Inspection Reports for Pioneer Manor Nursing Home
318 N 3rd Street, HAY SPRINGS, NE, 69347
Back to Facility ProfileDeficiencies (last 11 years)
Deficiencies (over 11 years)
9.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
119% worse than Nebraska average
Nebraska average: 4.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
50 residents
Based on a April 2019 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Renewal
Capacity: 57
Deficiencies: 0
Date: Feb 13, 2023
Visit Reason
The document is a Nursing Home Licensure Renewal Application and related certification and occupancy permit documents for Pioneer Manor Nursing Home, indicating the facility is renewing its license.
Findings
The documents certify that Pioneer Manor Nursing Home meets statutory requirements for licensure renewal, with no deficiencies or violations noted in the provided materials.
Report Facts
Number of beds to be relicensed: 57
Maximum occupancy: 57
Renewal license expiration date: Mar 23, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Krystyn Turman | Administrator | Named on Nursing Home Licensure Renewal Application |
| Kassandra Hartman | Director of Nursing | Named on Nursing Home Licensure Renewal Application |
| Glenn A. Muhr | Authorized Representative | Signed Nursing Home Licensure Renewal Application |
Inspection Report
Renewal
Capacity: 57
Deficiencies: 0
Date: Mar 9, 2020
Visit Reason
The document is related to the renewal of the nursing home license for Pioneer Manor Nursing Home, including submission of a renewal application and issuance of an occupancy permit.
Findings
The documents verify that Pioneer Manor Nursing Home meets statutory requirements for licensure renewal and has been issued an occupancy permit with a maximum capacity of 57 beds.
Report Facts
Number of beds to be relicensed: 57
Maximum occupancy: 57
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 2
Date: Apr 17, 2019
Visit Reason
An unannounced visit was conducted to investigate a complaint at Pioneer Manor Nursing Home regarding failure to use appropriate interventions to prevent injuries, failure to evaluate causal factors for falls, and failure to change interventions after residents were identified at risk for falls.
Complaint Details
The complaint alleged the facility failed to use appropriate interventions to prevent injuries, failed to evaluate causal factors for falls, and failed to change interventions after residents were identified at risk for falls. The investigation substantiated failures in the first and third allegations but found compliance with the second.
Findings
The facility failed to use appropriate interventions to prevent injuries and failed to change care plan interventions after increased fall risks were identified for two sampled residents, resulting in injuries including a hip fracture and lacerations. The facility was found compliant in evaluating causal factors for falls. The census was 50 with three sampled residents.
Deficiencies (2)
Failure to use appropriate interventions to prevent injuries for one sampled resident.
Failure to change care plan interventions after residents were identified at risk for falls.
Report Facts
Facility census: 50
Sampled residents: 3
Fall incident date: Feb 18, 2019
Plan of correction completion date: May 31, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Connie Vogt | Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed the complaint investigation letter |
| Krystyn Turman | Administrator | Facility administrator addressed in the report |
| ADON | Assistant Director of Nursing | Interviewed regarding care plan interventions and fall risks |
Notice
Deficiencies: 0
Date: Mar 5, 2019
Visit Reason
This Notice of Disciplinary Action was issued due to violations of licensure regulations related to accidents, including failure to ensure interventions to prevent elopement and to identify causal factors to minimize residents' fall risk, resulting in resident injuries.
Findings
The facility was found to have violated regulations by failing to implement adequate interventions to prevent resident elopement and falls, leading to resident injuries. The facility's license was placed on probation for 90 days with requirements to submit a Plan of Correction and regular reports on residents with accidents.
Report Facts
Probation period: 90
Report submission frequency: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Connie Vogt | RN, BSN, Program Manager | Contact person for submission of required reports and Plan of Correction |
| Bo Botelho | Interim Director | Signed the Notice of Disciplinary Action |
| Becky Wise | Administrator, Licensure Unit | Signed the Notice of Disciplinary Action |
Inspection Report
Renewal
Capacity: 57
Deficiencies: 0
Date: Mar 1, 2019
Visit Reason
The document is a renewal application and certification for the Pioneer Manor Nursing Home's SNF/NF dual certification license, verifying licensure through the renewal date and compliance with state regulations.
Findings
The facility is licensed for 57 beds and meets statutory requirements for skilled nursing and nursing facility dual certification. The Nebraska State Fire Marshal issued an occupancy permit confirming a maximum occupancy of 57 beds as of 2018.
Report Facts
Number of beds to be relicensed: 57
Renewal fee: 1550
Occupancy permit date issued: Nov 1, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Krystyn Turman | Administrator | Named as facility administrator on the renewal application |
| Tracy Pawnee-Leggins | Director of Nursing | Named as director of nursing on the renewal application |
| Pat Gould | Deputy State Fire Marshal | Inspected the facility and approved the occupancy permit |
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 4
Date: Feb 11, 2019
Visit Reason
An unannounced visit was conducted to investigate a complaint at Pioneer Manor Nursing Home regarding failure to protect residents from residents with behaviors, failure to submit investigations within 5 working days, failure to evaluate causal factors for falls, failure to provide a safe environment for residents at risk for elopement, failure to protect residents from injury, and failure to ensure resident property is accounted for to prevent loss.
Complaint Details
The complaint investigation was triggered by allegations that the facility failed to protect residents from residents with behaviors, failed to submit investigations within 5 working days, failed to evaluate causal factors for falls, failed to provide a safe environment for residents at risk for elopement, failed to protect residents from injury, and failed to ensure resident property was accounted for to prevent loss. The investigation included observations, record reviews, and interviews with residents, family members, and staff. Several deficiencies were substantiated as detailed in the findings.
