Other·January 29, 2020

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during a recertification survey conducted on 12/2/19 through 12/5/19. The facility was licensed for 98 beds. The census at the time of the survey was 88 and the sample size was 18. Representing the California Department of Public Health: Health Facilities Evaluator Nurses: 39111, 39220, and 38630. The following Complaints/FRI's were incorporated into the survey: Complaint: CA00665778 Category: Quality of Care No deficiency was issued Complaint: CA00664677 Category: Quality of Care/Treatment No deficiency was issued Facility Reported Incident: CA00665474 Category: Resident/Patient/Client Abuse No deficiency was issued Facility Reported Incident: CA00665495 Category: Resident/Patient/Client Abuse No deficiency was issued Facility Reported Incident: CA00665823 Category: Resident/Patient/Client Abuse Deficiencies were issued (see F609) Glossary: AA ACTIVITIES ASSISTANT AD ACTIVITIES DIRECTOR LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MDAV11 Facility ID: CA080000015 If continuation sheet 1 of 47 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555557 (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PIONEERS MEMORIAL SKILLED NURSING CENTER 320 Cattle Call Dr Brawley, CA 92227 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ADM ADMINISTRATOR BIMS BRIEF INTERVIEW FOR MENTAL STATUS CDM CERTIFIED DIETARY MANAGER CDPH CALIFORNIA DEPARTMENT OF PUBLIC HEALTH CDR CONTROLLED DRUG RECORD CNA CERTIFIED NURSE AIDE DA DIETARY AIDE DM DIRECTOR OF MAINTENANCE DON DIRECTOR OF NURSING DOR DIRECTOR OF REHABILITATION DSD DIRECTOR OF STAFF DEVELOPMENT F FAHRENHEIT gm GRAMS HSK HOUSEKEEPER HSKS HOUSEKEEPING SUPERVISOR IU INTERNATIONAL UNITS L LITER/S LN LICENSED NURSE LTC LONG TERM CARE MAR MEDICATION ADMINISTRATION RECORD MASD MOISTURE-ASSOCIATED SKIN DAMAGE M Dtr MAINTENANCE DIRECTOR MD MEDICAL DOCTOR MDS MINIMUM DATA SET Mg/mg MILLIGRAMS Ml/ml MILLILITERS MRR MEDICATION REGIMEN REVIEW NC NASAL CANNULA O2 OXYGEN OTC OVER THE COUNTER PPD PURIFIED PROTEIN DERIVATIVE PRN AS NEEDED QA QUALITY ASSURANCE COMMITTEE RD REGISTERED DIETITIAN RP RESPONSIBLE PARTY SSD SOCIAL SERVICES DIRECTOR FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MDAV11 Facility ID: CA080000015 If continuation sheet 2 of 47 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555557 (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PIONEERS MEMORIAL SKILLED NURSING CENTER 320 Cattle Call Dr Brawley, CA 92227 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F550 Resident Rights/Exercise of Rights CFR(s): 483.10(a)(1)(2)(b)(1)(2)

F550 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 01/06/2020 §483.10(a) Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. §483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. §483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. §483.10(b) Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. §483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MDAV11 Facility ID: CA080000015 If continuation sheet 3 of 47 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555557 (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PIONEERS MEMORIAL SKILLED NURSING CENTER 320 Cattle Call Dr Brawley, CA 92227 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE reprisal from the facility. §483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure five randomly sampled residents (1, 4, 14, 26, and 30) were treated with respect and dignity when they were not given bedside curtains that provided full privacy. This failure had the potential for Residents 1, 4, 14, 26, and 30 to experience embarrassment and shame. Findings: Resident 30 was admitted to the facility on 3/15/16, per the facility's Facesheet. Resident 14 was admitted to the facility on 4/23/19, per the facility's Facesheet. Resident 4 was admitted to the facility on 8/1/19, per the facility's Facesheet. Resident 1 was admitted to the facility on 12/3/14, per the facility's Facesheet. Resident 26 was admitted to the facility on 5/29/19, per the facility's Facesheet. On 12/4/19 at 5:53 P.M., a joint interview and observation of Resident 30's bedside curtain was conducted with LN 32. Resident 30's bedside curtain did not fit properly and had a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MDAV11 Facility ID: CA080000015 If continuation sheet 4 of 47 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555557 (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PIONEERS MEMORIAL SKILLED NURSING CENTER 320 Cattle Call Dr Brawley, CA 92227 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE gap approximately 5 feet wide that did not fully enclose the bed. LN 32 stated Resident 30's bedside curtain appeared to need repair and did not provide complete privacy. LN 32 stated the resident's bedside curtain should fully enclose the bed to provide privacy. On 12/4/19, a record review was conducted. Resident 30's MDS (an assessment tool) Section C, dated 9/19/19, indicated the resident scored a 5 out of 15 on the BIMS (brief interview of mental status), and was cognitively impaired. On 12/4/19 at 6:46 P.M., an interview was conducted with HSK 40. HSK 40 stated Resident 30's bedside curtain was broken and did not provide the resident with privacy. HSK 40 stated the housekeeping and maintenance department was responsible for making sure the bedside curtains worked and provided privacy. On 12/4/19 at 7:01 P.M., an interview was conducted with the DON. The DON stated Resident 30's bedside curtain should have provided full privacy. On 12/5/19 at 8:48 A.M., a joint interview and observation of Resident 14's bedside curtain was conducted with Resident 14 and LN 33. Resident 14's bedside curtain had a gap approximately six feet wide that did not fully enclose the bed. Resident 14 stated his bedside curtain did not provide him privacy and he did not like that. Resident 14 stated, "When I'm being changed someone could see my butt." Resident 14 stated his bedside curtain had been like that for some time and he did not think staff cared about his privacy. Resident 14 stated, "No one gives a (expletive)." LN 33 stated Resident 14's bedside curtain was unacceptable. LN 33 stated she had been FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MDAV11 Facility ID: CA080000015 If continuation sheet 5 of 47 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555557 (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PIONEERS MEMORIAL SKILLED NURSING CENTER 320 Cattle Call Dr Brawley, CA 92227 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE aware Resident 14's curtain was not adequate, and had not reported it. On 12/5/19 at 8:54 A.M., a joint interview and observation was conducted of roommates (Resident 14 and Resident 4's) bedside curtains with CNA 31. CNA 31 stated the bedside curtains did not fully enclose Resident 14's and Resident 4's beds. CNA 31 stated he would be unable to provide complete privacy to either resident during care. CNA 31 stated he had been aware the bedside curtains did not provide privacy, and had not reported it. Resident 4 was unavailable for interview. On 12/5/19 at 9:07 A.M., a joint interview and observation was conducted of Resident 14 and Resident 4's bedside curtains with the HSKS. The HSKS stated it was her responsibility to ensure bedside curtains were clean and provided residents with complete privacy. The HSKS stated Resident 14 and Resident 4's bedside curtains were unacceptable. The HSKS stated she would not want to receive care in a bed that did not afford full privacy. On 12/5/19 at 9:17 A.M., an interview was conducted with the M Drt. The M Drt stated Resident 1 and Resident 26's bedside curtains also did not provide complete privacy. The M Dtr stated it was disrespectful for the residents to have curtains that did not afford complete privacy. Resident 1 and Resident 26 were unavailable for interview. Per the facility's policy titled Quality of LifeDignity, revised August 2009, "Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality... 10. Staff shall promote, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MDAV11 Facility ID: CA080000015 If continuation sheet 6 of 47 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555557 (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PIONEERS MEMORIAL SKILLED NURSING CENTER 320 Cattle Call Dr Brawley, CA 92227 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE maintain and protect resident privacy...."

