Pioneers Memorial Skilled Nursing Center

In the surveyor’s words

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

• Actual harm, isolatedF689Apr 28, 2026

  Based 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. […]

• Actual harm, isolatedF725Apr 28, 2026

  Based 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. […]

• Actual harm, isolatedF684Feb 20, 2024

  Based 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. […]

• Actual harm, isolatedF686Feb 20, 2024

  Based 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). […]

• No harm, potential for more than minimal, widespreadF732Apr 28, 2026

  Based 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.Findings:On 4/27/26 at 4:18 P.M., a joint interview and record review was conducted with the Director of Staffing Development (DSD). The DSD stated she assisted with scheduling nursing staff while the staffer was on leave. […]