Pierz Villa Inc

In the surveyor’s words

From the most serious findings on record at Pierz Villa Inc, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Jan 29, 2026

  Based on observation, interview and document review, the facility failed to ensure 1 of 2 ice dispensers for resident use were maintained in a clean and sanitary manner. This had the potential to affect all residents residing at the facility. Findings include: During the initial kitchen tour on 1/26/26 at 12:02 p.m., the following was observed and confirmed by the facility Dietary Director (DD). An ice machine located in the kitchen was noted to be approximately half full of ice. The mechanism inside the machine where ice cubes were formed was noted to have a slimy brownish green substance coating the tray. The interior motor mechanism was noted to have a slimy brownish black substance on the pump and the wall immediately adjacent to the pump. […]

• No harm, potential for more than minimal, widespreadF851Mar 19, 2024

  Based on document review and interview, the facility failed to submit complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data, during 1 of 1 quarter reviewed (Quarter 1), to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS. Findings include: Review of the Payroll Based Journal (PBJ) [NAME] Report 1705D identified the following dates triggered for review: 10/21/23, 10/22/23, 10/29/23, and 11/11/23 for failure to have licensed nurse coverage 24 hours per day. Review of applicable nursing staff's timecards on the above-mentioned dates identified licensed nursing staff had worked 24 hours each day, therefore the data submitted in the PBJ to CMS was inaccurate. […]

• No harm, potential for more than minimal, patternF883Mar 19, 2024

  Based on interview and document review, the facility failed to ensure 4 of 5 residents (R20, R25, R29, R34) were appropriately vaccinated against pneumococcal disease upon admission and/or offer updated vaccination per Centers for Disease Control (CDC) vaccination recommendations. This had the ability to affect all 43 residents. Findings include: Review of the current CDC pneumococcal vaccine guidelines located at https://www.cdc.gov/vaccines/vpd/pneumo/hcp/pneumo-vaccine-timing.html, identified for: Adults [AGE] years of age or older, staff were to offer and/or provide based off previous vaccination status as shown below: a) If NO history of vaccination, offer and/or provide: aa) the PCV-20 OR bb) PCV-15 followed by PPSV-23 at least 1 year later. […]

• No harm, potential for more than minimal, isolatedF641Jul 23, 2026

  Based on interview and document review the facility failed to ensure the Minimum Data Set (MDS) was accurately coded to reflect facility acquired pressure ulcers for 1 of 1 resident (R3) reviewed with a pressure ulcer.Findings include:R3's Face Sheet indicated she admitted to the facility 6/11/26. R3'ds diagnoses included contact dermatitis, pressure ulcers of buttocks right and left, and pressure ulcer of sacral region.R3's hospital Progress Notes dated 6/5/26, identified pressure injuries to right and left heels.R3's Head to Toe Skin assessment dated [DATE], identified blanchable redness to R3's buttocks. The assessment indicated R3 did not have a pressure ulcer.R3's care plan dated 6/11/26, identified a risk for pressure ulcers. […]

• No harm, potential for more than minimal, isolatedF554Jan 29, 2026

  Based on observation, interview, and document review, the facility failed to ensure a self administration of medications (SAM) assessment was completed for 1 of 1 resident (R45) who had a physician order for a nebulizer.Findings include:R45 was admitted on 1/2726. R45's diagnosis included sepsis syndrome, congestive heart failure, respiratory failure, influenza A, and pneumonia. R45's physician orders indicated an order for Ipratropium-albuterol (combination medication used to treat bronchospasm associated with chronic obstructive pulmonary disease (COPD)) 0.5-2.5 mg (milligram) 3ml (milliliters) inhalation four times a day.An observation on 1/28/26 at 7:56 a.m., trained medication assistant (TMA)-A set up R45's physician ordered medications. TMA-A brought R45's medications to the room. […]