F552 SS=D Right to be Informed/Make Treatment Decisions CFR(s): 483.10(c)(1)(4)(5)

F552 01/06/2020 §483.10(c) Planning and Implementing Care. The resident has the right to be informed of, and participate in, his or her treatment, including: §483.10(c)(1) The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition. §483.10(c)(4) The right to be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish care. §483.10(c)(5) The right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to verify informed consent was obtained from the resident's responsible party (RP-a designated health care decision maker for the patient) prior to the administration of a psychotropic medication, (a medication capable of affecting the mind), for one of five residents (7) reviewed for unnecessary medication. This failure had the potential to compromise Resident 7's right to be fully informed of the risks and benefits when receiving the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MDAV11 Facility ID: CA080000015 If continuation sheet 7 of 47 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555557 (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PIONEERS MEMORIAL SKILLED NURSING CENTER 320 Cattle Call Dr Brawley, CA 92227 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE psychotropic medication. Findings: Resident 7 was admitted to the facility on 2/8/19, with diagnoses which included neoplasm of the brain (a brain tumor), per the facility's Facesheet. On 12/2/19 at 11:48 A.M., an observation of Resident 7 was conducted. Resident 7 was lying in bed with his eyes closed. Resident 7's bed was in a low position with fall prevention floor mats on both sides of the bed. On 12/3/19, Resident 7's clinical record was reviewed: Resident 74's physician order, dated 2/8/19, indicated Citalopram (a psychotropic medication used for mood disorder) for depression, the order included "consent obtained by MD and RP." Resident 7's History and Physical, dated 2/11/19, indicated the resident did not have the capacity to understand and make decisions. The facility's Verification of Informed Consent, undated for Resident 7, listed the psychotropic medication as Citalopram 20 mg by mouth every day. The section for "Verification" was blank and undated. The section for "Signature of Nurse" verifying consent was blank and undated. Resident 7's MAR was reviewed from 11/1/19 through 12/3/19, which indicated Resident 7 had received Citalopram every day. On 12/03/19 at 3:02 P.M., an interview was conducted with LN 1. LN 1 stated the physician must explain psychotropic medication FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MDAV11 Facility ID: CA080000015 If continuation sheet 8 of 47 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555557 (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PIONEERS MEMORIAL SKILLED NURSING CENTER 320 Cattle Call Dr Brawley, CA 92227 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE risks, benefits and side effects to the resident or RP. LN 1 stated LNs were required to verify with the resident or the RP, that consent was obtained by completing a Verification of Informed Consent form. LN 1 stated psychotropic medication should not have been administered to Resident 7 until the Verification of Informed Consent form was completed and signed. LN 1 stated if the LNs did not complete the form, the facility could not verify if the resident or RP wanted the medication to be given, or if they understood what the physician told them. On 12/4/19 at 12:03 P.M., an interview was conducted with the DON. The DON stated all psychotropic medications must have a verification of consent. The DON stated LNs were responsible for verifying consent by double checking the consent form prior to administration of medications. Per the facility's policy, titled Informed Consent, dated July 2016, " ...II. Procedure ...F. Each time a new order for a psychotropic drug ...the Licensed Nurse verifies with the resident and/or legal representative that informed consent has been obtained. The Licensed Nurse documents this verification on the NP-67-Form C-Informed Consent Verification."