Findings
The facility was found deficient in protecting residents from sexual abuse by another resident with ongoing inappropriate sexual behaviors, failure to timely submit investigation reports to the State Agency for multiple residents, failure to evaluate causal factors for falls and injuries, and failure to provide a safe environment to prevent elopement and related injuries. The facility was compliant in accounting for resident property to prevent loss.
Deficiencies (4)
Failed to provide interventions to manage ongoing sexual behaviors for one resident to prevent sexual abuse towards another resident.
Failed to submit investigation reports to the State Agency within 5 working days for seven residents.
Failed to complete investigation reports as required for two residents.
Failed to ensure interventions were in place to prevent elopement and resulting injuries, and failed to identify causal factors for skin injuries and falls for multiple residents.
Report Facts
Facility census: 51
Sampled residents: 9
Closed record reviewed: 1
Deficiency completion dates: 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Connie Vogt | RN, BSN, Program Manager | Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS, signed the complaint investigation letter |
| Krystyn Turman | Administrator | Administrator of Pioneer Manor Nursing Home, interviewed during investigation |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 19, 2018
Visit Reason
An unannounced visit was conducted to investigate a complaint alleging the facility failed to implement care planned fall interventions.
Complaint Details
The allegation was that the facility failed to implement care planned fall interventions. After investigation, the allegation was not substantiated and no violations were found.
Findings
The investigation included review of medical records, observations, and interviews with residents, staff, and administration. The facility was found to be in compliance with regulatory requirements and implemented fall prevention interventions for all sampled residents; no violations were cited.
Report Facts
Sample size of residents reviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Connie Vogt | Program Manager | Signed the report as Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS |
Inspection Report
Annual Inspection
Census: 50
Deficiencies: 14
Date: Nov 6, 2018
Visit Reason
Annual inspection survey of Pioneer Manor Nursing Home to assess compliance with state and federal regulations including resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including advance directive documentation, notification of changes, elopement reporting and management, care plan development and updates, medication administration timeliness, psychotropic medication management, food safety, bed maintenance, and life safety code compliance such as door self-closing devices and smoke detection.
Deficiencies (14)
Failed to ensure advance directives reflected resident wishes for 2 sampled residents.
Failed to notify physician of multiple elopements and ineffectiveness of medication interventions for one resident.
Failed to immediately report and investigate elopements to State Agency for one resident.
Failed to provide written notice of facility-initiated hospitalizations to residents, representatives, and State Ombudsman for 3 residents.
Failed to develop and implement care plans addressing smoking safety, skin injuries, and anticoagulant medication for sampled residents.
Failed to update care plans timely to reflect nutritional status and psychotropic medication administration for sampled residents.
Failed to re-evaluate interventions and notify physician regarding ongoing exit-seeking and wandering behaviors for one resident.
Failed to ensure medications were administered on time as ordered for three sampled residents.
Failed to ensure pharmacy services included accurate labeling and storage of medications for one resident and incomplete refrigerator temperature logs.
Failed to complete pre-employment criminal background and registry checks for 2 direct care staff members.
Failed to participate in required emergency preparedness full scale or tabletop exercises.
Failed to provide a door that would close and latch properly between the kitchen and dining room.
Failed to provide smoke detection device in alcove open to corridor across from kitchen.
Failed to provide smoke seals on fire separation doors in East and West resident corridors.
Report Facts
Facility census: 50
Sample size: 20
Late medication administrations: 4
Late medication administrations: 4
Late medication administrations: 4
Late medication administrations: 9
Late medication administrations: 7
PRN Ativan administrations: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN-E | Licensed Practical Nurse | Observed medication administration and described resident behaviors |
| Administrator | Interviewed regarding multiple deficiencies including registry checks, emergency preparedness, and medication labeling | |
| DON | Director of Nursing | Interviewed regarding care plans, medication management, elopement reporting, and emergency preparedness |
| Social Service Director | Responsible for auditing advance directives and notification processes | |
| RN-B | Registered Nurse | Interviewed regarding advance directives and medication administration |
| LPN-A | Licensed Practical Nurse | Observed medication preparation and identified labeling discrepancy |
| Maintenance Supervisor | Interviewed regarding bed maintenance and fire safety door issues | |
| Dietary Manager | Interviewed regarding food safety and preparation practices |
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 3
Date: Aug 7, 2018
Visit Reason
An unannounced visit was conducted to investigate a complaint regarding the facility's failure to implement care planned interventions for fall prevention.
Complaint Details
The complaint alleged the facility failed to implement care planned interventions for fall prevention. The investigation substantiated this allegation, finding failures in safe transfer methods and staff training.
Findings
The investigation found that the facility failed to ensure consistent and safe transfer methods for residents to prevent falls, resulting in major injuries for two residents. Additionally, a new employee did not receive proper orientation and competency training in safe transfers.
Deficiencies (3)
Failure to update care plans to prevent contradictory information regarding safe transfers for residents.
Failure to ensure the resident environment remains free of accident hazards and provide adequate supervision and assistance devices to prevent accidents.
Failure to ensure newly hired nursing employee received orientation competency demonstrations in safely transferring residents.
Report Facts
Sample size: 3
Facility census: 51
Deficiency completion date: 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dan Taylor | RN, Training Coordinator | Signed letter regarding complaint investigation |
| Krystyn Turman | Administrator | Facility administrator addressed in report |
| NA-D | Nurse Aide | Direct care staff involved in resident transfers and interviewed regarding fall incidents |
| NA-A | Nurse Aide | Newly hired nursing employee who failed to demonstrate competency in safe transfers, involved in resident fall |
| LPN-B | Licensed Practical Nurse, Charge Nurse | Interviewed regarding resident fall risk and care |
| RN-C | Registered Nurse, Assistant Director of Nursing | Interviewed regarding resident fall risk and care |
Inspection Report
Renewal
Capacity: 57
Deficiencies: 0
Date: Feb 7, 2018
Visit Reason
The document is a Nursing Home Licensure Renewal Application and related renewal certification for Pioneer Manor Nursing Home, verifying the facility's license renewal through the indicated date.
