Health inspection·August 3, 2023

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the staff followed their policy and procedure on receiving and returning personal belongings for three of three sampled residents (Resident 1, 2 and 3). As a result, there was a potential the residents' belongings were not returned to the family after discharge from the facility. Findings: 1) Resident 1 was admitted to the facility on [DATE] per the facility ' s admission Record. A review of records was conducted. The document titled Resident Inventory dated 8/1/22, indicated Resident 1 had personal belongings listed on admission. There were no signatures or dates from the resident/representative and the staff certifying the belongings were received by the facility on admission and received by the resident/representative upon Resident 1 ' s transfer to the hospital or discharge from the facility. On 7/18/23 at 1:25 P.M., an interview with the Medical Records (MR) staff was conducted. The MR stated there was no documentation in Resident 1 ' s chart the belongings were returned to the family upon Resident 1 ' s discharge from the facility. 2) Resident 2 was admitted to the facility on [DATE] per the facility ' s admission Record. A review of records was conducted.The document titled Resident Inventory dated 7/26/22, indicated Resident 2 had personal belongings listed on admission. There were no signatures or dates from the staff certifying the belongings were received by the facility on admission and received by the patient/representative upon Resident 2 ' s transfer to the hospital or discharge from the facility. 3) Resident 3 was admitted to the facility on [DATE] per the facility ' s admission Record. A review of records was conducted.The document titled Resident Inventory dated 7/11/22, indicated Resident 3 had a personal belonging listed on admission. There were no signatures or dates from the staff certifying the belonging was received by the facility on admission and received by the patient/representative upon Resident 3's discharge from the facility. On 8/1/23 at 8:37 A.M., an interview with the previous Assistant Director of Nursing (ADON) was conducted. The previous ADON stated when a resident was admitted to the facility, the Certified Nurse (continued on next page) 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 555557 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555557 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pioneers Memorial Skilled Nursing Center 320 Cattle Call Dr. Brawley, CA 92227 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)