F584 SS=E Safe/Clean/Comfortable/Homelike Environment F584 CFR(s): 483.10(i)(1)-(7) 01/06/2020 §483.10(i) Safe Environment. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MDAV11 Facility ID: CA080000015 If continuation sheet 9 of 47 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555557 (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PIONEERS MEMORIAL SKILLED NURSING CENTER 320 Cattle Call Dr Brawley, CA 92227 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. (i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. (ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft. §483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; §483.10(i)(3) Clean bed and bath linens that are in good condition; §483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2) (iv); §483.10(i)(5) Adequate and comfortable lighting levels in all areas; §483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and §483.10(i)(7) For the maintenance of comfortable sound levels. This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MDAV11 Facility ID: CA080000015 If continuation sheet 10 of 47 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555557 (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PIONEERS MEMORIAL SKILLED NURSING CENTER 320 Cattle Call Dr Brawley, CA 92227 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Based on observation, interview, and record review, the facility failed to ensure residents (4, 177, 10, 47, 14, 58, 30, 61, 37, 65, 31, 68, 41, and 229) were provided a safe, comfortable, and homelike environment, when: 1. Residents (4, 177, 10, 47, 14, 58, 30, 61, 37, 65) in Room 2 and Room 24 had bedroom and bathroom walls that were stained, heavily patched, had peeling paint and sections of broken drywall, a hole in the ceiling, a dust encrusted ceiling vent, and a fall safety hazard in the bathroom floor. 2. Bed pillows for two sampled residents, (31, 68), were ripped and torn, with the inside stuffing exposed. 3. Resident 41 and 229's room had recorded room temperatures below 71 degrees Fahrenheit (F). These deficient practices had the potential to cause accidents, discomfort, and to negatively impact the residents' quality of life. Findings: 1a. On 12/2/19, a record review was conducted. According to the facility's census, six residents resided in Room 2. Per resident Facesheets: Resident 4 was admitted to the facility on 8/1/19, Resident 177 was admitted to the facility on 11/27/19, Resident 10 was admitted to the facility on 5/28/18, Resident 47 was admitted to the facility on 7/12/19, Resident 14 was admitted to the facility on 4/23/19, and Resident 58 was admitted to the facility on 7/9/19. On 12/2/19 at 9:24 A.M., an observation was conducted of Room 2. There were several black marks along the walls in the room. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MDAV11 Facility ID: CA080000015 If continuation sheet 11 of 47 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555557 (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PIONEERS MEMORIAL SKILLED NURSING CENTER 320 Cattle Call Dr Brawley, CA 92227 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE walls had neutral colored paint that was peeling, large sections of unpainted patches, and areas of crumbling drywall. The resident closets had paint that was scratched off in several areas. The ceiling above Bed C had an approximate 8 inch long hole in the ceiling and the surrounding paint was discolored and peeling. The wall behind Bed F had approximately a five inch by four inch hole in the drywall that was approximately one inch deep. The wall behind Bed D had a section of cracked drywall with jagged edges that was approximately two feet by two feet in size and dented into the wall approximately three inches deep. Resident 177 resided in Room 2, and stated he did not like the way his room looked and did not like the large area of damaged drywall behind his bed. On 12/2/19 at 9:33 A.M., a joint interview and observation of Room 2 was conducted with the M Drt. The M Drt stated Room 2 was not in an acceptable condition. The M Drt stated he would not allow a family member of his to reside in Room 2. On 12/2/19 at 10:27 A.M., a joint interview and observation was conducted with LN 34 in Room 2. LN 34 stated Room 2 looked "ugly." LN 34 stated the condition of the room could make the residents who resided there feel depressed and sad. LN 34 stated she would be mad if her own mother were to reside in Room 2. LN 34 observed the resident bathroom in Room 2. The bathroom floor had what resembled a drain covered with a piece of linoleum that was approximately four inches in diameter and a half an inch deep lower than the floor. LN 34 stated the depression in the bathroom floor was located directly in the path residents took to use the toilet. LN 34 stated the depression in the floor could cause residents to fall when they tried to go to the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MDAV11 Facility ID: CA080000015 If continuation sheet 12 of 47 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555557 (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PIONEERS MEMORIAL SKILLED NURSING CENTER 320 Cattle Call Dr Brawley, CA 92227 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE toilet. LN 34 stated Room 2 was not a safe, homelike environment. A review of the the written plan of care titled, Resident Care Plan Fall Risk Prevention & Management, for each resident residing in Room 2 indicated, "...Provide an environment that supports minimized hazards over which the Facility has control..." On 12/2/19 at 10:30 A.M., a joint interview and observation was conducted with the DON in Room 2. The DON stated the depression in the bathroom floor was a fall safety hazard and should have been repaired to be level with the rest of the floor. The DON observed the dust caked on the bathroom ceiling vent, sections of missing paint and drywall in the bathroom, and the rest of Room 2. The DON stated Room 2 had been in this condition for a while. The DON acknowledged Room 2 was not in a safe, homelike condition. On 12/2/19 at 10:35 A.M., a joint interview and observation was conducted with the ADM in Room 2. The ADM stated Room 2 was not homelike. 1b. On 12/4/19, a record review was conducted. According to the facility's census, four residents resided in Room 24. Per resident Facesheets: Resident 30 was admitted to the facility on 3/15/16, Resident 61 was admitted to the facility on 8/27/09, Resident 37 was admitted to the facility on 6/24/16, and Resident 65 was admitted to the facility on 1/3/18. On 12/4/19 at 5:53 P.M., a joint interview and observation was conducted with LN 32 in Room 24. The wall behind the residents' beds had a section extending approximately three feet up from the floor and 12 feet across, which FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MDAV11 Facility ID: CA080000015 If continuation sheet 13 of 47 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555557 (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PIONEERS MEMORIAL SKILLED NURSING CENTER 320 Cattle Call Dr Brawley, CA 92227 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE had heavy black scuff marks and peeling paint. The resident closets were discolored with deep scratch marks. The closet door moldings were cracked and had edges that were broken off. The wall next to the resident closets had an unpainted wall patch approximately four feet by four feet. The baseboard next to the entry door was loose. LN 32 stated she would not want her own mother to reside in a room as "run down like this." LN 32 further stated the electrical outlet behind Bed B was loose and it was difficult to keep the resident's tube feeding machine consistently plugged in. LN 32 stated Room 24 had been in this condition for at least a couple of months. On 12/4/19 at 6:46 P.M., an interview was conducted with HSK 40. HSK 40 stated there were several resident rooms in need of repair. HSK 40 stated the walls in room 24 "were too damaged to clean." HSK 40 further stated he had received complaints Room 24 looked dirty, but "you can't clean a wall like that." HSK 40 stated Room 24 was not homelike and he would not want to reside in a room that looked like that. On 12/4/19 at 7:01 P.M., an interview was conducted with the DON. The DON stated the condition of Room 24 was unacceptable. Per the facility's policy titled Maintenance Service, revised January 2012, "The Maintenance Department is responsible for ... B. Maintaining the building in good repair and free from hazards...."2a. Resident 68 was admitted to the facility on 4/19/19, per the facility's face sheet. On 12/2/19 at 8:21 A.M., Resident 68 was observed lying in bed, with his head resting on a ripped and tattered blue pillow. The pillowcase was partially removed, exposing the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MDAV11 Facility ID: CA080000015 If continuation sheet 14 of 47 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555557 (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PIONEERS MEMORIAL SKILLED NURSING CENTER 320 Cattle Call Dr Brawley, CA 92227 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE rips and tears. Resident 68 was not aware of the condition of the bed pillow. On 12/3/19 at 10 A.M., Resident 68 was again observed lying in bed, with his head resting on a ripped and tattered blue pillow. The pillowcase was partially removed, exposing the rips and tears. 2b. Resident 31 was admitted to the facility on 12/13/17, per the facility's face sheet. On 12/4/19 at 2 P.M., Resident 31 was observed lying in bed, with his head resting on a white pillow. The pillow was not covered with a pillowcase. Two of the pillow seams were ripped, with the inside stuffing coming out. Resident 31 was not aware of the condition of the bed pillow. On 12/4/19 at 2 P.M., CNA 15 was interviewed. CNA 15 stated she cared for both Residents 31 and 68, and changed the pillow cases daily. CNA 15 stated she had not noticed the rips. On 12/4/19 at 2:15 P.M., the ADM was interviewed. The ADM stated the pillows were in poor condition, and should be replaced. Per the facility's policy, titled Soiled Laundry & Bedding, revised September 2016, "... VIII A. Discard pillows that are torn, damaged, or permanently stained."3a. On 12/2/19 at 8:42 A.M., an observation was conducted of Resident 229's room. Resident 229 was observed in bed covered with four blankets, and wore a blue beanie cap on their head. On 12/2/19 at 9:32 A.M., an interview an observation of Resident 229's room was conducted with the M Drt. The M Drt used a temperature laser gun to check Resident 229's room temperature. The temperature read 68 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MDAV11 Facility ID: CA080000015 If continuation sheet 15 of 47 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555557 (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PIONEERS MEMORIAL SKILLED NURSING CENTER 320 Cattle Call Dr Brawley, CA 92227 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE degrees F. The M Drt stated Resident 229's room was too cold and it would be uncomfortable. 3b. On 12/2/19 at 9:15 A.M., an interview was conducted with Resident 41. Resident 41 was observed lying in bed on his back, wearing a sweatshirt with the hood of the sweatshirt covering his head, and three blankets covered his body. Resident 41 stated in Spanish, "Es muy frio" which translated to "It's very cold." On 12/2/19 at 9:29 A.M., an observation and interview was conducted with the M Drt. The M Drt used a temperature laser gun to check Resident 41's room temperature, while the resident remained in bed. The temperature gun's digital reading was 63 degrees F. The M Drt stated the room was too cold and it would be uncomfortable. On 12/4/19 at 12:03 P.M., an interview was conducted with the DON. The DON stated room temperatures should be between 71-81 degrees F. The DON stated cold resident rooms did not reflect a homelike environment. Per the facility's policy, titled Resident Rooms and Environment, dated January 2012, " ...I. Facility Staff aim to create a personalized, homelike atmosphere, paying close attention to the following: ...F. Comfortable temperatures; ..."