Findings
The documents confirm that Pioneer Manor Nursing Home meets statutory requirements for licensure renewal and includes certification of services offered and ownership information. No deficiencies or inspection findings are noted.
Report Facts
Number of beds to be relicensed: 57
Renewal expiration date: Mar 31, 2019
Renewal fees: 1550
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Krystyn Turman | Administrator | Named as the facility administrator on the renewal application |
| Brenda Johnson | Director of Nursing, R.N. | Named as the director of nursing on the renewal application |
Inspection Report
Annual Inspection
Census: 49
Deficiencies: 12
Date: Dec 13, 2017
Visit Reason
Annual survey inspection of Pioneer Manor Nursing Home to assess compliance with federal and state regulations including emergency preparedness, medication administration, resident care planning, privacy, respiratory care, pharmacy services, psychotropic medication use, food safety, and life safety code compliance.
Findings
The facility was found deficient in multiple areas including failure to develop a comprehensive emergency preparedness plan, improper medication self-administration practices, lack of privacy during resident weighing, incomplete care plans for residents' medical and psychosocial needs, inadequate monitoring of psychotropic medication use, improper placement of oxygen concentrators, late medication administration, unsanitary food serving practices, and life safety code violations such as non-functioning exit lights and unsealed ceiling openings.
Deficiencies (12)
Failed to develop a comprehensive emergency preparedness plan including all required components.
Failed to identify medications at bedside, assess resident for safe self-administration, and obtain orders for bedside medications.
Failed to ensure weights were not obtained in public areas for three residents.
Failed to develop care plans addressing depression, hand splint use, and risks related to medications for sampled residents.
Failed to ensure nursing assistant attendance at care plan conferences for two residents.
Failed to place oxygen concentrator to ensure proper ventilation and efficient operation.
Failed to administer ordered medications within scheduled time frames for one resident.
Failed to monitor and document behaviors and sleep patterns related to psychotropic and hypnotic medication use for sampled residents.
Failed to serve food in a sanitary manner, including handling glasses and bowls with fingers on rims.
Failed to maintain exit lights in operating condition in 2 of 5 smoke compartments.
Failed to maintain required fire protection rating of ceiling in kitchen area due to unsealed openings.
Failed to provide continuing education for personnel on safe handling and use of medical gas (oxygen) cylinders and equipment.
Report Facts
Facility census: 49
Sample size: 18
Deficiencies cited: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Krystyn Turman | Administrator | Named as facility administrator and signer of compliance forms |
| Interim Director of Nursing | Interviewed multiple times regarding care plans, medication administration, and facility policies | |
| Dietary Manager | Interviewed regarding food service sanitation practices | |
| Employee A | Observed serving food unsanitarily | |
| Employee B | Observed serving food unsanitarily | |
| NA-E | Nurse Aide | Interviewed regarding resident behaviors |
| NA-F | Nurse Aide | Interviewed regarding resident behaviors |
| NA-G | Nurse Aide | Interviewed regarding resident behaviors |
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 5
Date: Sep 7, 2017
Visit Reason
An unannounced visit was conducted to investigate a complaint alleging the facility failed to protect residents from abuse.
Complaint Details
The complaint alleged the facility failed to protect residents from abuse. Investigation revealed that a nurse aide was rough with a resident and used a derogatory name. The allegation was reported to the facility but was not reported to the state agency within the required timeframe. The staff involved continued to work during the investigation period. The facility failed to investigate the allegation and notify the state agency as required.
Findings
The facility failed to protect residents from abuse, failed to investigate and report an allegation of abuse to the state agency within the required timeframe, and allowed the staff person involved to continue working. Additionally, the facility failed to complete required criminal background and registry checks for some staff, failed to maintain nurse staffing postings for 18 months, failed to verify nurse aide certification for one aide, and failed to ensure annual in-service education for multiple nurse aides.
Deficiencies (5)
Facility failed to protect residents from abuse and failed to report and investigate allegations timely.
Facility failed to complete and maintain documentation of pre-employment criminal background and registry checks on unlicensed direct care staff members.
Facility failed to maintain 18 months of nursing staff posting data.
Facility failed to verify current nurse aide certification for one nurse aide.
Facility failed to ensure 17 nurse aides completed the required 12 hours of annual in-service education.
Report Facts
Census: 49
Number of nurse aides without annual education: 17
Number of nurse aides reviewed for certification: 30
Number of nurse aides with missing APS/CPS registry checks: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA-B | Nurse Aide | Named in abuse allegation involving rough care and derogatory name calling of Resident 1 |
| NA-C | Nurse Aide | Worked with lapsed nurse aide certification |
| LPN-A | Licensed Practical Nurse | Received abuse allegation call and failed to report to state agency |
| Krystyn Turman | Administrator | Facility administrator interviewed regarding abuse allegation and registry check deficiencies |
| Eve Lewis | Program Manager - Office of LTC Facilities - Licensure Unit | Signed complaint investigation letter |
Inspection Report
Enforcement
Deficiencies: 1
Date: Sep 7, 2017
Visit Reason
A survey was conducted to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs. The survey was complaint-related and identified substandard quality of care conditions.
Complaint Details
The survey was complaint-related and identified conditions constituting substandard quality of care.
Findings
The facility was found not in substantial compliance with participation requirements, with deficiencies constituting substandard quality of care. A civil money penalty of $5,000 was imposed for failure to investigate/report allegations related to deficiency F0225.
