Pioneers Memorial Skilled Nursing Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of three residents (Resident 1 and 2), who were cognitively impaired and had a history of repeated falls, were free from falls with injury when:-Resident 1 and Resident 2's supervision needs were not assessed and care planned with individualized interventions to prevent falls.-Adequate supervision was not provided to Resident 1 and Resident 2.-The root cause of Resident 1 and Resident 2's falls were not thoroughly investigated. As a result:-Resident 1, who was placed in front of the nursing station for supervision, fell from his wheelchair on 3/26/26 after he made repeated attempts to stand up without staff being close enough to intervene. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure it had sufficient nursing staff on duty to provide supervision to 14 of 14 residents who were at high risk for falls and needed increased supervision due to cognitive impairment when:1. Resident 1, who was placed in front of the nurses' station on 3/26/26 for supervision, made repeated attempts to stand up from his wheelchair while staff were busy performing other tasks. Resident 1 had an unwitnessed fall at 5:29 A.M. while in front of the nurses' station.2. Resident 2, who was placed in front of the nurses' station for supervision on 1/15/26, had an unwitnessed fall at 6:30 A.M. while staff were busy performing other tasks.3a. Residents 40, 41, 42, 3, and 44, were placed in front of the nurses' station on Unit B for supervision on 4/27/26. Consistent supervision was not provided to these residents.3b. [...]

Inspectors wroteBased on interview and record review, the facility failed to post nursing staffing information which reflected the actual hours worked for staff responsible for resident care. In addition, actual hours worked for nursing staff were not available upon request. As a result, staffing information reflecting actual hours worked was not readily available in a readable format to residents and visitors at any given time. In addition, the facility was unaware of actual hours worked by its nursing staff.

Inspectors wroteBased on interview and record review, the facility failed to revise fall care plans with resident-specific interventions that addressed supervision needs for two of three residents (Resident 1 and 2) after falls occurred. As a result, there was the potential Resident 1 and 2 to experience further falls.

Inspectors wroteBased on interview and record review, the facility failed to ensure a registered nurse/unit manager (UM) 2 provided care and services to one of three residents (Resident 1) according to acceptable standards of nursing practice when she falsified a fall interdisciplinary team (IDT) note for Resident 1. As a result of this deficient practice, UM 2's falsified documentation misrepresented the facility's investigation into Resident 1's fall and fall aftercare.

Inspectors wroteBased on interview and record review, the facility failed to ensure pain management was provided to one of three residents (Resident 1) according to acceptable standards of practice, when:1. Resident 1's pain was not assessed on 3/26/26 when the resident was behaving in an agitated and antsy manner.2. Resident 1's pain assessments were based off a self-rated numeric scale (resident self-rates their pain level with 10 being the most pain possible and zero being no pain) when the resident was not cognitively able to express pain that way.3. Resident 1's pain care plan was not individualized or resident specific. As a result of these deficient practices, there were nursing staff who were unaware of how Resident 1 expressed pain. This had the potential for Resident 1's pain to go unmanaged.

Inspectors wroteBased on interview and record review, the facility failed to ensure its facility assessment (documented assessment of the facility's resident population and resources needed to provide care to residents) addressed and/or clearly described:1. The care required by residents with dementia/cognitive impairment.2. How the facility determined its resident acuity for purposes of sufficient staffing.3. The specific staffing needs on each resident unit to meet the needs of residents requiring increased supervision. As a result, the facility did not provide sufficient nursing staff to meet the supervision needs of residents with dementia/cognitive impairment. Cross reference F689 and F725.

Inspectors wroteBased on interview and record review, the facility failed to ensure a licensed nurse/unit manager (UM) 2 accurately documented a fall interdisciplinary team (IDT) note for one of three residents (Resident 1). As a result of this deficient practice, UM 2's falsified documentation misrepresented the facility's investigation into Resident 1's fall and fall aftercare.

Inspectors wroteBased on observation, interview, and record review, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify concerns related to lack of supervision and adequate nurse staffing as contributing to some of the facility's resident falls. This failure had the potential for deficiencies to remain uncorrected and placed the facility's residents' safety at risk. Cross reference F689 and F725.

Inspectors wroteBased on interview, and record review, the facility failed to ensure necessary care and services were provided according to the facility's fall policies and procedures for one resident (Resident 1) reviewed during a Facility Reported Incident (FRI) investigated after an unwitnessed fall. This deficient practice delayed Resident 1's necessary post-fall care and diagnosis (identifying injury from its signs and symptoms using tests) of multiple rib (chest bone) fractures that were sustained.

