Inspection Reports for
Pioneer Health Care Center
900 S 12TH ST, ROCKY FORD, CO, 81067-
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
4% better than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 4, 2025
Visit Reason
The inspection was conducted to investigate allegations of resident-to-resident physical abuse involving Residents #4, #5, #6, and #2 at Pioneer Health Care Center.
Complaint Details
The complaint investigation substantiated abuse by Resident #5 against Resident #4 and by Resident #2 against Resident #6. The facility unsubstantiated the initial allegation that Resident #6 pushed Resident #2, determining Resident #2 was the aggressor. Both incidents involved physical contact with no serious injuries noted.
Findings
The facility substantiated abuse when Resident #5 physically abused Resident #4 on 2/8/25. An incident involving Resident #2 pushing Resident #6 on 2/16/25 was also substantiated. The facility failed to protect residents from abuse despite behavioral care plans and interventions.
Deficiencies (1)
F 0600: The facility failed to protect residents from all types of abuse including physical abuse. Specifically, Resident #4 was physically abused by Resident #5 and Resident #6 was physically abused by Resident #2.
Report Facts
Residents Affected: 2
Date of abuse incident: Feb 8, 2025
Date of abuse incident: Feb 16, 2025
Inspection Report
Routine
Deficiencies: 3
Date: Aug 27, 2024
Visit Reason
The inspection was conducted to assess compliance with health and safety regulations, including environmental conditions, respiratory care, and pest control in the nursing home.
Findings
The facility failed to maintain a sanitary and comfortable environment in many resident rooms, with issues including mice feces, flies, damaged walls, and sticky floors. The facility also failed to administer oxygen therapy according to physician orders for several residents and lacked an effective pest control program to manage a fly infestation.
Deficiencies (3)
F 0584: The facility failed to maintain a safe, clean, and homelike environment, with unsanitary conditions such as mice feces in 28 of 55 resident rooms, damaged walls, missing ceiling tiles, sticky floors, and wood splinter hazards on handrails.
F 0695: The facility failed to provide safe and appropriate respiratory care by not administering oxygen according to physician orders for Residents #2 and #3 and lacking a physician's order for Resident #7's continuous oxygen use.
F 0925: The facility failed to provide an effective pest control program, resulting in a fly infestation observed throughout the secure unit and long-term care areas, with flies landing on residents and personal items.
Report Facts
Resident rooms affected: 28
Resident rooms inspected: 55
Residents reviewed for oxygen use: 10
Residents with respiratory deficiencies: 3
Ceiling tiles missing: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Checked Resident #3's oxygen saturation and portable oxygen concentrator |
| RN #1 | Registered Nurse | Interviewed regarding Resident #2's oxygen therapy and fly infestation |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding Resident #7's oxygen therapy and fly infestation |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding fly infestation in residents' rooms |
| MS | Maintenance Supervisor | Interviewed about environmental issues, mice and fly infestations, and repair work |
| NHA | Nursing Home Administrator | Interviewed about awareness of fly and mice issues |
| ADON | Assistant Director of Nursing | Interviewed about oxygen administration policies and risks |
| HSK #1 | Housekeeper | Interviewed about fly infestation and door management |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 18, 2024
Visit Reason
The inspection was conducted due to a complaint regarding failure to provide assistance with activities of daily living, specifically oral and personal hygiene, to Resident #8.
Complaint Details
The complaint was substantiated. Resident #8 reported not receiving morning oral and personal hygiene care on multiple days. Staff interviews and care plan reviews confirmed the failure to provide required assistance.
Findings
The facility failed to ensure Resident #8 received daily oral and personal hygiene care as required. Interviews, observations, and record reviews confirmed that staff did not consistently provide the necessary assistance despite care plans and resident preferences.
Deficiencies (1)
F 0676: The facility failed to provide daily oral and personal hygiene assistance to Resident #8 as required by her care plan and preferences. Staff interviews confirmed that personal and oral hygiene care was not consistently provided every morning.