Deficiencies (1)
Failure to investigate/report allegations/individuals as described at deficiency F0225
Report Facts
Civil Money Penalty: 5000
Denial of Payment for New Admissions: Effective October 10, 2017 through October 30, 2017 due to prior noncompliance
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Krystyn Turman | Administrator | Facility administrator addressed in the report |
| Marsophia R. Powers | Long Term Care Branch Manager | Signed the enforcement letter |
| Benton Williams | Health Insurance Specialist | Contact person for comments or concerns |
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 1
Date: Jun 13, 2017
Visit Reason
An unannounced visit was conducted to investigate a complaint regarding the facility's failure to investigate causative factors in falls and failure to follow the plan of care for fall prevention.
Complaint Details
The complaint alleged the facility failed to investigate causative factors in falls and failed to follow the plan of care for fall prevention. The allegation regarding failure to investigate causative factors was substantiated with violations found. The allegation regarding failure to follow the plan of care was not substantiated.
Findings
The facility was found to have failed to investigate causative factors in falls and implement interventions to prevent falls and injury for 2 of 3 sampled residents. However, the facility was found to be in compliance with following the plan of care for fall prevention. The facility lacked documentation and policies regarding fall risk assessment and interventions.
Deficiencies (1)
Facility failed to assess for causal factors and implement interventions to prevent potential falls and injury for 2 of 3 sampled residents.
Report Facts
Census: 49
Residents sampled: 3
Residents with deficiencies: 2
BIMS score: 12
BIMS score: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | Program Manager | Signed the letter from the Office of LTC Facilities - Licensure Unit |
| Krystyn Turman | Administrator | Facility administrator addressed in the report |
| DON | Director of Nursing | Interviewed regarding lack of documentation and policy on fall risk and interventions |
| LPN-A | Licensed Practical Nurse | Interviewed regarding incomplete fall risk assessment |
| LPN-B | Licensed Practical Nurse | Interviewed confirming lack of fall interventions on care plan |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 22, 2017
Visit Reason
An unannounced visit was conducted to investigate a complaint alleging that the facility fails to investigate for causative factors in falls.
Complaint Details
The complaint allegation was that the facility fails to investigate for causative factors in falls. The allegation was investigated and found to be unsubstantiated as the facility was in compliance.
Findings
The investigation found that the facility had investigated causative factors in falls and implemented interventions to prevent them. Staff followed fall interventions per care plan, and the facility was found to be in compliance with related regulatory requirements.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | Program Manager | Signed the report as Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS |
Inspection Report
Renewal
Capacity: 57
Deficiencies: 0
Date: Jan 30, 2017
Visit Reason
The document is a renewal application and certification for the Pioneer Manor Nursing Home license, verifying that the facility's SNF/NF dual certification is licensed through the indicated renewal date.
Findings
The facility is licensed as a Skilled Nursing Facility/Nursing Facility with a total capacity of 57 beds. The renewal application confirms compliance with statutory requirements and includes certification of services such as physical therapy, occupational therapy, and speech therapy. An occupancy permit issued by the Nebraska State Fire Marshal confirms the maximum occupancy of 57 beds.
Report Facts
Number of beds to be relicensed: 57
Renewal expiration date: Mar 31, 2018
Renewal application date: Jan 30, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brenda Johnson | Director of Nursing | Named in renewal application |
| Krystyn Turman | Administrator | Named in renewal application and signed as authorized representative |
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 1
Date: Jan 9, 2017
Visit Reason
An unannounced visit was conducted to investigate a complaint alleging the facility failed to protect a resident from abuse.
Complaint Details
The complaint alleged the facility failed to protect the resident from abuse. The allegation was investigated and found unsubstantiated regarding abuse, but the facility did not report a significant injury related to potential abuse to the State Agency as required.
Findings
The investigation found that residents reported feeling safe and no abuse by staff was observed. However, the facility failed to report an allegation of potential abuse involving a significant injury to the State Agency within the required timeframe.
Deficiencies (1)
Facility failed to report allegations of potential abuse evidenced by a significant injury to the State Agency within the regulatory timeframe for 1 of 3 sampled residents.
Report Facts
Facility Census: 48
Deficiencies cited: 1
Inspection Report
Annual Inspection
Census: 45
Capacity: 57
Deficiencies: 8
Date: Oct 5, 2016
Visit Reason
Annual survey inspection of Pioneer Manor Nursing Home to assess compliance with state regulations governing skilled nursing facilities.
Findings
The facility was found deficient in multiple areas including dignity and respect of residents, safe and homelike environment, comprehensive care plan development and revision, accident hazard prevention, drug regimen monitoring, food sanitation, infection control, and dining room accommodations.
Deficiencies (8)
Gait belts were left on residents when not in use and clothing protectors were not removed after meals, compromising dignity and respect.
The assist dining room did not provide a homelike environment or adequate space for residents to eat together at tables.
Failed to develop or revise comprehensive care plans addressing medication use and fall interventions for sampled residents.
Oxygen concentrators were left on when not in use for two residents, posing a fire hazard.
Food preparation and kitchen areas were not maintained in a sanitary condition, including dirty utensils, ovens, toaster, and dishwasher leaks.
Failed to monitor symptoms of depression and sleep patterns for residents on antidepressant and hypnotic medications.
Whirlpool seatbelt was worn and exposed canvas material, and towel bars were not labeled to prevent cross contamination.
Dining room lacked sufficient space to accommodate all residents at tables during meals.
