Pierz Villa Inc
PIERZ VILLA INC in PIERZ, MN — inspection on January 29, 2026.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
physician order for a nebulizer.Findings include:R45 was admitted on 1/2726. R45's diagnosis
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. TMA-A gave R45 the oral medications. TMA-A set up R45's nebulizer, put the Ipratropium-albuterol nebulizer solution in the medication cup and screwed it onto the face mask which was put on R45's face. TMA-A turned on the nebulizer machine and left R45 in the room alone.
TMA-A went to dispense another resident's medications. At 8:40 a.m. TMA-A stated I check on the resident when the nebulizer is running. TMA-A stated the nebulizer took about ten minutes. TMA-A stated sometimes I sit in the room with the resident until the nebulizer is done. An observation on 1/28/26 at 8:50 a.m., TMA-A went back to R45's room and made sure all the medication was dispensed out of the medication cup. TMA-A turned off the nebulizer machine, took the face mask off of R45. TMA-A had R45 rinse her mouth out and spit into a cup. TMA-A rinsed off the mask and medication cup and let air dry in R45's room.An interview on 1/29/26 at 10:45 a.m. with the case manager (CM)-A stated a SAM was done upon admission if required. CM-A stated I do not always do them but if it is a nebulizer that was ordered I would do an assessment. CM-A stated there was no SAM completed for R45. CM-A stated the registered nurse (RN) that admitted R45 on 1/27/26, must have missed it. CM-A stated the SAM should have been completed before the TMA left R45 alone with the nebulizer running. CM-A stated the TMA should have stayed in the room when the nebulizer was running to make sure all of the medication was given. An interview on 1/29/26 at 12:41 p.m., with the director of nursing (DON) stated a SAM assessment was done with a nebulizer and inhaler physician order. DON stated the nurse should do this assessment upon admit, before they gave the medications, and staff should stay in the room with the resident until the medication was done and until the SAM was completed.
The DON stated it was the residents right to be able to administer the medication by themselves and they did not want to take away their rights.
The DON stated R45 did not have a SAM, and it would be corrected.The facility policy Self-Administration of Medications and Nebulizers dated 12/25, indicated each resident had the right to self-administer mediation unless the practice was determined unsafe. On admission to the facility, the residents would be informed of the right to self-administer medication.
The interdisciplinary team will assess the resident's cognitive, physical and visual ability to carry out this responsibility.
Nursing would get an order from the physician for self-administration of medications.
Documentation of the ability to self-administer mediations would appear on the resident's care plan and on the electronic medication administration record.
245286 01/29/2026
Pierz Villa Inc 119 Faust Street Southeast Pierz, MN 56364
During interview on 1/26/26 at 7:04 p.m., R34 stated he had a personal funds account at the facility, however, did not receive any statements for this account. R34 stated he made his own financial decisions and was his own responsible party. R34 stated he could get money from his personal funds account but had 'no idea' how much money he had available as he did not receive a statement reflecting that information.
During interview on 01/28/2026 at 11:04 a.m. administrative assistant (AA) stated she was aware there had previously been a tracking system in place to ensure statements were sent however she was unable to locate any system that could identify statements were being sent to residents or their representatives. (AA) went on to state she was unsure of the last time statements were sent to residents or their representatives.
During interview on 1/28/26 at 11:13 a.m. facility Administrator stated there had been a delay in the system and it had been a few months since statements were sent to residents or their representatives.
Admin stated she became aware of the situation in July but acknowledged statements were not sent until September 2025.
Admin stated R34 requested and was given a statement in December 2025 when he requested money from his personal funds account.
Admin stated she was unaware of any document that reflected dates and times of statements being sent to residents or their representatives.
She went on to say she expected statements to be sent out at least every quarter and when requested by residents.
Admin stated it is important to provide residents with these statements to residents so they can manage their financial status and maintain their highest level of independence. A facility policy titled Resident Personal Funds with a last review date of 11/2025 indicated resident personal funds would be deposited into a separate account at the facilities financial institution and would be managed by the facility business office. A monthly statement will be mailed to the party responsible (resident/resident representative).
245286 01/29/2026
Pierz Villa Inc 119 Faust Street Southeast Pierz, MN 56364
Beneficiary Notice (SNFABN-10055) was provided to 1 or 3 residents (R59) reviewed for Beneficiary
(MDS) dated [DATE], indicated R59 was admitted on [DATE] and Medicare Part A discharge date of 8/13/25.R59's Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN), informed R59 services would end on 8/14/25.
However, this notice was given outside of the 48 hours prior to services ending requirement and was provided on 9/22/25.On 1/22/26 at 1:14 p.m., the MDS Coordinator (MDSC) stated the facility had struggled to identify the correct payer source for the resident and once they did they had R59 sign an SNFABN, however they were unable to locate form and had R59 sign a new SNFABN on 9/22/25.
The MDSC confirmed it was outside the required 48 hours prior to the end of services.On 1/22/25 at 10:18 a.m. the administrator stated their expectation was for the beneficiary notices to be provided to the residents 48 hours prior to the end of their services, and they were important to provide so the residents are aware of their payment changes and they may be responsible for payment.The facility policy was requested and was provided an undated document titled Beneficiary Notice Guidelines which indicated R59 should have received an SNFABN.
During observation and interview on 1/26/26 at 1:30 p.m., DD was observed in front of the empty ice machine and stated she threw out all the ice and was doing a deep clean of the unit.
She went on to state the cleaning and maintenance of the ice machines was the duty of the maintenance department and she could not identify when the ice machine had last been cleaned or serviced.
During interview on 1/26/26 at 2:22 p.m., maintenance director (MD) stated he cleaned and serviced the ice machine, however, it was not on a routine schedule. MD stated he was unsure how often the ice machine needed to be deep cleaned/sanitized.
A document with a handwritten title of ICE MACHINE PM indicated the ice machine had been cleaned 1/30/25, 5/6/25, 9/2/25, and 12/16/25. In the right margin was a handwritten note by each date that said, filter change.
Facility policy for ice machine cleaning and maintenance was requested and was not received.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
245286 01/29/2026
Pierz Villa Inc 119 Faust Street Southeast Pierz, MN 56364