Inspectors wroteBased on interview, and record review, the facility failed to provide supervision and maintain a safe environment to prevent accidents for one resident (Resident 1) which resulted in an unwitnessed fall. As a result, this deficient practice resulted in harm for Resident 1, who sustained multiple rib (chest bone) fractures and pain.

Inspectors wroteBased on observation, interview and record review, the facility failed to store foods under sanitary conditions when eight loaves of bread with use by labels (date when food should be consumed) were not discarded. This failure had the potential to cause food contamination and spread food-borne illness (illness resulting from contaminated food) in a population of 72 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure confidential information was kept private for one of five sampled residents (Resident 28 ). As a result, Resident 28's right to privacy and confidentiality was violated.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide communication tool for 2 of 18 sampled residents (Resident 13 and Resident 36). As a result, there was a potential for Resident 13 and Resident 36 to not be able to communicate their needs to staff and effect their quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the needed care for one of three residents (Resident 54) when Resident 54's skin discoloration was not assessed and documented for monitoring. This failure had the potential for nursing staff to not identify any deterioration on Resident 54's skin discoloration which could result in delay of treatment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a gastric tube (GT - tube surgically inserted inserted into the stomach to provide food and medication) was free from a possible complication for one of one resident (Resident 23) when Resident 23's GT had an air bubble (pocket of air trapped)in the line. This failure had the potential to compromise Resident 23's health condition.

Inspectors wroteBased on observation, interview and record review, the facility failed to replace an oxygen cylinder for one of three residents (Resident 61) in a timely manner. This failure had the potential for Resident 61 to run out of oxygen and affect her wellbeing.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Licensed Nurse followed the physician order and had adequate competency in providing care to: 1. 4 of 18 (Resident 2, Resident 13, Resident 23, and Resident 52) sampled residents with low air loss mattress (mattress that uses air to relieve pressure). 2. 2 of 19 (Resident 2 and Resident 72) sampled residents with wound vacuum (wound vac - a device that uses negative pressure to help wounds heal). This failure had the potential risk to resident's care and well-being.

Inspectors wroteBased on interview and record review, the facility failed to provide a registered nurse (RN) for at least eight hours a day to 99 residents. This failure had the potential to affect residents care, health, and wellbeing.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure administration of medication were implemented per physician orders to 2 of 18 sampled residents. This failure had the potential risk to the residents' well-being and care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication error rate for medication pass did not exceed 5 percent. There were 25 medication opportunities. Four medication errors were identified. The error rate was 16%. This failure had the potential to cause harm to the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection control procedures were maintained in the facility when: 1) A water reservoir tank was observed to be leaking and with greenish black substance. 2) A suprapubic catheter (a tube inserted into the bladder through a cut in the tummy to drain urine from the bladder) bag and dignity bag (a bag used to cover and conceal contents inside), was lying on the floor for one of three residents reviewed for urinary catheter care (Resident 13). These failures had the potential for the spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assure that resident rooms housed no more than four residents. Two rooms had the potential to accommodate five residents in each room (rooms [ROOM NUMBERS]). Seven rooms had the potential to accommodate six residents in each room (Rooms 2, 3, 4, 5, 13, 15, and 18). As a result, the potential existed to impact resident care and quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assure that resident rooms measured at least 80 square feet per resident in resident room [ROOM NUMBER]. As a result, the potential existed to impact resident care and quality of life.

Inspectors wroteBased on observation, interview and record reviews, the facility failed to provide two-person physical assistance with transferring for one of one resident (Resident 1) when Resident 1 was transferred from bed to the Hoyer lift by a staff alone. This failure had the potential to result in harm or even death.

Inspectors wroteBased on interview and record review, the facility failed to ensure a care plan (a document providing a way of communication among facility staff) was revised for one of two residents (Resident 1) when Resident 1 ' s care plan did not reflect that he had an inappropriate behavior toward a female resident. This failure had the potential for Resident 1 ' s inappropriate behavior to continue.