Report Facts
Facility census: 45
Total licensed capacity: 57
Residents observed in assist dining room: 17
Residents affected by whirlpool seatbelt issue: 12
Residents affected by unlabeled towel bars: 4
Residents sampled for medication review: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Krystyn Jurman | Administrator | Signed civil rights compliance form and involved in interviews |
| Assistant Director of Nursing (ADON) | Interviewed regarding gait belt use, clothing protector removal, oxygen concentrator use, care plan updates, and infection control | |
| Licensed Practical Nurse - A (LPN-A) | Interviewed regarding assist dining room space and seating | |
| Dietary Manager | Interviewed regarding kitchen cleanliness and food preparation sanitation |
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 1
Date: Feb 22, 2016
Visit Reason
An unannounced visit was conducted to investigate a complaint survey at Pioneer Manor Nursing Home on February 22, 2016, by representatives of the Department of Health and Human Services Division of Public Health.
Complaint Details
The complaint alleged the facility failed to ensure clean and groomed hair, skin, teeth, and/or nails; failed to ensure residents had access to communication; failed to notify the physician of change in condition; and failed to provide appropriate positioning. The investigation disproved the first, second, and fourth allegations but substantiated the third allegation regarding failure to notify the physician and family/POA of changes in condition or medication.
Findings
The investigation found no deficiencies related to grooming, communication access, or resident positioning. However, deficiencies were identified related to failure to notify the physician and family/Power of Attorney of changes in condition or medication for two sampled residents, resulting in a citation under Federal Licensure tag F 157.
Deficiencies (1)
Failure to notify the physician and family/Power of Attorney of changes in condition or medication for sampled residents.
Report Facts
Facility census: 49
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Krystyn Turman | Administrator | Named in relation to interviews and findings regarding notification deficiencies |
| Eve Lewis | Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed the complaint investigation letter |
Inspection Report
Annual Inspection
Census: 50
Capacity: 57
Deficiencies: 6
Date: Jul 29, 2015
Visit Reason
Annual inspection of Pioneer Manor Nursing Home to assess compliance with regulatory requirements including resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to ensure CPR certification for transportation and supervisory staff, failure to maintain resident dignity regarding mechanical lift slings, incomplete and inaccurate resident care plans, lack of procedures to ensure water availability in emergencies, failure to conduct quarterly fire drills on each shift, and failure to maintain and test the fire sprinkler system as required.
Deficiencies (6)
Failure to ensure 18 sampled employees responsible for resident transportation and supervision maintained up-to-date CPR certification affecting 6 residents requesting CPR.
Failure to assure mechanical lift slings were not left in full view of residents, staff, and visitors affecting 6 residents.
Failure to develop comprehensive care plans addressing hypnotic medication use, risk for elopement, diabetic and psychotropic medication use, hospice services, and anticoagulant use for 5 sampled residents.
Failure to establish procedures to ensure water availability to essential areas during loss of normal water supply.
Failure to conduct fire drills quarterly on each shift under varying conditions.
Failure to maintain fire sprinkler system in reliable operating condition by not testing the system quarterly as required.
Report Facts
Facility census: 50
Total licensed capacity: 57
Number of employees without up-to-date CPR: 18
Number of residents affected by CPR deficiency: 6
Number of residents affected by mechanical lift sling issue: 6
Number of sampled residents with incomplete care plans: 5
Date of last fire drill before inspection: Jan 1, 2015
Date of last fire sprinkler inspection: Feb 3, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator A | Administrator | Interviewed regarding fire drills and sprinkler system deficiencies |
| Director of Nursing | Director of Nursing | Interviewed regarding CPR certification, care plans, and emergency water procedures |
| Maintenance Supervisor | Maintenance Supervisor | Interviewed regarding fire sprinkler system testing and fire system operation |
| LPN Q | Licensed Practical Nurse | Interviewed regarding resident care plans and hospice services |
| NA H | Nursing Assistant | Interviewed regarding resident care and medication awareness |
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 5
Date: Jul 17, 2014
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Pioneer Manor Nursing Home on July 15-17, 2014. The complaint allegations included failure to ensure unrestricted visitation and failure to provide care and treatment for bladder elimination.
Complaint Details
The complaint alleged the facility failed to ensure residents were allowed unrestricted visitation and failed to provide care and treatment for bladder elimination. The investigation found no violation regarding visitation or bladder care but identified other deficiencies as noted.
Findings
The facility was found to permit unrestricted visitation and to provide appropriate care and treatment for bladder elimination. However, deficiencies were identified including failure to notify family and physician promptly of a resident's rapid condition change, failure to assess resident ability to self-administer medication, failure to maintain resident dignity in public areas, lack of documentation of pneumococcal vaccine education and refusal, and infection control issues such as improper storage of urine samples, oxygen masks, creams, and urinary devices.
Deficiencies (5)
Failure to notify resident's family and medical practitioner promptly of a rapid change in condition for Resident 35.
Failure to assess Resident 28's ability to safely self-administer medication kept at bedside.
Failure to ensure Resident 67 was dressed in a manner to promote dignity while in public areas.
Failure to provide documentation of pneumococcal vaccine education and refusal for Residents 36 and 49.
Infection control deficiencies including urine sample stored in medication refrigerator, uncovered oxygen mask, medicated creams stored on bathroom floor, uncovered urinal and urinary measuring device stored on bathroom floors.
Report Facts
Facility census: 48
Deficiencies cited: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Krystyn Turman | Administrator | Named in letter and involved in facility administration |
| Joseph Schumacher | Registered Nurse | Surveyor conducting investigation |
| Kaylene Straetker | Registered Nurse | Surveyor conducting investigation |
| Eve Lewis | Program Manager | Signed letter from Office of Long Term Care Facilities |
| RN/ADON-A | Registered Nurse/Assistant Director of Nursing | Responsible for infection control program and vaccine education |
| DON | Director of Nursing | Interviewed regarding resident condition change and medication self-administration |
| LPN-B | Licensed Practical Nurse | Interviewed regarding medication administration |
Notice
Deficiencies: 0
Date: Jun 3, 2014
Visit Reason
The notice was issued to inform the facility of disciplinary action placing its license on probation for 90 days starting June 18, 2014, due to violations found in the CMS-2567 Report regarding failure to identify and respond to changes in residents' conditions.
