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Deficiency Records for Pioneers Memorial Skilled Nursing Center
A list of the most recent deficiencies for Pioneers Memorial Skilled Nursing Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Pioneers Memorial Skilled Nursing Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2024-02-20 | 2024-05-06 | N |
| 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. | Health | 2024-02-20 | 2024-04-25 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2024-02-20 | 2024-04-11 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-02-20 | 2024-04-11 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-02-20 | 2024-04-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-02-20 | 2024-04-11 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-02-20 | 2024-04-11 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2024-02-20 | 2024-04-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-20 | 2024-04-11 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-02-20 | 2024-04-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-20 | 2024-04-11 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-02-20 | 2024-04-11 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2024-02-20 | 2024-04-11 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-02-20 | 2024-04-11 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2024-02-20 | 2024-04-11 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2024-02-20 | 2024-04-11 | N |
| Post nurse staffing information every day. | Health | 2024-02-20 | 2024-04-11 | N |
| 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. | Health | 2024-02-20 | 2024-04-11 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2024-02-20 | 2024-04-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-20 | 2024-04-11 | N |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2024-02-20 | 2024-04-11 | N |
| Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. | Health | 2024-02-20 | 2024-04-11 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2024-02-20 | 2024-04-11 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-02-20 | 2024-04-11 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2024-02-20 | 2024-04-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-02-20 | 2024-04-11 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2024-02-20 | 2024-04-11 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-02-20 | 2024-03-04 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2024-02-20 | 2024-03-04 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2024-02-20 | 2024-03-04 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-02-20 | 2024-03-04 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-02-20 | 2024-03-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-02-20 | 2024-03-04 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-02-20 | 2024-03-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-02-20 | 2024-03-04 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-02-20 | 2024-03-04 | N |
| Meet other general requirements. | Fire Safety | 2023-09-06 | 2023-09-26 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2023-09-06 | 2023-09-26 | Y |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-09-06 | 2023-09-26 | Y |
| Use approved construction type or materials. | Fire Safety | 2023-08-18 | 2023-09-25 | Y |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-08-18 | 2023-09-25 | Y |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-08-18 | 2023-09-25 | Y |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-18 | 2023-09-25 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-08-03 | 2023-08-24 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-03 | 2023-08-24 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-04-12 | 2023-05-10 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-04-12 | 2023-05-10 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-02-21 | 2023-03-07 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2022-12-20 | 2023-01-12 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-12-20 | 2023-01-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-20 | 2023-01-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-12-20 | 2023-01-12 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-12-20 | 2023-01-12 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-12-20 | 2023-01-12 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-12-15 | 2023-01-06 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-12-15 | 2023-01-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-15 | 2023-01-06 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-12-15 | 2023-01-06 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-12-15 | 2023-01-06 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-12-15 | 2023-01-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-15 | 2023-01-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-15 | 2023-01-06 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2022-12-15 | 2023-01-06 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2022-12-15 | 2023-01-06 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-11-23 | 2022-12-22 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-09-01 | 2022-09-19 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-28 | 2022-01-30 | Y |
| Provide primary/alternate means for communication. | Fire Safety | 2020-01-15 | 2020-02-03 | N |
| Use approved construction type or materials. | Fire Safety | 2020-01-15 | 2020-02-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-15 | 2020-02-03 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2020-01-15 | 2020-02-03 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2020-01-15 | 2020-02-03 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2020-01-15 | 2020-02-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-01-15 | 2020-02-03 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-12-05 | 2020-01-06 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-12-05 | 2020-01-06 | N |
| 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. | Health | 2019-12-05 | 2020-01-06 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-12-05 | 2020-01-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-12-05 | 2020-01-06 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-12-05 | 2020-01-06 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-12-05 | 2020-01-06 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-12-05 | 2020-01-06 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-12-05 | 2020-01-06 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-12-05 | 2020-01-06 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-12-05 | 2020-01-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-12-05 | 2020-01-06 | N |
| Put firmly secured handrails on each side of hallways. | Health | 2019-12-05 | 2020-01-06 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2024-02-20 | Not Fixed | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2024-02-20 | Not Fixed | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2019-12-05 | Not Fixed | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-12-05 | Not Fixed | N |
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