Inspectors wroteBased on interview and record review, the facility failed to provide the necessary care and treatment for one of five residents (Resident 51) reviewed for diabetes (a chronic [long lasting] health condition that affects how your body turns food into energy) care when: • Resident 51's physician was not notified of the resident's hypoglycemic (low blood sugar) episodes. • Resident 51's blood sugar was not monitored in accordance with the standard of practice (scope and authority related to a specific activity by defining who can do what activity, with what level of supervision and when) for residents with diabetes. • Resident 51 received multiple oral diabetic medications. As a result, Resident 51's became unresponsive and was sent to the hospital on 1/31/24. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent a further decline of a pressure ulcer (skin damaged by lack of movement due to staying in a position for too long), for one of six residents (Resident 35) reviewed for pressure ulcer. As a result, Resident 35's sacral (tailbone) pressure ulcer worsened from a stage II (shallow wound like a blister or abrasion) to a stage III (full thickness tissue injury; open wound that goes deeper into the tissue beneath).

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care and services to maintain the highest quality of life, when haircuts were not provided for one of two resident (Resident 42) reviewed for Activities of Daily Living (ADL-basic daily care such as showers, grooming, dressing, nail care, and personal hygiene). The facility failed to ensure a system was in place to address the haircut needs for all 83 residents in the facility, when haircutting services were not offered or provided by the facility from April 1, 2023 through February 14, 2024 (a 10-month period). As a result, all residents had the potential for diminished dignity and self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to develop an effective Quality Assurance Performance Improvement (QAPI) program, when the committee did not consistently track, address, and follow up on quality issues affecting the residents as follows: 1. The call light system was not functional for several days. Cross reference: Title 22, 72541 2. Infection control practices were not implemented when Covid immunizations were not offered to residents. Cross reference F887 3. A pressure ulcer worsened for a resident. Cross reference F686 4. Haircuts were not offered to residents over an 10-month period. Cross reference F676 5. A resident with diabetes had unidentified hypoglycemia for two days, leading to a 10-day hospitalization. Cross reference F684 6. Gradual Dose Reductions (GDRs) were not routinely performed for residents on antipsychotic medications. [...]

Inspectors wroteBased on interview and record review, the facility failed to have an effective Quality Assurance Performance Improvement (QAPI) program, when the committee did not consistently track, address, and follow up on quality issues affecting the residents as follows: 1. The call light system was not functional for several days. Cross reference Title 22 72541 2. Infection control practices were not implemented when Covid immunizations were not offered to residents. Cross reference F887 3. A pressure ulcer worsened for a resident. Cross reference F686 4. Haircuts were not offered to residents over an 11-month period. Cross reference F676 5. A resident with diabetes had unidentified hypoglycemia for two days, leading to a 10-day hospitalization. Cross reference F684 6. Gradual Dose Reductions (GDRs) were not routinely performed for residents on antipsychotic medications. [...]

Inspectors wroteBased on interview and record review, the facility Quality Assurance Performance Improvement (QAPI) committee failed meet at least quarterly, and as needed to develop meaningful activities that identified areas for improvement. This failure had the potential to affect the safety and quality of care provided to residents. Cross reference: Title 22 72541, F887, F686, F676, F684, F758, HSC 1418.8.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement individualized care plans for three of 18 residents sampled (Residents 14, 51, 7). These failures had the potential for the residents to not receive the care and services needed to preserve optimal health status and prevent further decline.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Consistently evaluate Fall Risk Assessments and conduct Care Conferences after each resident fall, in order to prevent future falls for two of four residents (Residents 19, 49), reviewed for falls, and 2. Complete continuous quarterly safety smoking evaluations for five of five residents reviewed for smoking (Resident 22, Resident 60, Resident 5, Resident 21, and Resident 26). As a result, there was the potential for additional falls with possible injuries and for residents who smoked to be at risk for smoking-related burn injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to document non-pharmaceutical interventions or gradual dose reductions (GDR) for three of five residents (Resident 3, 42, and 10) reviewed for unnecessary medication review. As a result, Resident's 3, 42 and 10 did not have non-pharmaceutical interventions attempted and Gradual Dose Reductions were not initiated per Federal and State regulations.