Findings
The facility violated licensure regulations related to charge nurse requirements, provision of care and treatment, and skin integrity. The violations were evidenced by failure to identify and respond to changes in residents' conditions as specified in the CMS-2567 Report dated June 3, 2014.
Report Facts
Probation period: 90
Report due date: 28
Notice finalization date: 18
Notice mailing date: 3
Response timeframe: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | RNC, Program Manager | Contact for submission of reports and response to the Notice |
| Joseph M. Acierno | Chief Medical Officer, Director, Division of Public Health | Signed the Notice of Disciplinary Action |
| Helen L. Meeks | Administrator, Licensure Unit | Signed the Notice of Disciplinary Action |
| Linda Stenvers | Staff Assistant II | Certified mailing of the Notice |
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 3
Date: May 19, 2014
Visit Reason
An unannounced visit was conducted to investigate a complaint regarding failure to notify healthcare practitioners and family of changes in residents' conditions, failure to identify changes in condition, and failure to provide care to promote wound healing.
Complaint Details
The complaint alleged failure to notify healthcare practitioners and family of changes in condition, failure to identify changes in condition, and failure to provide care to promote wound healing. The investigation confirmed these allegations for two residents.
Findings
The facility failed to notify physicians and family members of changes in residents' conditions for two sampled residents, failed to identify changes in condition, and failed to provide appropriate wound care and pain management for one resident. Two residents had documented issues with notification and wound care, including one with a right leg amputation and infection and another with a pressure ulcer.
Deficiencies (3)
Failure to notify healthcare practitioner and family of changes in condition for residents.
Failure to identify a change of condition and provide appropriate care.
Failure to provide care and treatment to promote wound healing and manage pain.
Report Facts
Facility census: 47
Deficiency citations: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Krystyn Turman | Provisional Administrator | Named in letter receiving complaint investigation results |
| Eve Lewis | Program Manager, Office of Long Term Care Facilities | Signed complaint investigation letter |
| Keeli Klein | Registered Nurse | Investigator |
| Joseph Schumacher | Registered Nurse | Investigator |
| Kaylene Straetker | Registered Nurse | Investigator |
Notice
Deficiencies: 1
Date: Sep 26, 2013
Visit Reason
The document serves as a Notice of Disciplinary Action issued to Pioneer Manor Nursing Home for violations related to medication errors that resulted in a resident's hospitalization, placing the facility on probation for 90 days starting October 11, 2013.
Findings
The facility failed to assure medications were administered properly, leading to a medication error and resident hospitalization. The facility is required to submit a Plan of Correction addressing medication errors and submit regular reports during the probation period.
Deficiencies (1)
Violation of licensure regulation 175 NAC 12-006.10 pertaining to Medication Errors
Report Facts
Probation period length: 90
Report due date: Oct 21, 2013
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | RNC, Program Manager | Recipient of required reports and contact for the Office of Long Term Care Facilities |
| Joseph M. Acierno | Chief Medical Officer, Director, Division of Public Health | Signed the Notice of Disciplinary Action |
| Helen L. Meeks | Administrator, Licensure Unit | Signed the Notice of Disciplinary Action |
| Linda Stenvers | Staff Assistant II | Certified mailing of the Notice of Disciplinary Action |
| Sandra Perkins | Administrator | Facility administrator addressed in the follow-up letter |
Inspection Report
Routine
Census: 41
Deficiencies: 2
Date: Sep 16, 2013
Visit Reason
The inspection was conducted to assess compliance with regulations governing licensure of skilled nursing facilities, nursing facilities, and intermediate care facilities, focusing on medication administration and drug storage.
Findings
The facility failed to ensure residents were free of significant medication errors, as one resident was given the wrong medication resulting in hospitalization. Additionally, medication labels for another resident were found to be illegible, not meeting professional standards.
Deficiencies (2)
Facility failed to ensure residents received medications in accordance with the five rights, resulting in a significant medication error for one resident.
Medication labels were not legible for one resident, failing to meet acceptable standards of professional practice.
Report Facts
Facility census: 41
Medication dosage: 200
Medication dosage: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director Of Nursing | Confirmed medication errors and label issues during interviews | |
| Licensed Practical Nurse | Administered wrong medication to Resident 11 |
Inspection Report
Annual Inspection
Census: 44
Deficiencies: 8
Date: May 29, 2013
Visit Reason
Annual inspection of Pioneer Manor Nursing Home to assess compliance with federal and state regulations including resident care, medication management, nutrition, and life safety code.
Findings
The facility was found in compliance with the Life Safety Code. Deficiencies were identified in resident assessment accuracy, care plan development, medication management including unnecessary drug use and medication errors, nutritional supplementation, food temperature control, and medication labeling accuracy.
Deficiencies (8)
Failed to accurately code resident's incontinence status on Minimum Data Set (MDS) assessments.
Failed to develop comprehensive care plans addressing various resident needs including behavioral symptoms, medication use, and incontinence.
Failed to provide care plan intervention for nutritional supplementation for a resident at high risk for weight loss.
Resident received unnecessary duplicative medications including diuretics and antidepressants.
Significant medication error involving inconsistent titration and administration of insulin.
Failed to ensure hot meals were kept hot and served at proper temperatures.
Pharmacist failed to identify irregularity in insulin order and administration.
Medication labels for two residents did not match physician orders and Medication Administration Records (MAR).