F609 SS=D Reporting of Alleged Violations CFR(s): 483.12(c)(1)(4) FORM CMS-2567(02-99) Previous Versions Obsolete

F609 Event ID: MDAV11 01/06/2020 Facility ID: CA080000015 If continuation sheet 16 of 47 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555557 (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PIONEERS MEMORIAL SKILLED NURSING CENTER 320 Cattle Call Dr Brawley, CA 92227 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to implement its abuse policies and procedures, when: 1. An allegation of abuse involving one of 18 residents (180) was not reported to the facility's administrator. 2. The allegation of abuse was not reported to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MDAV11 Facility ID: CA080000015 If continuation sheet 17 of 47 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555557 (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PIONEERS MEMORIAL SKILLED NURSING CENTER 320 Cattle Call Dr Brawley, CA 92227 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the ombudsman, law enforcement, and the State Agency within 24 hours. 3. A staff member who failed to report the allegation of abuse had not received mandatory annual abuse prevention training. As a result of not following the facility's abuse policies and procedures, the facility's investigation into the abuse allegation was delayed and had the potential to put residents at risk for abuse. Findings: Resident 180 was admitted to the facility on 7/5/17, with diagnoses to include aphasia (loss of ability to understand or express speech), per the resident's Facesheet. On 12/3/19, Resident 180's clinical record was reviewed. The document titled, Certified Nursing Assistant Incident Report, dated 11/29/19, indicated, "Volunteer [V 1] reported to nurse [LN 35] that [Resident 180] had a bruise on her eye. Volunteer said pt [patient]said it happened last week by a CNA...." On 12/4/19 at 12:38 P.M., a telephone interview was conducted with V 1. V 1 stated she was outside with Resident 180 on 11/29/19 when she saw a purple mark, oval in shape and about the size of a dime, below the resident's right eye. V1 stated Resident 180 indicated to her a CNA had hit her eye. V 1 stated she reported the allegation of abuse to AA 1 and to LN 35. V 1 stated LN 35 told her the allegation was not worth reporting because they did not know who was involved or when the alleged incident happened. V 1 stated she felt facility staff did not take the allegation seriously. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MDAV11 Facility ID: CA080000015 If continuation sheet 18 of 47 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555557 (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PIONEERS MEMORIAL SKILLED NURSING CENTER 320 Cattle Call Dr Brawley, CA 92227 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 12/4/19 at 11:08 A.M., a telephone interview was conducted with LN 35. LN 35 stated he assessed Resident 180 on 11/29/19 and observed what appeared to be a bruise beneath the resident's eye. LN 35 stated he did not report Resident 180's bruise or the abuse allegation to the facility's administrator. LN 35 stated he did not think the abuse allegation needed to be reported because the alleged abuse did not take place during his shift, and he did not know who the potential perpetrator was. LN 35 stated he should have reported the allegation of abuse to the administrator. On 12/4/19 at 11:42 A.M., a telephone interview was conducted with AA 1. AA 1 stated she was aware of the abuse allegation involving Resident 180. AA 1 stated she did not report Resident 180's bruise or the abuse allegation to the facility's administrator. AA 1 stated, "I feel a bit guilty now that I didn't tell [the administrator]. I wish I had." On 12/4/19 at 12:44 P.M., an interview was conducted with the ADM. The ADM stated he became aware of the abuse allegation on 12/2/19 when medical records staff discovered the Certified Nursing Assistant Incident Report, dated 11/29/19, in Resident 180's chart. The ADM stated his expectation was for staff to report any allegation of abuse to him immediately as per policy. The ADM stated he should have been informed of the abuse allegation on 11/29/19, and the facility's abuse policy had not been followed. The ADM stated because staff had not reported the abuse allegation to him on 11/29/19, the mandated reporting of the allegation to the appropriate agencies (ombudsman, law enforcement, and State Agency) was not done within 24 hours. The ADM stated his investigation of the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MDAV11 Facility ID: CA080000015 If continuation sheet 19 of 47 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555557 (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PIONEERS MEMORIAL SKILLED NURSING CENTER 320 Cattle Call Dr Brawley, CA 92227 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE allegation was delayed, and had the potential to put other residents at risk for abuse. On 12/4/19 at 4:56 P.M., an interview was conducted with the ADM. The ADM stated employee records were reviewed, and LN 35 did not have annual abuse training. The ADM stated employees were expected to attend their annual abuse training as it was the facility's policy. Per the facility's policy titled Abuse- Reporting & Investigations, revised November 2016, "...I. Administrator as Abuse Prevention Coordinator A. Allegations of abuse, neglect, mistreatment, or exploitation are to be reported to the Administrator or designated representative immediately... B. ... Within twenty-four (24) [sic] of the report of alleged physical abuse a written report (SOC 341) will be sent to the LTC Ombudsman, and CDPH Licensing Certification [State Agency]...." Per the facility's policy titled Abuse -Prevention Program, revised November 2016, "... II. Staff Training A. The facility conducts mandatory Facility Staff training programs during orientation, annually and as needed on: ...ii. Identifying and reporting abuse...."