Inspectors wroteBased on interview and record review, the facility did not ensure Governing Body had an effective oversight and necessary resources for resident care services. Governing Body (the entity responsible for establishing and implementing facility policies) failed to ensure effective oversight and necessary resources to ensure resident care services were met to attain or maintain the highest practical physical, mental, and psychosocial well-being of each resident. This failure had the potential to affect the quality of care to residents. Cross Reference: F726, F732, F841 and HSC 1418.8, F865, F867, F868, F880, F887, Title 22 72541

Inspectors wroteBased on interview and record review, the facility's Medical Director (MD 1) did not oversee care area concerns related to psychotropic drug (mind-altering drugs) use and Gradual Dose Reductions (GDR) for 38 out of 83 residents, listed on the facility Matrix currently receiving psychotropic medications. As a result, 38 residents were not having their psychotropic medications evaluated monthly, and their care needs were not addressed in a timely manner such as no psychotropic care conferences and no GDR were attempted for nine months. (Cross reference to F-758 and H&S Code 1418.8)

Inspectors wroteBased on interview and record review, the facility failed to: 1. Offer/re-offer/administer COVID-19 vaccinations to five residents (56, 30, 73, 52, 55) sampled for COVID-19 vaccination and 34 residents (64, 55, 81, 85, 193, 2, 22, 84, 40, 19, 15, 76, 79, 1, 26, 83, 39, 56, 11, 5, 33, 23, 67, 80, 17, 51, 78, 82, 44, 31, 36, 190, 240, 192) newly admitted to the facility after 9/14/23. 2. Accurately document COVID-19 vaccination refusals on the facility's vaccination tracking list. 3. Implement their policy and procedure titled COVID-19 Vaccination Program. As a result of this deficient practice, there was the potential for residents, staff, and visitors to be placed at risk for COVID-19 infection.

Inspectors wroteBased on interview and record review, the facility was unaware of an Advanced Directive (a legal document which lists preferences for life-saving measures) related to a resident wishes for resuscitative efforts (life-saving measures) for one of three residents (Resident 36), reviewed for Advanced Directives. As a result, there was the potential Resident 36's wishes for resuscitative efforts would not be honored.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe, homelike environment when: 1. An exterior resident room door for one of 25 rooms (room A) had peeling paint, and 2. An exterior shower room door frame for one of two shower rooms (Station B), had holes and exposed drywall, along with two protruding nails. As a result, there was the potential for residents to experience diminished self-worth and the possibility of injury from the environment hazards (peeling paint and protruding nails).

Inspectors wroteBased on interview and record review, the facility failed to capture and transmit accurate MDS (a clinical assessment tool) information to the Centers for Medicare and Medicaid Services (CMS-a Federal agency), for two of five residents (Resident 3 and Resident 36) reviewed for Resident Assessment. This failure had the potential to affect the care and services provided to Resident 3 and Resident 36.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Pre-admission Screening and Resident Review Level 2 (PASARR- a Federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) was completed after a new diagnoses of schizophrenia was made for one of one resident (Resident 3) reviewed for PASARR. As a result, there was potential for Resident 3 to be improperly placed at the facility where necessary services were not available.

Inspectors wroteBased on observation, interview and record review, the facility failed to update and revise individualized care plans for two of 18 residents sampled (Residents 19, 21). These failures had the potential for the residents to not receive the care and services needed to preserve optimal health status and prevent further decline.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a recommendation for diet changes related to weight loss was followed up for one of three residents reviewed for nutrition (Resident 21). This failure had the potential to affect the health and well-being of Resident 21.

Inspectors wroteBased on observation, interview, and record review, the facility failed to date and time enteral tube feedings (a method of delivering nutrition in liquid form into the stomach through a tube), feeding for two of two residents (Resident 49 and Resident 81), reviewed for tube feedings. As a result, there was the potential for Resident 49 and 81 to have complications related to the tube feedings and/or risk for infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify a resident's source of pain for one of one residents reviewed for pain management (Resident 7). This failure had the potential for Resident 7 to experience unrelieved pain. (Cross Reference F656)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the physician (MD 2) supervised and managed the care of one of three residents reviewed for nutrition (Resident 21). This failure had the potential for Resident 21 to experience additional weight loss and other medical complications affecting his overall well-being. Cross reference:

Inspectors wroteBased on interview and record review, the facility failed to ensure staff were competent in managing residents with diabetes (abnormal blood sugar levels) for one of three residents reviewed for closed record review (Resident 51). This failure had the potential to negatively affect Resident 51's health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the nurse staffing data was posted and readily accessible to the residents and public, and to accurately document the total number and actual hours worked by the nursing staff. As a result, staff and the public were unaware of the daily facility staffing.

