Pioneer Health Care Center

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Environmental Deficiencies

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Egress Deficiencies

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Services Deficiencies

Have an externally vented heating system.

Miscellaneous Deficiencies

Have restrictions on the use of flammable curtains.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

Nursing and Physician Services Deficiencies

Observe each nurse aide's job performance and give regular training.

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Quality of Life and Care Deficiencies

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Infection Control Deficiencies

Perform COVID19 testing on residents and staff.

A complaint survey, prompted by #CO39394, #CO39398, #CO39420, Incident #39335 and Incident #39408 was conducted on 3/3/25 to 3/4/25. One deficiency was cited. Based on observations, record review and interviews, the facility failed to ensure two (#4 and #6) of four residents reviewed for abuse out of seven sample residents were kept free from abuse.Specifically, the facility failed to:-Protect Resident #4 from physical abuse by Resident #5; and, -Protect Resident #6 from physical abuse by Resident #2.Findings include:I. Facility policy and procedureThe Abuse and Neglect policy, undated, was provided by the director of nursing (DON) on 3/4/25 at 11:14 a.m. It read in pertinent part, "Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish."The physician and staff will help identify risk factors for abuse within the facility. "The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect."II. Incident of physical abuse towards Resident #4 by Resident #5 on 2/8/25 A. Facility investigationThe investigation documented the following:On 2/8/25 it was alleged that Resident #5 hit Resident #4 in the head while walking past her in the hall. The incident was witnessed by Resident #7. Both residents were placed on 15-minute checks. The facility substantiated the abuse.A. Resident #5 (assailant)1. Resident statusResident #5, age greater than 65, was admitted on 11/11/17 and readmitted on 12/12/22. According to the March 2025 computerized physician orders (CPO), diagnosis included schizophrenia, unspecified dementia with behavioral disturbances and wandering. The 1/16/25 minimum data set (MDS) assessment revealed, per staff assessment, the resident was rarely or never understood. He had short and long-term memory problems. His cognitive skills for daily living were moderately impaired. He had inattention and disorganized thinking which fluctuated. He required moderate assistance with bathing. He was independent with positioning, transfers and walking. He received an antipsychotic (medication to tr..

A complaint survey, prompted by #CO37238, #CO37269, and #CO37270 was conducted on 8/27/24 to 8/29/24. Three deficiencies were cited. Based on observations and staff interviews, the facility failed to maintain a sanitary, orderly and comfortable environment for residents in 28 of 55 resident rooms. Specifically, the facility failed to ensure:-The walls, ceilings, baseboards and floors were properly maintained;-The resident' s rooms were cleaned and free of mice feces, flies; and, -The wooden handrails in the hallways were cleaned and free of wood splinters.Findings include: I. ObservationsObservations of the resident' s living environment were conducted on 8/27/24 at 9:44 a.m. and revealed the following:Room #100: The ceiling had three missing 12 inch by 12 inch tiles. The walls had several sections approximately four inches in circumference on the wall next to the bathroom. The resident had a five drawer dresser in the corner of his room with each drawer containing dried mice droppings. The floor was sticky. There were tissues and other trash under the resident' s bed. Room #113: The wall next to the bathroom had chipped and peeling plaster.. Based on observations, record review and interviews, the facility failed to ensure residents received proper respiratory treatment and care for three (#3, #2 and #7) of four residents reviewed for supplemental oxygen use out of 10 sample residents. Specifically, the facility failed to:-Administer oxygen in accordance with the physician' s order for Resident #3 and #2; and,-Ensure a physician' s order was in place for Resident #7' s continuous use of oxygen. Findings include:I. Facility policy The Oxygen Administration Policy, revised October 2010, was provided on 8/29/24 at 10:47 a.m. by the corporate consultant (CC). It read in pertinent part, "The purpose of this procedure is to provide guidelines for safe oxygen administration." II. Resident # 3 A. Resident status Resident #3, age 74, was admitted on 3/19/21. According to the August 2024 computerized physician orders (CPO), diagnoses included depression, delusional disorder, chronic obstructive pulmonary disease (COPD). &nb.. 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. Insects and rodents can serve as agents for the mechanical transmission of microorganisms, or as active participants in the disease transmission process by passing pathogens from one source to another. Insects and rodents should be kept out of all areas of a health-care facility.&..