Pioneer Health Care Center

In the surveyor’s words

From the most serious findings on record at Pioneer Health Care Center, in the surveyor’s own words.

• Actual harm, isolatedF689Apr 18, 2024

  Based on observations, record review and interviews, the facility failed to ensure the residents environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for one (#13) of three residents reviewed for accidents/hazards out of 28 samples residents. Resident #13 had been evaluated and determined to be a supervised smoker, which included she was not able to keep smoking supplies with her. The supplies were to be kept and monitored by the facility. During the scheduled smoke breaks, the facility would provide the resident with the cigarette and light the cigarette with a lighter. On 3/29/24 at 12:30 a.m. certified nurse aide (CNA) #8 heard screams coming from Resident #13's room. […]

• Actual harm, isolatedF600Sep 16, 2021

  Based on observations, record review and interviews, the facility failed to ensure residents had the right to be free from physical abuse for four (#34, #62 #65 and #69) residents involved in three facility reported incidents on the South unit out of 46 sample residents. The facility failed to prevent an altercation between Resident #65 and Resident #34. Resident #34 was physically abused by Resident #65, which resulted in Resident #34 requiring hospital treatment where he received 12 staples to his head and medication for pain. Resident #62 was physically abused by Resident #34. Resident #34 pushed Resident #62's wheelchair into a wall resulting in Resident #62's bilateral lower extremities making contact with the wall. […]

• Actual harm, isolatedF684Sep 16, 2021

  Based on record review, interviews and observations, the facility failed to ensure one (#60) of three residents reviewed for post surgical wounds and monitoring out of 46 sample residents received treatment, care and monitoring in accordance with professional standards of practice. Specifically, the facility failed to monitor Resident #60's new post surgical wound and clinically monitor changes in vital signs timely for which she required rehospitalization . Resident #60 admitted to the facility on [DATE] and readmitted on [DATE] with an Intra-abdominal and pelvic mass (which required surgical repair with staples). […]

• Actual harm, isolatedF744Sep 16, 2021

  Based on observations, record review and interviews, the facility failed to ensure a resident who displayed or was diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for five (#34, #62 #65, #50 and #69) of five out of 46 sample residents. Specifically, the facility failed to consistently provide person-centered approaches to Resident #65's dementia care services to address triggered physically aggressive behavior in order to prevent physical altercations with other residents on the secured unit. The facility was aware Resident #65 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF925Aug 29, 2024

  Based on observations, record review and interviews, the facility failed to provide an effective pest control program to ensure the facility was free of pests. Specifically, the facility failed to take the appropriate measures to control a fly infestation in the facility. Findings include: I. Professional reference According to the Center for Disease Control (CDC) Guidelines for Environmental Infection Control in Health-Care Facilities, updated 2/15/19, pp. 94-95, retrieved on 9/5/24 from https://www.cdc.gov/infection-control/media/pdfs/Guideline-Environmental-H.pdf, Cockroaches, spiders, and mice are among the typical pest populations found in health-care facilities. […]