F656 SS=D Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) 01/06/2020 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MDAV11 Facility ID: CA080000015 If continuation sheet 20 of 47 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555557 (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PIONEERS MEMORIAL SKILLED NURSING CENTER 320 Cattle Call Dr Brawley, CA 92227 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)(A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to develop and implement care plans for two of 18 residents (34, 230), reviewed for person-centered care plans when: 1. Resident 230's care plan was not implemented for floating the heels (when the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MDAV11 Facility ID: CA080000015 If continuation sheet 21 of 47 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555557 (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PIONEERS MEMORIAL SKILLED NURSING CENTER 320 Cattle Call Dr Brawley, CA 92227 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE heels are positioned and lifted to remove all contact between the heels and the bed), as ordered by the physician and as indicated in the written care plan, for pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure on an area). 2. Resident 34's written care plan was not developed to include nursing interventions for alleviating pressure causing wound discomfort to the right and left great toes. These failures had the potential for delayed healing and for wounds to worsen. Findings: 1. Resident 230 was admitted to the facility on 11/13/19, with diagnoses which included right 2nd through 4th toe amputation aftercare and right heel deep tissue injury (DTI-a tissue injury resulting from prolonged pressure), per the facility's Facesheet. On 12/2/19 at 9:51 A.M., an observation and interview was conducted with Resident 230. Resident 230 was lying in bed on a regular mattress. Kerlix (white gauze dressing) was observed around both feet. Resident 230's toes were exposed and a pillow was under both calves. Resident 230's heels were resting directly on the mattress. Resident 230 stated he thought he had wounds on his feet, but he could not feel anything. Resident 230's clinical record was reviewed on 12/2/19: Resident 230's physician's order dated 11/29/19, indicated "... Float heels while in bed ..." Resident 230's Care Plan, titled Skin-Short FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MDAV11 Facility ID: CA080000015 If continuation sheet 22 of 47 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555557 (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PIONEERS MEMORIAL SKILLED NURSING CENTER 320 Cattle Call Dr Brawley, CA 92227 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Term Pressure Ulcer: right/left heel, dated 11/14/19, listed an approach to "float heels while in bed." On 12/2/19 at 3:31 P.M., Resident 230 was observed lying in bed with both heels resting directly on the mattress. On 12/3/19 at 7:55 A.M., Resident 230 was observed sitting up in bed with both heels directly in contact with the mattress. A pillow was under his calves, and there was no elevation of the feet. On 12/3/19 at 2:15 P.M., Resident 230 was observed lying in bed with an egg crate mattress (a foam mattress) added to the bed. Resident 230's feet were resting on top of a pillow, with the heels directly touching the pillow. On 12/4/19 at 10:23 A.M., Resident 230 was observed asleep in bed with both heels resting directly on the mattress. On 12/4/19 at 11:19 A.M., an observation and interview was conducted with LN 2 during Resident 230's wound care. LN 2 stated Resident 230 needed to have both heels floated at all times when in bed. LN 2 stated if the heels were not floated, the wounds would not heal, and they would eventually get worse. LN 2 stated the pillow should have been under the ankles, to lift the feet off the mattress. LN 2 stated it was everyone's responsibility to make sure Resident 230's heels were floated. On 12/4/19 at 12:03 P.M., an interview was conducted with the DON. The DON stated she expected Resident 230's physician's order for floating the heels to be followed by all staff. The DON stated if the pressure ulcer plan of care was not followed, Resident 230's heels FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MDAV11 Facility ID: CA080000015 If continuation sheet 23 of 47 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555557 (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PIONEERS MEMORIAL SKILLED NURSING CENTER 320 Cattle Call Dr Brawley, CA 92227 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE "could worsen and contribute to his poor circulation." 2. Resident 34 was admitted to the facility on 9/16/19, with diagnoses to include diabetes mellitus (the body's inability to control blood sugar levels), per the facility's Facesheet. On 12/2/19 at 3:23 P.M., an observation and interview was conducted with Resident 34. CNA 32 was present and translated the interview. Resident 34 grimaced, and stated he was having pain in his right great toe. Resident 34 was observed with blankets covering the toes on each foot. Resident 34 stated the weight of his blankets sometimes hurt his toes. Resident 34 stated the blankets felt like they were pressing down on the wounds on his toes. CNA 32 removed Resident 34's blankets and sock to reveal a wound on the top of the resident's right great toe, just above the toe nail. CNA 32 reapplied the resident's sock, and covered the resident's feet with the blankets. CNA 32 stated she was unaware of any interventions for Resident 34's toes. A record review was conducted on 12/2/19. Resident 34's written plan of care, titled SkinShort Term Non-Pressure Ulcer, indicated the resident had diabetic ulcers on both great toes. The written care plan did not have interventions to relieve wound discomfort on the great toes related to the applied pressure of blankets. On 12/2/19 at 3:34 P.M., a joint interview and observation was conducted with LN 2 in Resident 34's room. LN 2 stated she was the facility's wound treatment nurse. LN 2 observed the blankets covering Resident 34's toes, and stated the blankets should not have been covering the resident's toes. LN 2 stated pressure from the blankets could impede healing. LN 2 stated keeping pressure off FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MDAV11 Facility ID: CA080000015 If continuation sheet 24 of 47 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555557 (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PIONEERS MEMORIAL SKILLED NURSING CENTER 320 Cattle Call Dr Brawley, CA 92227 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 34's toes was a nursing intervention, and should have been included in Resident 34's written plan of care. LN 2 further stated resident-specific nursing interventions on a written care plan communicated the resident's needs to all staff. On 12/5/19 at 10:26 A.M., an interview was conducted with the DON. The DON stated the nursing interventions to relieve pressure on Resident 34's toe wounds should have been part of the resident's written plan of care. Per the facility's policy, titled Comprehensive Person-Centered Care Planning, dated November 2017, "...IV. Comprehensive Care Plan a. Within 7 days from the completion of the comprehensive MDS assessment, the comprehensive care plan will be developed... b. Additional changes or updates to the resident's comprehensive care plan will be made based on the assessed needs of the resident...."

F695 SS=D Respiratory/Tracheostomy Care and Suctioning F695 CFR(s): 483.25(i) 01/06/2020 § 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning. The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart. This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed to ensure safety signs indicating the use of O2 were posted at residents' room doorways FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MDAV11 Facility ID: CA080000015 If continuation sheet 25 of 47 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555557 (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PIONEERS MEMORIAL SKILLED NURSING CENTER 320 Cattle Call Dr Brawley, CA 92227 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE for two of two residents (127,128) sampled for oxygen therapy. This failure placed the residents at increased risk of harm in the event of a fire. Findings: a. Resident 127 was admitted to the facility on 11/28/19, with diagnoses to include chronic respiratory failure, according to the facility's face sheet. On 12/2/19 at 9:20 A.M., Resident 127 was observed lying in bed wearing a NC (tubing used to deliver oxygen) connected to an oxygen tank, set to deliver oxygen at 2 liters per minute (lpm). There was no sign in Resident 127's room, or on the room's doorway to indicate oxygen was in use in the room or that smoking was prohibited. On 12/2/19, Resident 127's health record was reviewed. The physician's admission orders, dated 11/28/19, included an order for oxygen at 2 lpm via NC to be administered continuously. b. Resident 128 was admitted to the facility on 12/1/19, with diagnoses to include diabetes mellitus (difficulty controlling sugar in the blood), according to the facility's face sheet. On 12/2/19 at 11:55 A.M., Resident 128 was observed lying in bed wearing an NC connected to an oxygen tank, set to deliver oxygen at 2 lpm. There was no sign in Resident 128's room, or on the room's doorway to indicate oxygen was in use in the room or that smoking was prohibited. On 12/2/19, Resident 128's health record was reviewed. The physician's admission orders, dated 12/1/19, included an order for oxygen at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MDAV11 Facility ID: CA080000015 If continuation sheet 26 of 47 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555557 (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PIONEERS MEMORIAL SKILLED NURSING CENTER 320 Cattle Call Dr Brawley, CA 92227 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 2 lpm via NC to be administered as needed. On 12/3/19 at 8 A.M., a tour of the facility was conducted. There were no oxygen signs posted at Residents 127's or 128's rooms. On 12/3/19 at 4:29 P.M., concurrent observations and interviews were conducted with LN 32. LN 32 stated there should be signs on the doorways indicating oxygen was in use by the resident. LN 32 stated posting of the signs was the responsibility of any staff member caring for the resident. On 12/5/19 at 11:35 A.M., the DON was interviewed. The DON stated the oxygen safety signs should have been posted on Residents 127's and 128's doors when they were admitted. The DON further stated any resident admitted with oxygen should have a safety sign. According to the facility's policy, titled Oxygen Therapy, revised November 2017, "... A. 'No Smoking' signs will be prominently displayed wherever oxygen is being ... administered."

F755 SS=D Pharmacy Srvcs/Procedures/Pharmacist/Records CFR(s): 483.45(a)(b)(1)-(3)