Inspectors wroteBased on observation, interview and record review, the facility failed to label and store medications properly when: 1. A medication was left unsecured and unmonitored at a nurses station, 2. A medication was stored improperly within a medication cart, and 3. An Automated Drug Dispensing System (ADDS) was not being monitored for temperature controls. These failure had the potential for accidental ingestion of an unprescribed medication, and for medications to be at risk for degradation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow food preferences during meal service for one of two residents, (Resident 73) reviewed for choices. As a result, Resident 73 felt ignored and disrespected.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, date, and protect food under sanitary conditions in one of two freezers (mobile kitchen freezer), reviewed for kitchen sanitation. This improper food safety practice had the potential to cause foodborne illness and/or food contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one Staff 21 adhered to proper glove use and hand hygiene (acceptable methods for cleaning hands such as handwashing or using hand sanitizer) while bringing soiled linens into the facility laundry. This deficient practice had the potential to spread harmful microorganisms around the facility which could lead to residents developing infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assure that resident rooms housed no more than four residents. Two rooms had the potential to accommodate five residents in each room (rooms [ROOM NUMBERS]). Seven rooms had the potential to accommodate six residents in each room (Rooms 2, 3, 4, 5, 13, 15, and 18). As a result, the potential existed to impact resident care and quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assure that resident rooms measured at least 80 square feet per resident in resident room [ROOM NUMBER]. As a result the potential existed to impact resident care and quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff followed infection control practices and appropriate transmission-based precautions when: 1. An ice scoop was found laying on top of the ice in the ice chest in one of two nursing stations (Station A). 2. A resident (Resident 55) was observed crossing into and out of a red zone area (a designated Isolation area). 3. Two of eight urinary catheter drainage bags were in contact with the floor. ( Resident 26 and 61). 4. A staff member did not don (to put on) PPE (personal protective equipment) when entering one of one transmission based isolation room. 5. A licensed nurse (LN) did not perform hand hygiene or change gloves during medication administration. These failures had the potential to increase the risk of infection to residents and staff within the facility due to cross - contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a call light assessable to activate for one of one resident (Resident 39) reviewed for accommodation of needs. As a result, there was the potential for Resident 39 to not have her needs met.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Physicians Orders for Life Sustaining Treatment (POLST-a form which indicated a resident's code status) forms and the code status (the level of medical interventions a person wishes to have if their heart or breathing stops) order was available to the staff for two of three residents reviewed for Advanced Directives (Residents 42 and 46). This failure had the potential for Resident 42 and Resident 46 to receive incorrect care in the event of a medical emergency.

Inspectors wroteBased on interview and record review, the facility failed to develop person-centered comprehensive care plans for two of six residents (Resident 22 and Resident 39), reviewed for care plans. As a result, there was a potential for inconsistent care and for the needs of Resident 22 and 39's to not be met. 1. Resident 22 was admitted to the facility on [DATE] with diagnoses which included left hemiplegia (left sided weakness) following a cerebral infarction (stroke), per the facility's admission Record. On 12/15/22, Resident 22's clinical record was reviewed. According to the physician's order, dated 12/9/22, the resident was admitted to hospice (end of life, comfort care). There was no documented evidence a hospice care plan had been developed. On 12/15/22 at 9:26 A.M., an interview was conducted with LN 17. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently provide catheter (a tube inserted into the bladder) care for one of four residents (44) reviewed for catheter. This failure had the potential to increase the risk of urinary infection for Resident 44.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow a physician's order related to oxygen use for one of one resident (12) reviewed for respiratory care. This failure had the potential for Resident 12 to develop oxygen toxicity (an adverse effect).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dialysis (the process of cleaning the blood through a machine) access site was properly cared for timely for one of one resident investigated for dialysis (37). The deficient practice had a potential for Resident 37's dialysis access to clot.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure proper food storage's were met when expired food were found in the refrigerator. This failure has the potential to result in harmful bacteria growth and cross contamination that could lead to foodborne illnesses to residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assure that resident rooms housed no more than four residents. Two rooms had the potential to accommodate five residents in each room (rooms [ROOM NUMBERS]). Seven rooms had the potential to accommodate six residents in each room (Rooms 2, 3, 4, 5, 13, 15, and 18). As a result, the potential existed to impact resident care and quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assure the resident rooms measured at least 80 square feet per resident in resident room [ROOM NUMBER]. As a result, the potential existed to impact resident care and quality of life.