Report Facts
Residents reviewed for ADL care: 5
Sample residents: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) #3 | Interviewed regarding Resident #8's care and confirmed ADL care should be provided daily | |
| Certified Nurse Aide (CNA) #5 | Interviewed and stated responsibility for providing personal and oral hygiene but admitted not providing it to Resident #8 | |
| Director of Nursing (DON) | Interviewed and confirmed CNAs are responsible for daily personal and oral hygiene care; spoke with Resident #8 and ordered basin placement |
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Apr 18, 2024
Visit Reason
The inspection was conducted as part of the annual recertification survey to assess compliance with health and safety regulations and standards for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to notify physicians of elevated blood sugar levels, inadequate assistance with activities of daily living, unsafe smoking supervision leading to resident injury, improper oxygen therapy administration, incomplete nurse aide performance reviews, improper medication labeling and storage, and unsanitary kitchen conditions with improper food temperature control.
Deficiencies (7)
F 0580: The facility failed to notify the physician of Resident #29's elevated blood sugar levels on multiple occasions as ordered, risking serious health complications.
F 0676: The facility failed to provide daily oral and personal hygiene assistance to Resident #8, impacting her ability to perform activities of daily living.
F 0689: The facility failed to prevent a fire accident when Resident #13, a supervised smoker, obtained a lighter from family, resulting in first and second degree burns.
F 0695: The facility failed to ensure Resident #40 received oxygen therapy at the correct liter flow as ordered by the physician, risking oxygen toxicity or hypoxia.
F 0730: The facility failed to complete annual performance reviews and provide in-service education for five certified nurse aides, risking quality of care.
F 0761: The facility failed to ensure medications were properly labeled with open dates and expired medications discarded, including an expired Anoro inhaler and undated insulin pen.
F 0812: The facility failed to maintain a clean and sanitary kitchen environment and failed to hold food at safe temperatures during meal service, risking foodborne illness.
Report Facts
Elevated blood sugar readings: 19
Resident sample size: 28
Food temperature: 116
Food temperature: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Interviewed regarding failure to notify physician of elevated blood sugar and oxygen therapy administration. |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including notification failures, oxygen therapy, medication labeling, and staff education. |
| CNA #8 | Certified Nurse Aide | Responded to fire incident involving Resident #13. |
| DA #1 | Dietary Aide | Interviewed regarding food temperature control during meal service. |
| DS | Dietary Supervisor | Interviewed regarding kitchen sanitation and food safety. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 13, 2023
Visit Reason
The inspection was conducted to investigate complaints of resident-to-resident abuse and altercations at Pioneer Health Care Center.
Complaint Details
The complaint investigation substantiated that Resident #1 hit Resident #2 on 2/15/23. Resident #3 reported inappropriate touching by Resident #4 on 4/14/23, which was confirmed. On 5/16/23, Resident #6 hit Resident #5, but the facility found no fear or harm intended.
Findings
The facility failed to prevent multiple resident-to-resident altercations involving residents #1 and #2, #3 and #4, and #5 and #6. Investigations substantiated physical contact and inappropriate behavior, though no injuries or fear were reported.
Deficiencies (1)
F 0600: The facility failed to protect residents from all types of abuse including physical and sexual abuse by not preventing resident-to-resident altercations between Residents #1 and #2, #3 and #4, and #5 and #6.
Report Facts
Residents reviewed for abuse: 9
Residents involved in abuse incidents: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide (CNA) #3 | Witnessed Resident #1 hitting Resident #2 | |
| Certified Nurse Aide (CNA) #4 | Witnessed Resident #6 hitting Resident #5 | |
| Director of Nursing (DON) | Interviewed regarding altercations and facility response | |
| Nursing Home Administrator (NHA) | Interviewed regarding altercations and facility response |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jun 1, 2023
Visit Reason
Annual survey inspection of Pioneer Health Care Center to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Deficiencies: 3
Date: Dec 29, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to PASRR screening, dementia care, and COVID-19 testing in a nursing home facility.
Findings
The facility failed to ensure proper PASRR level I and II screenings and follow-up for several residents, did not provide adequate person-centered and meaningful activities for residents with dementia on the secured unit, and failed to document COVID-19 test results in resident records for multiple residents.
Deficiencies (3)
F 0645: The facility failed to complete required PASRR level I and II screenings and follow recommendations for four residents, impacting their medical, emotional, and psychosocial well-being.
F 0744: The facility failed to provide appropriate treatment and meaningful activities for residents with dementia on the secured unit, resulting in lack of engagement and stimulation.
F 0886: The facility failed to document COVID-19 test results in the medical records for six residents, compromising consistent documentation and compliance.