F755 01/06/2020 §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MDAV11 Facility ID: CA080000015 If continuation sheet 27 of 47 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555557 (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PIONEERS MEMORIAL SKILLED NURSING CENTER 320 Cattle Call Dr Brawley, CA 92227 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. §483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility. §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure LNs correctly documented the administration of a controlled medication (medications with a high potential to cause dependence) for one of two randomly sampled residents (27). This failure resulted in the potential for medication error and drug diversion. Findings: On 12/5/19 at 11:22 A.M., an inspection of medication cart two was conducted with LN 18. The CDR for Resident 27's hydrocodoneacetaminophen 5/325 mg (pain medication) was reviewed and compared with the MAR. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MDAV11 Facility ID: CA080000015 If continuation sheet 28 of 47 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555557 (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PIONEERS MEMORIAL SKILLED NURSING CENTER 320 Cattle Call Dr Brawley, CA 92227 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE According to the CDR, one tablet of hydrocodone-acetaminophen 5/325 mg was removed from the controlled medication lock box on 11/9/19, 11/14/19, and 11/23/19. According to documentation on the MAR, there was no evidence the medication had been given to Resident 27 on 11/9/19 and 11/14/19. LN 18 stated the medication should have been documented immediately in three places, on the CDR, the MAR, and the Pain Assessment Flow Sheet. On 12/5/19, Resident 27's medical record was reviewed. On 11/6/19, the physician ordered hydrocodone-acetaminophen 5/325 mg, one tablet by mouth every four hours as needed for moderate pain. The Pain Assessment Flow Sheet did not show evidence Resident 27's pain had been assessed, or hydrocodoneacetaminophen administered, on 11/9/19 and 11/23/19. On 12/5/19 at 12:50 P.M., the DON was interviewed. The DON stated the expectation was for LNs to document immediately on the MAR and the CDR, administer the medication to the resident, then return to the MAR to complete the pain assessment sheet. According to the facility's policy, titled Medication-Administration, revised January 2012, "... A. The time and dose of the drug ... administered to the patient will be recorded in the patient's individual medication record by the person who administers the drug ...." According to the facility's policy, titled Administration of Pain Medication, revised November 2016, "... B. Document the administration of PRN pain medication on the Pain Flow Sheet ...." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MDAV11 Facility ID: CA080000015 If continuation sheet 29 of 47 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555557 (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PIONEERS MEMORIAL SKILLED NURSING CENTER 320 Cattle Call Dr Brawley, CA 92227 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F756 Drug Regimen Review, Report Irregular, Act On CFR(s): 483.45(c)(1)(2)(4)(5)

F756 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 01/06/2020 §483.45(c) Drug Regimen Review. §483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. §483.45(c)(2) This review must include a review of the resident's medical chart. §483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon. (i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug. (ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified. (iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. §483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MDAV11 Facility ID: CA080000015 If continuation sheet 30 of 47 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555557 (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PIONEERS MEMORIAL SKILLED NURSING CENTER 320 Cattle Call Dr Brawley, CA 92227 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE must take when he or she identifies an irregularity that requires urgent action to protect the resident. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure the consulting pharmacist (CP) identified a medication irregularity for one randomly selected resident (14) during the MRR (a monthly medication review conducted by the facility's consulting pharmacist of residents' medications in order to identify medication irregularities and to make recommendations to physicians). This failure had the potential for residents to not receive the correct dosage of medications, and put residents at risk of receiving unnecessary medications. Findings: On 12/5/19 at 8:36 A.M., LN 33 was observed preparing and administering one tablet of vitamin D3 1000 IU for Resident 14. On 12/5/19, a record review was conducted. Resident 14's physician orders, dated 4/23/19, indicated, "... Vitamin D3 1000 mg ...." On 12/5/19 at 9:38 A.M., a joint interview and record review was conducted with LN 33. LN 33 reviewed Resident 14's physician orders and MAR and stated she did not realize IU and mg were not equivalent units of measurement. On 12/5/19 at 10:30 A.M., a joint interview and record review was conducted with the DON. The DON reviewed Resident 14's physician orders and stated vitamin D3 was not formulated in mg. The DON stated Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MDAV11 Facility ID: CA080000015 If continuation sheet 31 of 47 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555557 (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PIONEERS MEMORIAL SKILLED NURSING CENTER 320 Cattle Call Dr Brawley, CA 92227 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 14's order for vitamin D3 had been written and rewritten by nurses using mg on the order sheet since April 2019. The DON stated nursing should have identified the mistake, clarified it with the physician, and corrected the order to read vitamin D3 1000 IU. The DON stated the CP had not identified the irregularity during MRRs conducted in May 2019 through November 2019. The DON stated this should have been identified during the pharmacist's MRR. On 12/5/19 at 12:13 P.M., a telephone interview was conducted with the facility's CP. The CP stated he performed the facility's monthly MRRs. The CP stated vitamin D3 was not formulated in mg, and mg were not equivalent to IU. The CP stated he made an error, and should have caught Resident 14's medication irregularity for vitamin D3. The consultant pharmacist's medication regimen reviews for Resident 14 were reviewed from May 2019 through November 2019. The MRRs were as follows: 5/21/19 no recommendations 6/23/19 recommendation for a lab test to check an ammonia level 7/26/19 no recommendations 8/22/19 recommendation for a BMP (basic metabolic panel) 9/10/19 recommendation to monitor blood pressure 10/12/19 no recommendations 11/12/19 no recommendations FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MDAV11 Facility ID: CA080000015 If continuation sheet 32 of 47 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555557 (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PIONEERS MEMORIAL SKILLED NURSING CENTER 320 Cattle Call Dr Brawley, CA 92227 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Per the facility's policy, titled Drug Regimen Review, revised December 2016, "...1. Facility must ensure that a pharmacist reviews each residents medical chart every month and perform a drug regimen review,... B. report any irregularities to the facility's medical director, attending physician and director of nursing or charge nurse...."

F759 SS=D Free of Medication Error Rts 5 Prcnt or More CFR(s): 483.45(f)(1)

F759 01/06/2020 §483.45(f) Medication Errors. The facility must ensure that its§483.45(f)(1) Medication error rates are not 5 percent or greater; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure the medication error rate was below 5 percent. The medication error rate was 6.45 percent. Two medication errors were observed, from a total of 31 opportunities, during the medication administration process for five randomly observed residents (14, 61, 181, 75, and 227). As a result, the facility could not ensure medications were correctly administered to residents. Findings: On 12/5/19 at 8:36 A.M., LN 33 was observed preparing medication for Resident 14. LN 33 put one tablet of vitamin D3 1000 IU in a medication cup. LN 33 poured 25 ml of lactulose (laxative) into a separate medication cup. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MDAV11 Facility ID: CA080000015 If continuation sheet 33 of 47 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555557 (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PIONEERS MEMORIAL SKILLED NURSING CENTER 320 Cattle Call Dr Brawley, CA 92227 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE At 8:41 A.M., LN 33 stated she was ready to administer medications to Resident 14 and entered the resident's room. LN 33 stated she poured 30 ml of lactulose. LN 33 was asked to reconfirm the dosage. LN 33 acknowledged she did not pour the correct amount of lactulose. LN 33 stated, "I need to put 5 milliliters more." On 12/5/19 at 8:46 A.M., LN 33 administered medications to Resident 14. On 12/5/19, Resident 14's physician orders, dated 7/4/19, were reviewed and indicated, "...lactulose 10 gm/15 ml sol (solution) give 30 ml..." Resident 14's physician orders dated 4/23/19, indicated, "... Vitamin D3 1000 mg 2 tabs (tablets)...." On 12/5/19 at 9:38 A.M., a joint interview and record review was conducted with LN 33. LN 33 reviewed Resident 14's physician orders and MAR, and stated she should have given two tablets of vitamin D3 as was ordered. On 12/5/19 at 10:30 A.M., a joint interview and record review was conducted with the DON. The DON reviewed Resident 14's physician orders and stated vitamin D3 was not formulated in mg. The DON stated nursing should have identified the mistake, clarified it with the physician, and corrected the order to read vitamin D3 IU. The DON stated Resident 14 should have received two tablets of vitamin D3 1000 IU. The DON stated it was her expectation for medications to be administered as ordered. Per the facility's policy titled MedicationAdministration, revised January 2012, "... ii. Medications and treatments will be administered as prescribed to ensure compliance with dose guidelines..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MDAV11 Facility ID: CA080000015 If continuation sheet 34 of 47 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555557 (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PIONEERS MEMORIAL SKILLED NURSING CENTER 320 Cattle Call Dr Brawley, CA 92227 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F842 Resident Records - Identifiable Information CFR(s): 483.20(f)(5), 483.70(i)(1)-(5)

