Pembilier Nursing Center

In the surveyor’s words

From the most serious findings on record at Pembilier Nursing Center, in the surveyor’s own words.

• Actual harm, isolatedF684Jan 25, 2024

  Based on record review, review of professional reference, and review of facility policy, the facility failed to provide care and services to maintain the resident's highest level of well-being for 1 of 1 closed record (Resident #83) transferred to the emergency room (ER) for a change in health status. Failure to monitor and assess the resident's condition on a continuing basis resulted in a worsening of symptoms delay in hospitalization , and possible death. Findings include: Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 189, stated, . Nurses have responsibilities related to both medical and nursing diagnoses. […]

• No harm, potential for more than minimal, widespreadF812Apr 29, 2026

  Based on observation and staff interview, the facility failed to maintain a sanitary kitchen environment for 1 of 1 facility kitchen. Failure to ensure the sanitizer test strips used to test the concentration of sanitizing solution are not expired has the potential for inadequate sanitization and may result in foodborne illness.Findings include:Observation in the kitchen on 04/27/26 at 11:13 a.m. showed a dietary staff member (#4) tested the concentration of a premixed sanitizing solution with test strips that expired October 2025.During an interview on 04/27/26 at 11:25 a.m., a dietary staff member (#4) stated staff should not use expired test strips.

• No harm, potential for more than minimal, patternF880Apr 29, 2026

  Based on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control for 4 of 12 sampled residents (Residents #3, #4, #18, and #20) and 1 supplemental resident (Resident #8) observed during cares. Failure to follow infection control standards for hand hygiene and glove use during cares and while performing procedures has the potential to transmit infections to residents, staff, and visitors. Findings include: Review of the facility policy titled Handwashing/Hand Hygiene occurred on 04/29/26. This undated policy stated, . Staff will perform hand hygiene when indicated using proper technique and consistent with accepted standards of practice. The use of gloves does not replace hand hygiene. […]

• No harm, potential for more than minimal, patternF880Sep 30, 2021

  Based on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control for 3 of 4 days of survey (September 27-29, 2021). Failure to follow infection control practices related to hand hygiene/glove use (Resident #3, #5, and #7) and properly donning personal protective equipment (staff member #5) has the potential to transmit infections to other residents, staff, and visitors. Findings include: HAND HYGIENE/GLOVE USAGE Review of the facility policy titled Personal Protective Equipment occurred on 9/29/21. This policy, revised 2021, stated, . Wear gloves when direct contact with blood, body fluids . is anticipated. Perform hand hygiene before donning gloves and after removal. Gloves are not a substitute for hand hygiene. […]

• No harm, potential for more than minimal, isolatedF583Apr 29, 2026

  Based on observation, review of facility policy, and staff interview, the facility failed to promote privacy and confidentiality of the electronic medication administration record (eMAR) on 1 of 1 medication cart. Failure to promote resident privacy and lock computer screens may result in unauthorized viewing of the residents' private health information records by other residents, visitors, or unlicensed staff. Findings include: Review of the facility policy titled Safeguarding of Resident Identifiable Information occurred on 04/29/26. This undated policy stated, . Facility's policy to implement reasonable and appropriate measures to protect and maintain the safety and confidentiality of the resident's identifiable information . […]