Report Facts
Facility census: 44
Weight loss: 24
Medication doses: 10
Temperature: 102
Temperature: 132
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sandra Perkins | Nursing Home Administrator | Signed initial comments on life safety compliance |
| RN F | Registered Nurse | Involved in resident care planning and medication administration |
| LPN B | Licensed Practical Nurse | Administered medications and confirmed insulin titration inconsistency |
| Dietary Manager | Certified Dietary Manager | Confirmed nutritional supplement and food temperature deficiencies |
| Administrator | Confirmed medication duplication and insulin order issues | |
| Assistant Director of Nursing | ADON | Confirmed care plan and medication labeling deficiencies |
| Director of Nursing | DON | Confirmed care plan and medication labeling deficiencies |
Inspection Report
Annual Inspection
Census: 41
Deficiencies: 7
Date: Jun 20, 2012
Visit Reason
The inspection was an annual survey to assess compliance with federal and state regulations for Pioneer Manor Nursing Home.
Findings
The facility was found to have multiple deficiencies including failure to report abuse investigations to the State Agency, inaccurate resident assessments, incomplete care plans, failure to implement care plans, improper handwashing by dietary staff, failure to identify duplicative medication therapies, and expired medications available for resident use. A follow-up life safety code inspection found no deficiencies.
Deficiencies (7)
Failure to submit investigations of alleged abuse incidents to the State Agency for three incidents involving residents.
Failure to ensure MDS assessments were coded accurately for Resident 25 regarding medication use.
Failure to develop comprehensive care plans addressing high fall risk and psychotropic medication use for sampled residents.
Failure to implement and follow care plan interventions related to activities for Resident 1.
Dietary staff failed to wash hands according to facility policy and Nebraska Food Code, risking foodborne illness.
Consulting pharmacist failed to identify duplicative medication therapies for Resident 15.
Expired medications were found available for resident use in the medication room and laboratory supplies.
Report Facts
Facility census: 41
Sample size: 12
Closed records sample size: 2
Hand wash scrub times (seconds): 10
Hand wash scrub times (seconds): 8
Hand wash scrub times (seconds): 5
Hand wash scrub times (seconds): 6
Hand wash scrub times (seconds): 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN-A | Identified expired medications during inspection of medication room. | |
| Director of Nursing | DON | Interviewed regarding abuse investigations, medication assessments, care plans, and pharmacist reviews. |
| Dietary Manager | Interviewed regarding handwashing practices of dietary staff. | |
| Activities Director | Interviewed regarding Resident 1's participation in activities. |
Inspection Report
Annual Inspection
Census: 49
Capacity: 57
Deficiencies: 17
Date: May 26, 2011
Visit Reason
Annual survey to assess compliance with federal and state regulations governing nursing facilities, including care and treatment, resident rights, infection control, safety, and quality assurance.
Findings
The facility was found deficient in multiple areas including failure to complete physician-ordered lab tests, maintain resident privacy, resolve grievances, report abuse, ensure dignity and respect, maintain housekeeping and maintenance, manage disruptive behaviors, develop comprehensive care plans, revise care plans, prevent accidents, provide immunizations, prepare and serve food properly, conduct timely drug regimen reviews, maintain infection control, document medications accurately, and maintain a quality assurance program. Additionally, life safety code violations were noted with corridor doors.
Deficiencies (17)
Failure to ensure physician orders for laboratory tests were completed as ordered for Resident 12.
Failure to maintain resident privacy by posting private information on daily census and staffing posters.
Failure to investigate and resolve resident grievance regarding missing personal property for Resident 1.
Failure to follow abuse reporting policy for resident to resident incidents involving Residents 40 and 44.
Failure to maintain dignity and respect including knocking before entering rooms, providing privacy during hair drying, and appropriate dining room seating.
Failure to maintain housekeeping and maintenance services including repair of vanity cabinet doors, bathroom doors, and walls in resident rooms.
Failure to maintain comfortable sound levels by not managing loud and disruptive verbalizations from Resident 33 during meal service.
Failure to develop and revise comprehensive care plans reflecting discharge plans, medication changes, accident prevention, and monitoring needs for multiple residents.
Failure to ensure resident environment is free of accident hazards including hazardous coffee temperatures, unsecured chemicals, and inadequate fall prevention interventions.
Failure to document education and consent/refusal for influenza and pneumococcal immunizations for multiple residents.
Failure to prepare pureed foods according to recipe and ensure food palatability and temperature for residents requiring assistance.
Failure to ensure food safety including removal of outdated leftovers, proper storage of cleaning towels and kitchenware.
Failure to provide timely pharmacist drug regimen reviews for residents.
Failure to maintain an effective infection control program including monitoring employee illness, antibiotic use, infection control techniques, and hand hygiene.
Failure to accurately document routine medication administration on the Medication Administration Record (MAR) for Resident 7.
Failure of Quality Assurance Committee to identify and correct ongoing deficiencies related to dignity, infection control, and pharmacy review timeliness.
Failure to maintain corridor doors that close and latch properly to meet the 20-minute fire rating as required by Life Safety Code.
