Pioneer Skilled Nursing Center

In the surveyor’s words

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

• Immediate jeopardy, patternF678May 24, 2021

  Based on interview and record review, the facility failed to provide proper Cardio Pulmonary Resuscitation (CPR, emergency procedure that combines chest compressions often with artificial ventilation in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person who is in [CONDITION(S)]) for one resident (Resident #1) who had a [CONDITION(S)] (permanent or temporary opening into the trachea (windpipe) in which a [CONDITION(S)] (tube) is inserted to provide an airway and to remove secretions from the lungs) and was a full code in a review of four sampled residents, when staff did not provide breaths to the resident during CPR. The resident expired. […]

• Immediate jeopardy, isolatedF684Jun 13, 2023

  Based on interview and a closed record review for six residents, the facility failed to notify one resident's physician (Resident #55) timely when the resident had continued diarrhea after the implementation of medication to stop diarrhea, incontinence and vomiting with stomach pain. In addition, the facility failed to notify the resident's physician timely of abnormal laboratory results, faxing rather than calling the physician. The physician did not see the laboratory results for review for two days (faxed on [DATE], a weekend, and not reviewed until [DATE]). The resident had repeatedly requested to be sent to the hospital for treatment over a period of twelve days. The resident's physician was not aware of these repeated requests. […]

• Immediate jeopardy, isolatedF695May 24, 2021

  Based on interview and record review, the facility failed to ensure care staff, including licensed nurses, were proficient in the care of a tracheotomy (a tube placed through an opening in the windpipe for respiration), prior to accepting one resident with a tracheotomy, (Resident #1) of four sampled residents. The facility failed to ensure the resident's baseline care plan addressed his/her tracheotomy, failed to ensure orders were in place regarding care of the tracheotomy, and failed to ensure staff were trained to appropriately place an ambu bag (a hand-held device commonly used to provide positive pressure ventilation to residents who are not breathing or not breathing adequately) to provide respirations for a resident with a tracheotomy during cardiopulmonary resuscitation (CPR). […]

• Actual harm, isolatedF600Jan 26, 2023

  Based on interview and record review, the facility failed ensure two residents (Residents #1 and #2), in a review of three sampled residents, were free from abuse when Certified Nurse Assistant (CNA) A was forceful and cursed at Resident #2 during care, and made derogatory comments and was forceful and restrained Resident #1 when assisting him/her to eat his/her meal. Both residents, who have dementia, were upset in response to the abuse at the time the abuse occurred. Nurse Aide (NA) B reported CNA A yelled at Resident #1, taunted the resident, told the resident he/she was crazy, and restrained the resident's arms and shoved the spoon in the resident's closed mouth. Resident #1 responded with crying, flinched as CNA A put the spoon to his/her mouth, and spit food at CNA A. […]

• No harm, potential for more than minimal, widespreadF812Mar 20, 2025

  Based on observation, interview and record review the facility failed to ensure the range hood was free of a buildup of grease and debris, failed to ensure food items were closed/sealed, discarded when expired, and stored according to the manufacturer's label; failed to ensure the wall behind the fryer was free of a buildup of grease; and failed to ensure one refrigerator in the kitchen was equipped with a thermometer. The facility census was 47. 1. Review of the undated facility policy, Kitchen Hood Inspection and Cleaning, showed the following: -A safe and healthful work environment will be provided for all employees, residents and visitors. […]