F842 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 01/06/2020 §483.20(f)(5) Resident-identifiable information. (i) A facility may not release information that is resident-identifiable to the public. (ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so. §483.70(i) Medical records. §483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are(i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized §483.70(i)(2) The facility must keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is(i) To the individual, or their resident representative where permitted by applicable law; (ii) Required by Law; (iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506; (iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MDAV11 Facility ID: CA080000015 If continuation sheet 35 of 47 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555557 (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PIONEERS MEMORIAL SKILLED NURSING CENTER 320 Cattle Call Dr Brawley, CA 92227 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512. §483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use. §483.70(i)(4) Medical records must be retained for(i) The period of time required by State law; or (ii) Five years from the date of discharge when there is no requirement in State law; or (iii) For a minor, 3 years after a resident reaches legal age under State law. §483.70(i)(5) The medical record must contain(i) Sufficient information to identify the resident; (ii) A record of the resident's assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician's, nurse's, and other licensed professional's progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure LNs consistently documented medication administrations on the MAR for one of 18 residents reviewed (178). This failure had the potential for Resident 178's MAR to reflect inaccurate documentation. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MDAV11 Facility ID: CA080000015 If continuation sheet 36 of 47 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555557 (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PIONEERS MEMORIAL SKILLED NURSING CENTER 320 Cattle Call Dr Brawley, CA 92227 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 178 was admitted to the facility on 11/16/19, with diagnoses to include anemia (lack of red blood cells) and kidney transplant, per the facility's Facesheet. On 12/3/19 at 10:56 A.M., a joint interview and record review was conducted with LN 33. LN 33 stated she had completed her 9 A.M. medication pass. LN 33 reviewed Resident 178's MAR for December 2019. There was no documented evidence the following medications were administered: Multivitamin 1 tablet on 12/2/19 and 12/3/19; Ferrous sulfate (iron) 325 mg on 12/2/19 and 12/3/19; Prednisone (steroid) 5 mg on 12/1/19 through 12/3/19. The medications were scheduled to be given daily at 9 A.M. LN 33 stated she should have signed the MAR when she gave the medications. LN 33 stated the MAR should not have blank spaces. A review of Resident 178's November 2019 MAR indicated the following medications were unsigned and blank: Gabapentin (pain medication) 100 mg on 11/18/19 and 11/19/19 Hydralazine (blood pressure medication) 25 mg on 11/18/19 and 11/19/19 Tacrolimus (kidney transplant medication) 1 mg on 11/29/19 Eliquis (prevents blood clots) 5 mg on 11/22/19 and 11/30/19 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MDAV11 Facility ID: CA080000015 If continuation sheet 37 of 47 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555557 (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PIONEERS MEMORIAL SKILLED NURSING CENTER 320 Cattle Call Dr Brawley, CA 92227 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 12/3/19 at 11:09 A.M., an interview was conducted with the DON. The DON stated it was her expectation for nurses to sign the MAR when medications were administered to residents. The DON stated Resident 178's MAR should not have had unsigned, blank dates. The DON further stated if a resident refused medications or was not in the facility, LNs were still expected to sign the MAR, and a note should be written on the back of the MAR indicating why the medication was not administered. Per the facility's policy titled MedicationAdministration, revised January 2012, "...IX. Documentation A. The time and dose of the drug or treatment administered to the patient will be recorded in the patient's individual medication record by the person who administers the drug or treatment...."

F867 SS=D QAPI/QAA Improvement Activities CFR(s): 483.75(g)(2)(ii)

F867 01/06/2020 §483.75(g) Quality assessment and assurance. §483.75(g)(2) The quality assessment and assurance committee must: (ii) Develop and implement appropriate plans of action to correct identified quality deficiencies; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility's QAA/QAPI committee failed to identify, develop, and implement action plans related to unsecured handrails and the residents' environment (cross reference F 550, F 584, and F 942). These failures had the potential to affect the health and safety of the residents. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MDAV11 Facility ID: CA080000015 If continuation sheet 38 of 47 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555557 (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PIONEERS MEMORIAL SKILLED NURSING CENTER 320 Cattle Call Dr Brawley, CA 92227 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Findings: On 12/5/19 at 1:07 P.M., an interview was conducted with the ADM. The ADM stated the QAA/QAPI committee identified areas of concern through multiple sources, which included feedback from the facility's department heads. The ADM stated the handrails in the facility's corridors were "a problem." The ADM stated he was aware of the environmental concerns and lack of homelike environment affecting resident rooms. The ADM stated the handrails and the condition of resident rooms should have been identified by the department heads and brought to the QAA/QAPI committee in order for appropriate plans of action to be developed and implemented. Per the facility's policy titled Quality Assurance and Performance Improvement (QAPI) Program, revised September 2019, "...This facility implements and maintains and ongoing, facility-wide Quality Assurance and Performance Improvement (QAPI) Program designed to monitor and evaluate the quality of resident care, pursue methods to improve quality of care and resolve identified problems...."

F880 SS=D Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f)

F880 01/06/2020 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MDAV11 Facility ID: CA080000015 If continuation sheet 39 of 47 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555557 (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PIONEERS MEMORIAL SKILLED NURSING CENTER 320 Cattle Call Dr Brawley, CA 92227 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MDAV11 Facility ID: CA080000015 If continuation sheet 40 of 47 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555557 (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PIONEERS MEMORIAL SKILLED NURSING CENTER 320 Cattle Call Dr Brawley, CA 92227 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed to ensure staff followed appropriate transmission-based precautions for one sampled resident (128) when: a. A laundry hamper was not used for handling soiled laundry and bed linens. b. A staff member did not use gloves when removing trash. These failures had the potential to increase the risk of cross-contamination. Findings: a. Resident 128 was admitted to the facility on 12/1/19 with diagnoses that included diabetes (difficulty controlling blood sugar), per the facility's face sheet. Physician's admission orders, dated 12/1/19, included contact isolation (procedures used in addition to standard precautions that decrease the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MDAV11 Facility ID: CA080000015 If continuation sheet 41 of 47 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555557 (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PIONEERS MEMORIAL SKILLED NURSING CENTER 320 Cattle Call Dr Brawley, CA 92227 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE likelihood of infection by microorganisms transmitted through direct or indirect contact with the patient or patient care items). On 12/2/19 at 9:05 A.M., an isolation set-up, with protective personal equipment (PPEdisposable gowns and gloves) was observed in the hall outside of Resident 128's room. CNA 16 was observed putting bed linens into a plastic bag. CNA 16 stated there was no laundry hamper for Resident 128's soiled linens. CNA 16 stated she kept the soiled linen on top of the bed until she put it into the plastic bag, and carried the bag through the hall to the laundry. CNA 16 was unable to verbalize how she managed the soiled linen while removing her PPE and performing hand hygiene. On 12/2/19 at 9:12 A.M., the IP was interviewed. The IP stated the facility soiled laundry hampers should be brought to the isolation room area, and bagged linen labeled as isolation should be placed inside. b. On 12/2/19 at 11:55 A.M., CNA 15 was observed entering Resident 128's isolation room, and removing the clear, plastic bag from the small trash container. The bag was filled with used PPE. CNA 15 was not wearing gloves. CNA 15 sealed the top of the bag with a knot, placed a clean bag in the container, and exited the room. CNA 15 stated she should have applied gloves before changing the trash bag. On 12/3/19 at 3:08 P.M., the DON was interviewed. The DON stated the expectation was for staff to follow infection control guidelines when caring for residents on isolation to prevent cross-contamination. The DON stated staff should have worn gloves when handling isolation trash. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MDAV11 Facility ID: CA080000015 If continuation sheet 42 of 47 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555557 (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PIONEERS MEMORIAL SKILLED NURSING CENTER 320 Cattle Call Dr Brawley, CA 92227 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE According to the facility's policy, titled Laundry Isolation Rooms, revised September 2016, "... C. Soiled linen will be placed in hampers clearly labeled for soiled linen." According to the facility's policy, titled Resident Isolation-Initiating Transmission-Based Precautions, revised 4/22/16, "... V. ... C. Ensures that an appropriate linen barrel/hamper ... is placed within reasonable distance from the resident's room. According to the facility's policy, titled Resident Isolation-Categories of Transmission-Based Precautions, revised 1/1/12, "... III. Contact Isolation ... C. ... gloves (clean, non-sterile) are worn when entering the room ..."