Report Facts
Facility census: 49
Facility capacity: 57
Sample size: 16
Temperature of coffee: 156
Days leftover food stored: 5
Days leftover food stored (observed): 3
Medication review delay: 60
Medication review delay: 83
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator A | Administrator | Interviewed regarding corridor door deficiencies and privacy issues |
| Maintenance Person A | Maintenance Person | Interviewed regarding corridor door deficiencies |
| Dietary Aide-J | Dietary Aide | Observed preparing pureed foods and handling leftovers |
| Dietary Manager | Dietary Manager | Interviewed regarding food preparation, leftover food policy, and coffee hazards |
| Laundry Supervisor | Laundry Supervisor | Interviewed regarding missing resident clothing grievance |
| ADON | Assistant Director of Nursing | Interviewed regarding lab orders, infection control, and glucometer use |
| DON | Director of Nursing | Interviewed regarding medication documentation, infection control, and staff education |
| LPN-G | Licensed Practical Nurse | Observed improper glucometer use |
| Housekeeper D | Housekeeper | Observed improper cleaning and glove use |
| NA-E | Nurse Aide | Observed improper hand hygiene during resident care |
| NA-F | Nurse Aide | Observed improper hand hygiene during resident care |
| NA-K | Nurse Aide | Observed improper hand hygiene during resident care |
Inspection Report
Life Safety
Deficiencies: 0
Date: May 24, 2011
Visit Reason
A Life Safety Code survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the facility was not in substantial compliance with participation requirements. A revisit had not been conducted initially, resulting in a denial of payment for new Medicare and Medicaid admissions effective August 26, 2011. However, a subsequent revisit on August 4, 2011, established that corrections were made and the facility was then in substantial compliance, lifting the denial of payment.
Report Facts
CMP amount: 5000
Denial of payment effective date: Aug 26, 2011
Compliance correction revisit date: Aug 4, 2011
Noncompliance termination date: Nov 26, 2011
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dianne Cooper | Administrator | Administrator of Pioneer Manor Nursing Home, recipient of the letters. |
| Jennifer King | Branch Manager | Branch Manager, Survey, Certification & Enforcement Branch, sender of the enforcement letters. |
| Jane Weiler | Health Quality Review Specialist | Contact person for additional comments or concerns at Kansas City Office. |
Document
Capacity: 57
Deficiencies: 0
Date: APP2016
Visit Reason
The document set serves to verify and renew the licensure of Pioneer Manor Nursing Home as a Skilled Nursing Facility, including certification for Medicare and Medicaid, and to provide the occupancy permit and fire plan for the facility.
Findings
The documents confirm that Pioneer Manor Nursing Home meets statutory requirements for licensure renewal, with a licensed capacity of 57 beds, and includes an occupancy permit issued by the Nebraska State Fire Marshal. No inspection findings or deficiencies are reported.
Report Facts
Licensed capacity: 57
Renewal fee: 1550
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brenda Johnson | Director of Nursing | Named on the Nursing Home Licensure Renewal Application |
| Krystyn Turman | Administrator | Named on the Nursing Home Licensure Renewal Application and signed as authorized representative |
| Richard McKay | Mayor | Signed as authorized representative on the Nursing Home Licensure Renewal Application |
Document
Capacity: 57
Deficiencies: 0
Date: APP2020
Visit Reason
The documents verify the licensure renewal and certification of Pioneer Manor Nursing Home and provide the state fire marshal occupancy permit indicating the licensed bed capacity.
Findings
The documents confirm that Pioneer Manor Nursing Home meets statutory requirements for licensure renewal and holds a valid occupancy permit for 57 beds. No inspection findings or deficiencies are reported.
Report Facts
Licensed bed capacity: 57
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Krystyn Turman | Administrator | Authorized representative signing the licensure application |
| Rachel Belknap | Director of Nursing | Named as Director of Nursing on facility information |
| Richard McKay | Mayor | Authorized representative signing the licensure application and appointing board members |
Document
Capacity: 57
Deficiencies: 0
Date: APP2022
Visit Reason
The documents serve to verify and renew the nursing home license for Pioneer Manor Nursing Home, including submission of the renewal application and confirmation of licensure status.
Findings
No inspection findings or deficiencies are reported in these documents. They primarily provide administrative and licensing information.
Report Facts
Total licensed beds: 57
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Krystyn Turman | Administrator | Named as Administrator on the renewal application. |
| Kassandra Hartman | Director of Nursing | Named as Director of Nursing on the renewal application. |
Notice
Capacity: 57
Deficiencies: 0
Date: APP2024
Visit Reason
The document serves as a renewal application for the nursing home license of Pioneer Manor Nursing Home and includes related licensing and occupancy permit information.
Findings
The documents certify that Pioneer Manor Nursing Home meets statutory requirements for licensure renewal and occupancy, with no inspection findings or deficiencies reported.
Report Facts
Number of beds to be relicensed: 57
Maximum occupancy: 57
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Krystyn Turman | Administrator | Named on the Nursing Home Licensure Renewal Application |
| Kassandra Hartman | Director of Nursing | Named on the Nursing Home Licensure Renewal Application |
| Glenn Muhr | Mayor | Authorized representative signing the renewal application and appointing board members |
Notice
Capacity: 57
Deficiencies: 0
Date: APP2025
Visit Reason
The document serves as a licensure renewal application for Pioneer Manor Nursing Home and includes certification of licensure, occupancy permit, and board of directors information.
Findings
The documents confirm the facility's licensure renewal status, maximum bed capacity, and compliance with state requirements for licensure and occupancy. No inspection findings or deficiencies are reported.
Report Facts
Total licensed beds: 57
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Krystyn Turman | Administrator | Named as administrator on the licensure renewal application. |
| Krystyn Turman | NHA | Authorized representative signing the renewal application. |
| Dana Reece | Deputy State Fire Marshal | Inspected the facility for occupancy permit. |
Notice
Deficiencies: 0
Date: DAN080718
Visit Reason
This Notice of Disciplinary Action was issued to Pioneer Manor Nursing Home due to violations of licensure regulations related to accidents and resident safety, specifically failure to identify and implement safe transfer interventions.
Findings
The facility's license is placed on probation for 90 days starting September 5, 2018, requiring submission of a Plan of Correction and biweekly reports on residents with accidents. Violations were evidenced by failure to identify and implement safe transfer interventions as detailed in the CMS-2567 Report dated August 21, 2018.
Report Facts
Probation period: 90
Report submission frequency: 14
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