 2 residents (R23 and R3) reviewed for self-administration of medications. Surveyor observed R23 to have a cup of medications left on her bedside table on her meal tray for her to take independently. R23 did not have an assessment for self-administration of medications and did not have a physician's order. Surveyor observed R3 to have medication at bedside. R3 did not have a self-administration of medication assessment for the medications at bedside and did not have a physician's order. Evidenced by: The facility's Self-Administration of Medications policy, dated 4/30/07, states, in part: [...]

Inspectors wroteBased on record review and interview, the facility did not implement policy and procedures related to screening employees for a prior history of abuse, neglect, exploitation of residents, or misappropriation of resident property for 1 of 8 employees reviewed. RN J (Registered Nurse) did not have a complete background check completed every 4 years. Evidenced by: The facility's policy entitled, Abuse Investigation and Reporting, dated 10/23/22, states, in part: . IV: PROCEDURE: For screening: Employees: All potential employees will be screened for a history of abuse, neglect, mistreatment, or exploitation of a resident or misappropriation of property by attempting to obtain information from previous and current employers and checking with the appropriate licensing boards and registries. The facility will also do background checks on all caregiver staff that are hired by the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that it was free of medication error rates of 5% or greater. There were 11 errors out of 27 opportunities that affected 2 out of 7 residents (R56 & R36) included in the medication pass task, which resulted in an error rate of 40.74%. R56 did not receive morning medications ordered for 7:30 AM at the correct ordered time. R36 did not receive morning medications ordered for 7:30 AM at the correct ordered time. Evidenced by: The facility policy entitled, Medication Administration, dated 4/08/25, states, in part: .Policy: Medication Administration will be accomplished according to physician order, in compliance with long-term care regulation and standard of practice. Procedure: Administration/Documentation: . 7. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that all drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles. Surveyor observed medication on top of an unsupervised medication cart in common space of facility. Evidenced by: The facility's Medication Administration policy, dated 4/10/25, states, in part: .Storage: 1. Medication will be stored in medication carts or in locked medication rooms located on each unit. 2. Medication carts not stored in medication rooms will be locked when not in use or within line of sight of the nurse. On 5/21/25 at 10:01 AM, Surveyor observed R53's bottle of polyethylene glycol powder for oral solution (MiraLAX, a bowel medication) sitting on top of the 300 hall medication cart. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not maintain an infection control program that ensures hand hygiene is performed during wound care per standards of care to help prevent the development and transmission of communicable diseases and infections. This had the potential to affect 1 of 19 sampled Resident (R10). LPN I (Licensed Practical Nurse) did not complete hand hygiene per standards of practice. As evidenced by The facility policy, Wound Cleansing / Wound Irrigations, revised 7/2/15, indicates, in part, as follows: All wounds will be cleansed to remove bacteria and debris with as little chemical and mechanical force as possible, while protecting the healthy granulating tissue. Wound will be cleansed initially and before applying new dressings. While cleansing nurses will use standard precautions Procedure: .6. Wash hands and apply gloves. 7. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that each resident receives treatment and care in accordance with professional standards of practice for 2 out of 8 total sampled Residents (R4 and R5). Staff failed to recognize a change of condition in R5 until the Nurse Practitioner (NP) assessed the patient. Facility staff did not assess and monitor R5's condition as ordered by the physician. R5 was not sent to the emergency room (ER) per the NP's directive until 22 hours later, by which time R5's condition had worsened, resulting in R5 being admitted to Hospital where R5 was diagnosed with Sepsis, Pneumonia, and Acute Respiratory Failure with Hypoxia. R5 passed away two days later at the hospital. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that in response to allegations of abuse, neglect, exploitation, or mistreatment, the alleged violations are thoroughly investigated for 1 of 8 residents (R2) reviewed for abuse. R2 reported to staff she was missing money. SS I (Social Services Director) initiated the investigation, but failed to interview other residents to ensure there were no other allegations or concerns. Evidenced by: The facility policy entitled, Abuse Investigation and Reporting, last revision date of 3/6/2024, states, in part; .For Abuse Investigation: Upon discovery of alleged violations involving mistreatment: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that a Certified Nursing Assistant (CNA) was currently certified on the Nurse Aide Registry before continuing to work in the facility for 1 of 5 staff reviewed. CNA E's Wisconsin Nurse Aide Registry certification was expired and CNA E continued working in the facility.

Inspectors wroteBased on interview and record review the facility did not complete a performance review of every nurse aide at least once every 12 months for 3 of 5 Certified Nursing Assistants (CNAs) reviewed. CNA K did not have an annual performance evaluation completed. CNA L did not have an annual performance evaluation completed. CNA M did not have an annual performance evaluation completed. This is evidence by: The Facilities Policy and Procedure entitled Training/competencies of Nursing Staff dated 8/4/17 documents, in part: The facility will complete a performance review of every CNA at least once every 12 months and provide regular in service education based on the outcome of these reviews. Example 1 CNA K's hire date was 8/6/18. CNA K did not have an annual performance evaluation completed. Example 2 CNA L's hire date was 11/19/18. CNA L did not have an annual performance evaluation completed. [...]

Inspectors wroteBased on observation and interview, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect all 62 Residents. Nutritional supplements and food items were not dated or were expired. Boxes of food were observed sitting on the floor in multiple areas of the kitchen. Facility staff was observed walking through the kitchen without a hairnet. The temperature of a dishwasher was not being monitored.

Inspectors wroteBased on interview and record review, the facility failed to ensure the reporting of a reasonable suspicion of a crime for 2 of 2 residents (R) with allegations of abuse to law enforcement (R49 and R58). On 8/6/23, R58 made an allegation of abuse against a staff member. Law Enforcement was not contacted immediately after the allegation of R58 stating, The black man hurt me last night. R49 made an allegation of abuse and the facility did not contact local law enforcement.