Health inspection·December 18, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record reviews, the facility failed to provide two-person physical assistance with transferring for one of one resident (Resident 1) when Resident 1 was transferred from bed to the Hoyer lift by a staff alone. This failure had the potential to result in harm or even death. Findings: The department received a facility reported incident on 12/16/2024. It was reported that, his (Resident 1) amputee was caught during a weight measuring procedure, skin tear occurred and bleeding. A record review of the facility's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that include acquired absence of left leg above the knee , and difficulty walking , not elsewhere classified. A joint observation and interview on 12/17/2024 at 11:40 A.M., with Resident 1 was conducted. Resident 1 had a bandage on his left leg s/p left above the knee amputation. Resident 1 stated the treatment nurse (TXN) last Sunday told him there was bleeding on his left leg. Resident 1 stated he told the TXN he had discomfort on the sling that was used when he was weighed by the staff. Resident 1 further stated he thought it was from that incident that caused the skin tear. An interview on 12/17/2024 at 4:13 P.M., with the RNA (restorative nursing assistant ) was conducted. The RNA stated she was alone when she did the transfer of resident 1 from his bed to the Hoyer lift when she weighed Resident 1. The RNA stated it was important to have two people with transfers of any resident in the facility to ensure safety and prevent accidents and falls. An interview on 12/18/2024 at 10:10 A.M., with TXN was conducted. The TXN stated she was called by Resident 1's CNA ( certified nursing assistant ) to his room and showed her the skin tear on Resident 1's left leg. The TXN asked Resident 1 what had happened, and Resident 1 stated he was not sure, but the sling caused him a bit of discomfort when he was weighed. The TXN stated with Hoyer lift transfers it was to her knowledge that the facility required two-person physical assistance to ensure safety and prevent accidents and falls. A record review of Resident 1's Minimum Data Set (MDS-a federally mandated assessment tool) dated 12/13/24, indicated a BIMS (brief interview for mental status) score of 14 which meant Resident 1's cognition was intact. (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 2 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 12/18/2024 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)