Pigeon Falls Hcc

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Staffing

How full it usually is: this home is certified for 37 beds and averages 35.8 residents a day — about 97% occupied, or roughly 1 bed typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.65 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.91 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.37 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.41 hrs/resident/day on weekends vs 3.75 on weekdays — 9% thinner on weekends. RN hours go from 1.07 to 0.51 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 14% is below the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

• Potential for harm · Fcited before2025-07-23 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review, the facility failed to distribute food under sanitary conditions. This had the potential to affect all 35 residents. Observations revealed Food Service Worker (FSW) F serving and handling food on 2 of 3 days of survey with his facial hair cover under the level of his lips, allowing his moustache to remain uncovered.This is evidenced by: The facility policy titled Uniform Dress Code, dated last revised 01/24/25, states in part: Associates working with food .-Wear the approved hair restraint when on duty regardless of length or presence of hair.-Restrain all facial hair with a beard net/restraint.On 07/21/2025 at 12:15 PM, Surveyor observed FSW F in the main dining room kitchen area. FSW was plating food for multiple residents. As FSW F did this, he wore a facial hair cover under the level of his lips which allowed his moustache to remain uncovered. On 07/22/2025 at 9:00 AM, Surveyor observed FSW F go into the dining room kitchen area, retrieve food and take it to the main kitchen. As FSW F did this, he wore a facial hair covering…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-07-23 · tag F0605 — failed to not use drugs as a restraint — isolated
  Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, a resident's medication order was not limited to 14 days, and prescribing practitioner did not document the rationale for the extended time use or a specific duration for use for 1 of 2 sampled residents, (R) R21, reviewed for PRN (as needed) psychotropic medications. R21 was prescribed PRN Hydroxyzine for anxiety on 06/06/2025; there was no rationale for extended use written and no specific duration for use.This is evidenced by: R21 was admitted to the facility in 2016 and has diagnoses that include anxiety disorder, vascular dementia, cerebral infarct, depressive disorder, dysphagia and aphasia. R21's physician order dated 06/06/25 states: Hydroxyzine 25mg as needed two times a day for anxiety. Review of R1's medication administration record (MAR) revealed R1 used Hydroxyzine 25mg for anxiety on 06/07/25, 06/09/25, 06/13/25, 06/16/25, 07/01/25, 07/02/25, 07/17/25, and 07/22/25. On 07/21/25-07/23/25, Surveyor reviewed R21's medical record and was unable to locate a rationale for the extended use for the as needed Hydroxyzine and did not locate…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-07-23 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure that the resident received treatment and care in accordance with professional standards of practice of comprehensive weekly wound assessments for 1 of 1 resident (R) 5 reviewed. This is evidenced by:R5 was admitted to the facility on [DATE]. R5's current diagnoses include in part, non-pressure chronic ulcer of left lower leg and long term use of anticoagulants.Minimum Data Set (MDS) dated [DATE] a quarterly assessment documented a brief interview for mental status (BIMS) score of 15/15, meaning R5 is cognitively intact. R5 had no impairment to all extremities and is independent with activities of daily living. R5 is not at risk for pressure injuries. On 05/01/25, a Braden assessment for risk of pressure injury was completed with a score of 21. A score of 19 or higher the resident is not at risk for pressure injury. Physician orders document on 07/18/25 Change dressing to L lower leg area. Cleanse wound with cleanser, Apply collagen particles and…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-07-23 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure 1 of 2 residents (R) reviewed for pressure injuries (PI) received care consistent with professional standards of practice to prevent the development of a new pressure injury and promote healing of existing PIs (R8).R8 developed one medical device related PI on 05/20/25. The facility did not have preventive measures to reduce friction related to medical device in place. The facility did not complete weekly comprehensive assessments with staging of the PI upon discovery and did not care plan new interventions timely to promote healing.This is evidenced by:Facility policy titled, Pressure Ulcers, Prevention & Treatment, with a reviewed date of 01/2025, states in part: General Guidelines of Prevention: 3. Pressure can also come from splints, casts, bandages, and wrinkles in the bed linen. If pressure ulcers are not treated when discovered, they quickly get larger, become very painful for the resident/client, and oftentimes become…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-07-23 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
  Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure residents (R) with indwelling Foley catheters received care and treatment consistent with professional standards of practice to prevent complications or urinary tract infections from the catheter, for 1 of 1 resident (R7) reviewed with a Foley catheter. R7's Foley catheter was changed on a routine monthly basis without clinical indications and not following professional standards of practice. This is evidenced by:The Centers for Disease Control and Prevention (CDC), Healthcare Infection Control Practices Advisory Committee (HICPAC), Guideline for prevention of catheter-associated urinary tract infections 2009, read in part, E. Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised. Facility's policy titled, Catheter, Foley Insertion, with the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-07-23 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, 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 for 1 of 1 resident (R) (R5) observed.Facility did not place enhanced barrier precautions (EBP) for R5 who has an open wound. Facility staff did not wear appropriate Personal Protective Equipment (PPE) when providing wound care for R5. Activity Aide E was observed to perform ineffective hand hygiene. This is evidenced by: Example 1 Facility's policy titled Enhanced Barrier Precautions with reviewed date 01/08/25, documented 2.b. An order for enhanced barrier precautions (in accordance with physician-approved standing orders) will be initiated for residents with any of the following: i. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers)…even if the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2023-05-10 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, interview and policy review, the facility did not prepare and distribute food under sanitary conditions. This has the potential to affect 35 of 35 residents. Staff were observed touching food with contaminated gloves. Scoop left in flour bin. Staff not properly washing hands. Dirty dishes crossing clean dishes. Dietary staff observed to touch food and clean items with contaminated gloves, observed to change gloves without washing hands and observed to place paper directly onto peoples food. This is evidenced by: On 05/08/23 at 12:10 PM, Surveyor was observing lunch being served on Hickory Heights Dining Room. Dietary Staff (DS) E has gloved hands, serving up plates, using same gloved hands to hold baked potato with one gloved hand and used a knife to cut in half then serving up another plate, with same gloved hands, touching resident meal slips with same gloved hands, pulled at mask with gloved hands, grabbed and held a baked potato with left gloved hand and cut with knife, touching resident meal slips with same gloved hands, pulled up mask over her nose with…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

CMS files one row per role, so the 24 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

What families pay in WI