Pioneer Nursing Home

In the surveyor’s words

From the most serious findings on record at Pioneer Nursing Home, in the surveyor’s own words.

• Immediate jeopardy, isolatedF658Dec 10, 2023

  Based on interview and record review it was determined the facility failed to ensure 2 of 2 staff (RNs) adhered to professional standards of nursing practice related to the provision of care for a resident after a fall with potential neck and back injuries. This was determined to be an immediate jeopardy situation which resulted from a lack of assessment of the resident and provision of appropriate neck and spine precautions for 1 of 1 sampled resident (#1) who was injured in a fall resulting in blunt trauma to the back of the resident's head, complaints of neck pain and inability to move extremities. The fall resulted in a cervical spine (neck) fracture and spinal cord injury requiring emergency surgical intervention. […]

• Immediate jeopardy, isolatedF689Dec 10, 2023

  Based on interview and record review it was determined the facility failed to ensure the resident environment remained free of accident hazards including failure to secure the resident's wheelchair during transport in the facility van for 1 of 3 sampled residents (#1) reviewed for falls. The facility's failure was determined to be an immediate jeopardy situation. The fall resulted in a cervical spine (neck) fracture and spinal cord injury requiring hospitalization and emergency surgical intervention. According to hospital records the resident died on [DATE] as a result of this fall. […]

• No harm, potential for more than minimal, isolatedF605Apr 23, 2026

  Based on interview and record review it was determined the facility failed to ensure PRN psychotropic medication orders had an end date and failed to ensure a clinical rationale was obtained to extend the use of PRN psychotropic medications beyond 14 days for 1 of 5 sampled residents (#4) reviewed for medications. This placed residents at risk for adverse side effects of psychotropic medication. Findings include: Resident 4 was admitted to the facility on [DATE] with diagnoses including adult failure to thrive, depression and anxiety. A review of the 2/27/26 admission MDS revealed Resident 4 had a BIMS score of 14 indicating she/he was cognitively intact. The MDS also indicated Resident 4 received hospice services. […]

• No harm, potential for more than minimal, isolatedF838Dec 10, 2023

  Based on interview and record review it was determined the facility failed to conduct and complete a comprehensive facility wide assessment for 1 of 1 sampled facility. This placed residents at risk for lack of quality of care and reduced quality of life. Findings include: On 12/7/23 at 1:30 PM Staff 1 (Administrator) provided a copy of the facility's assessment. The assessment lacked evaluation and information for the following areas: -There was no identification or evaluation of the specific diseases, conditions or physical and cognitive disabilities of the current resident population. -The was no description or evaluation of training programs for staff, including nursing, food service, maintenance or administrative areas. […]

• No harm, potential for more than minimal, isolatedF947Dec 10, 2023

  Based on interview and record review it was determined the facility failed to have a system in place to ensure CNA staff received 12 hours of required in-service training annually for 4 of 5 sampled CNAs (#s 12, 13, 14, 15) and failed to ensure 2 of 2 ALF (Assisted Living Facility) CNAs (#s 12 and 13) received training prior to working in the Nursing Facility reviewed for required in-service training for CNAs. This placed residents at risk for lack of competent staff. Findings include: Review of the facility's CNA staff training records on 12/9/23 at 4:20 PM revealed the following: -Staff 12 (CNA), hired 8/19/21, had three hours of documented training from 8/19/22 through 8/19/23. -Staff 13 (CNA), hired 2/2/11, had six hours of documented training from 2/2/22 through 2/2/23. […]