F911 SS=B Bedroom Number of Residents CFR(s): 483.90(e)(1)(i)

F911 §483.90 (e)(1) Bedrooms must §483.90(e)(1)(i) Accommodate no more than four residents. For facilities that receive approval of construction or reconstruction plans by State and local authorities or are newly certified after November 28, 2016, bedrooms must accommodate no more than two residents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to assure that resident rooms housed no more than four residents. Two rooms had the potential to accommodate five residents in each room (Rooms 9 and 20). Seven rooms had the potential to accommodate six residents in each room FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MDAV11 Facility ID: CA080000015 If continuation sheet 43 of 47 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555557 (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PIONEERS MEMORIAL SKILLED NURSING CENTER 320 Cattle Call Dr Brawley, CA 92227 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (Rooms 2, 3, 4, 5, 13, 15, and 18). As a result, the potential existed to impact resident care and quality of life. Findings: On 12/2/19 through 12/5/19, observations were conducted during the course of the annual recertification survey at the facility. Additionally, interviews and records reviews were conducted. There were no observed quality of care or quality of life concerns related the number of residents in the rooms. A continuance of the waiver (variation) from the requirements of 42 CFR section 483.70(d)(1)(i) as granted pursuant to a letter from the Centers for Medicare and Medicaid Services (CMS), dated January 25, 2019, and allowing more than four residents per room, is hereby recommended. This recommendation is also made with the expectation that the facility will obtain a timely renewal of the current waiver (variation) granted by CMS as reflected in the January 25, 2019 letter to the facility from CMS.

F912 SS=B Bedrooms Measure at Least 80 Sq Ft/Resident F912 CFR(s): 483.90(e)(1)(ii) §483.90(e)(1)(ii) Measure at least 80 square feet per resident in multiple resident bedrooms, and at least 100 square feet in single resident rooms; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to assure that resident rooms measured at least 80 square feet per resident in resident room 18. As a result the potential existed to impact resident care and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MDAV11 Facility ID: CA080000015 If continuation sheet 44 of 47 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555557 (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PIONEERS MEMORIAL SKILLED NURSING CENTER 320 Cattle Call Dr Brawley, CA 92227 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE quality of life. Findings: On 12/2/19 through 12/5/19, observations were conducted during the course of the annual recertification survey at the facility. The facility had 1 multiple resident room (room 18) that did not meet the minimum 80 square feet per resident. Room 18 measured 479 square feet and had the potential to house 6 residents. The allocated space for each resident would measure 79.83 square feet. The five residents occupying the room had no complaints. There were no observed quality of care or quality of life concerns that negatively impacted the residents residing in the identified room. A continuance of the waiver (variation) from the requirements of Code 42 of the Federal Regulations (CFR) section 483.70(d)(1)(ii) as granted pursuant to a letter from the Centers for Medicare and Medicaid Services (CMS), dated January 25, 2019, and allowing less than 80 square feet per resident per room per room, is hereby recommended. This recommendation is also made with the expectation that the facility will obtain a timely renewal of the current waiver (variation) granted by CMS as reflected in the January 25, 2019 letter to the facility from CMS.

F924 SS=E Corridors have Firmly Secured Handrails CFR(s): 483.90(i)(3)

F924 01/06/2020 §483.90(i)(3) Equip corridors with firmly secured handrails on each side. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MDAV11 Facility ID: CA080000015 If continuation sheet 45 of 47 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555557 (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PIONEERS MEMORIAL SKILLED NURSING CENTER 320 Cattle Call Dr Brawley, CA 92227 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed to maintain handrails in a safe operating condition in the corridors, when: 1. Handrails were broken or not firmly secured to the walls. 2. Handrails had sharp, protruding metal ends where sections of the handrails were missing endcaps. This deficient practice had the potential to cause injury to residents, visitors, and staff. Findings: On 12/2/19 at 3:30 P.M., observations of the handrails in the facility's corridors was conducted. Several sections of the handrails were loosely affixed to the wall and wobbled. Other sections of the handrails had missing support brackets or had broken brackets which caused the handrails to move and shift away from the wall. The handrails had several sections missing corner endcaps, leaving the ends of the handrails exposed with sharp, protruding metal parts. On 12/2/19 at 3:35 P.M., a joint interview and observation of the facility's handrails was conducted with the M Dtr. The M Dtr stated the facility's handrails were outdated and replacement parts could no longer be purchased. The M Dtr stated sections of the handrails were unsafe and needed to be replaced. The M Dtr stated the handrails had sharp corners that should not be exposed. On 12/3/19 at 8:08 A.M., an interview was conducted with the M Dtr. The M Dtr stated the facility's handrails were missing 12 endcaps FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MDAV11 Facility ID: CA080000015 If continuation sheet 46 of 47 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555557 (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PIONEERS MEMORIAL SKILLED NURSING CENTER 320 Cattle Call Dr Brawley, CA 92227 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE where the corners met, and he had to use tennis balls as endcaps to cover the sharp protruding metal. On 12/3/19 at 3:19 P.M., an interview was conducted with LN 31. LN 31 stated the handrails in the corridors should not be broken or loose. LN 31 stated the handrails in their current condition could cause injury to residents who tried to use them and could contribute to falls. On 12/3/19 at 3:26 P.M., an interview was conducted with the DOR. The DOR stated handrails in the corridors were used by ambulating residents to steady themselves. The DOR stated handrails were considered a safety feature, and should not be loose, broken, or have sharp edges. The DOR stated unsecured and broken handrails were a safety concern that could contribute to resident falls. The DOR stated the handrails should have been in good repair. On 12/4/19 at 1:17 P.M., an interview was conducted with the ADM and the DON. The ADM and DON stated the handrails should have been firmly secured to the wall and should not have had sharp exposed edges. Per the facility's policy titled Maintenance Service, revised January 2012, "Purpose to protect the health and safety of residents, visitors, and facility staff... I. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times...." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MDAV11 Facility ID: CA080000015 If continuation sheet 47 of 47