Pigeon Falls HCC

In the surveyor’s words

From the most serious findings on record at Pigeon Falls HCC, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Jul 23, 2025

  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. […]

• No harm, potential for more than minimal, widespreadF812May 10, 2023

  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. […]

• No harm, potential for more than minimal, widespreadF880Apr 20, 2022

  Based on interview, observation, and record review, the facility did not maintain an infection prevention and control program (IPCP) that included a system for identifying, investigating, and controlling infections and communicable diseases for all residents. Additionally, staff did not adhere to standard precautions to prevent spread of infections. This had the potential to affect all 37 residents. The facility did not implement a plan for identifying and monitoring, that included resident surveillance of fever, respiratory illness, or other signs/symptoms of COVID-19 at least daily and identify residents that required laboratory testing and/or the implementation of appropriate transmission-based precautions. This occurred for 3 of 3 newly admitted residents (R236, R237, and R35). […]

• No harm, potential for more than minimal, widespreadF563Feb 3, 2021

  Based on observation, record review and interview, the facility did not honor the resident's right to receive visitors of his or her choosing at the time of his or her choosing, and in a manner that does not impose on the rights of another resident. This practice had the potential to affect 33 of 35 residents. The facility did not expand their visitation guidelines to allow private and uninterrupted visits according to current standards of practice and visitation recommendations outlined in the CMS QSO 20-39NH memo Nursing Home Visitation - COVID 19 dated September 17, 2020. This is evidenced by: CMS QSO-20-39 NH states, .facilities may not restrict visitation without a reasonable clinical or safety cause, consistent with §483.10(f)(4)(v). […]

• No harm, potential for more than minimal, patternF812Apr 20, 2022

  Based on observation and interview, the staff did not distribute food under sanitary conditions on 2 of 3 days of survey. Staff was observed to handle clean items and serve food with contaminated gloves. The same staff was observed to do dishes and go between clean and dirty items without changing gloves or performing hand antisepsis. Staff was observed to dish up a resident's food with no hair restraint on. Staff was observed to transport food thru the halls of the facility uncovered. Staff was observed to touch ready to eat foods with contaminated gloves on during meal service. This is evidenced by: The facility policy entitled, Safety & Sanitation, date revised September 2013, states in part: The number one cause of cross-contamination by team members is improper hand washing. […]