Report Facts
Residents reviewed for PASRR: 31
Residents affected by PASRR deficiencies: 4
Residents reviewed for COVID-19 testing: 31
Residents affected by COVID-19 testing documentation deficiency: 6
Residents with dementia care deficiencies: 2
Residents on secured unit: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Social Services Director | Interviewed regarding PASRR completion and facility processes |
| Director of Nursing | Director of Nursing | Interviewed regarding PASRR completion and dementia care activities |
| Activities Assistant | Activities Assistant | Observed and interviewed regarding activity provision on secured unit |
| Activities Director | Activities Director | Interviewed regarding activity program and staff training |
| Infection Preventionist | Infection Preventionist | Interviewed regarding COVID-19 testing documentation |
| Certified Nursing Aide #11 | Certified Nursing Aide | Observed and interviewed regarding activities and resident care |
| Certified Nursing Aide #12 | Certified Nursing Aide | Observed and interviewed regarding activities and resident care |
| Behavioral Health Specialist | Behavioral Health Specialist | Observed on secured unit regarding resident engagement |
| Regional Clinical Consultant | Regional Clinical Consultant | Interviewed regarding PASRR completion and facility oversight |
| Social Services Consultant | Social Services Consultant | Interviewed regarding psychosocial program on secured unit |
Inspection Report
Complaint Investigation
Capacity: 75
Deficiencies: 9
Date: Sep 16, 2021
Visit Reason
Investigation of multiple resident-to-resident abuse incidents and failure to provide appropriate dementia care and other regulatory compliance issues.
Complaint Details
The complaint investigation was triggered by allegations of resident-to-resident abuse, failure to provide appropriate dementia care, failure to monitor post-surgical wounds, failure to prevent elopement, and failure to provide required staff training. Some abuse incidents were substantiated with actual harm to residents.
Findings
The facility failed to prevent resident-to-resident physical abuse resulting in injury, failed to provide appropriate post-surgical wound care leading to rehospitalization, failed to ensure proper use of physical restraints, failed to provide person-centered dementia care, failed to provide required dementia training for staff, and failed to maintain a safe environment preventing resident elopement.
Deficiencies (9)
F0600: The facility failed to protect residents from physical abuse by other residents, resulting in injuries including a resident requiring 12 staples to the head.
F0604: The facility failed to ensure a resident was not physically restrained in the dining room, restricting freedom of movement without physician order.
F0609: The facility failed to timely report suspected abuse involving physical abuse of a resident by another resident to the abuse coordinator and State Agency.
F0684: The facility failed to monitor a resident's post-surgical wound and vital signs timely, resulting in wound dehiscence, sepsis, and rehospitalization.
F0688: The facility failed to ensure a resident's left hand splint was applied per physician orders to manage contracture.
F0689: The facility failed to maintain a safe environment preventing a resident from eloping by exiting through unlocked doors on a secure unit.
F0695: The facility failed to ensure oxygen therapy was administered according to physician orders for a resident.
F0744: The facility failed to provide appropriate person-centered dementia care and interventions to prevent resident-to-resident altercations and manage behaviors for multiple residents with dementia.
F0947: The facility failed to provide required dementia training for all certified nurse aides reviewed.
Report Facts
Total residents: 75
Residents with dementia: 42
Residents with behavioral healthcare needs: 50
Staples to head: 12
Minutes occupational therapy: 51
Oxygen liters per minute: 2
Oxygen liters per minute observed: 2.5
BIMS scores: 8
BIMS scores: 4
BIMS scores: 9
BIMS scores: 10
BIMS scores: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Named in abuse incident reporting and assessment for Resident #62 and Resident #34 altercation |
| Certified Nurse Aide #1 | Certified Nurse Aide | Witnessed resident altercation and described resident behaviors |
| Social Service Director | Social Service Director | Interviewed regarding abuse incidents and resident behaviors |
| Director of Nursing | Director of Nursing | Interviewed regarding abuse incidents, resident care, and facility corrective actions |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Interviewed regarding Resident #50 behaviors and staff response |
| Occupational Therapist | Occupational Therapist | Interviewed regarding Resident #67 splint application and restorative care |
| Nursing Home Administrator | Nursing Home Administrator | Interviewed regarding facility policies, training, and corrective actions |
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