Pioneers Memorial Skilled Nursing Center
PIONEERS MEMORIAL SKILLED NURSING CENTER in BRAWLEY, CA — inspection on April 28, 2026.
Found 9 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
describing pain rate.3/5/26, .[12:19 P.M.] Resident fall [sic] in front nurse station, called
wheelchair.Resident.has been able to verbalize pain to [left] shoulder, headache, and backache at
with UM 1. UM 3 was also present. UM 1 stated Resident 2 wanted to remain independent but that the resident had confusion, was frail, and required staff to monitor her every 15 minutes to make sure she was not trying to get up on her own.UM 1 reviewed Resident 2's fall risk evaluation and stated the last fall risk evaluation done before her 1/15/26 fall was in June 2025.
The UM stated Resident 2 should have been reassessed for fall risk when her quarterly MDS assessments were done. UM 1 stated her last MDS assessment before her fall was in December 2025. UM 1 reviewed Resident 2's written care plans and stated the care plan for The Resident Is (High) Risk for Falls R/T [related to] Confusion, Gait/Balance Problems, Poor Communication/Comprehension, Unaware of Safety Needs had been created on 9/25/23 with revisions made to the care plan on 9/9/24 and 1/16/26. UM 1 stated this care plan was in place at the time of Resident 2's fall on 1/15/26, and that it was vague.
UM 1 reviewed the care plan intervention, If resident is a fall risk, initiate fall precautions. UM 1 stated the resident's fall risk should have been determined a long time ago and had clear fall precautions. UM 1 stated the care plan intervention, Determine Residents ability to transfer, should have been determined a long time ago. UM 1 stated the care plan intervention, increase rounding frequency, date initiated 1/26/26, should have been more clear to include who was responsible for doing the rounding and that it should be at 15 minute intervals. UM 1 reviewed the care plan intervention initiated 1/26/26, .When resident is up on w/c [wheelchair], resident is placed at nursing station. UM 1 stated Resident 2 should not have had another unwitnessed fall on 3/5/26 after being placed in front of the nurses' station for supervision. UM 1 stated adequate supervision should have been provided when Resident 2 was placed in front of the nurses' station.UM 1 reviewed Resident 2's IDT note dated 1/16/26, indicated the IDT met to discuss the resident's fall that occurred on 1/15/26.
The IDT note included the confirmation of the resident's compression fracture (occurs when a spinal bone collapses) but lacked any discussion as to the root cause of the fall and had no recommendations to prevent further falls from occurring.On 4/28/26 at 2:55 P.M., a telephone interview was conducted with the interim director of nursing (DON).
The DON stated she was hired about two weeks ago.
The DON stated, All the residents' falls should not be happening.
The DON stated this week she began asking, What are we doing about it? The DON stated she reviewed documentation of residents who had falls over the last few months including Resident 1 and Resident 2 and that there had not been thorough investigations into the cause of the falls.
The DON stated the IDT documentation of the falls she reviewed just described the fall but there had been no determination of the root cause.
The DON stated, If you don't determine how the fall happened, you can't put relevant interventions in the care plan to prevent further falls.
The DON stated falls needed to be investigated and the cause had to be determined.
The DON stated care plans should have been updated with individualized interventions after falls occurred to address fall risk and to prevent more from happening.On 4/28/26 at 3:37 P.M., an interview was conducted with the medical records director (MRD).
The MRD stated the facility did not have a policy for care plan development or revision.
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Pioneers Memorial Skilled Nursing Center 320 Cattle Call Dr.
Brawley, CA 92227
provided care and services to one of three residents (Resident 1) according to acceptable standards
result of this deficient practice, UM 2's falsified documentation misrepresented the facility's investigation into Resident 1's fall and fall aftercare.Findings:A review of Resident 1's Face Sheet indicated the resident was admitted on [DATE] and re-admitted on [DATE] with diagnoses to include unspecified dementia (progressive brain disorder causing cognitive decline, memory loss, confusion, and behavioral changes), impulse disorder (mental health condition characterized by inability to resist urges or impulses that may harm oneself), anxiety disorder, and a history of falling.A review of Resident 1's IDT Progress Note-Falls dated 4/13/26 at 10:48 A.M., indicated the IDT was composed of the director of rehabilitation, social services director, the director of staff development, infection preventionist, quality assurance nurse, and the MDS coordinator.
The IDT note further indicated, .Resident experienced an unwitnessed fall in front of the nurse's station.IDT reviewed the incident and contributing factors, including fall risk status, environment and current care plan.
The following interventions will be implemented/reinforced: 30-minute rounding and floor mats.On 4/13/26 at 3:23 P.M., a joint interview and record review was conducted with the director of staff development (DSD).
The DSD stated that an IDT meeting was supposed to be conducted after a resident fell in the facility.
The DSD stated that there was no IDT conducted to investigate Resident 1's fall on 3/26/26.
The DSD reviewed Resident 1's IDT Progress Note-Falls dated 4/13/26.
The IDT note indicated the DSD had attended and participated in the IDT meeting.
The DSD stated she was not aware of this IDT meeting on 4/13/26 and she was not present during the IDT meeting. On 4/27/26 at 7:29 A.M., a joint interview and record review was conducted with UM 2. UM 2 stated the IDT team met after each fall to investigate the fall, determine its cause, to gather as much information as possible, and to make proper care plans with interventions that were relevant to the residents' needs. UM 2 reviewed documentation of the IDT conducted on 4/13/26 to investigate Resident 1's fall that occurred on 3/26/26. UM 2 stated Resident 1's IDT meeting actually did not occur, and his fall was not investigated. UM 2 stated she was the author of Resident 1's fall IDT note dated 4/13/26. UM 2 stated the IDT members were too busy to conduct Resident 1's fall IDT meeting. UM 2 stated she was aware surveyors were looking into Resident 1's fall and that the IDT for the resident's fall needed to be done. UM 2 stated Resident 1's fall IDT never happened and, It's falsified. UM 2 stated documentation of an IDT meeting should be factual and accurate, reflecting what occurred.On 4/28/26 at 2:38 P.M., an interview was conducted with the administrator (ADM).
The ADM stated falsifying resident documentation was unacceptable.
The ADM stated his main objective as an administrator of the facility was to promote telling the truth.
The ADM stated, We don't lie. We take our lumps and learn from them.On 4/28/26 at 2:55 P.M., a telephone interview was conducted with the interim director of nursing (DON).
The DON stated IDT notes and other clinical documentation should be true and accurate.A review of the facility's Position Description for Registered Nurse revised 4/7/25, indicated, .Provides nursing care as prescribed by physicians/health care professionals following the legal scope of practice, any Board of Licensing restrictions, and within established standards of care, policies, and procedures.
Administers professional services.
Records care information accurately, timely, and concise manner.
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Pioneers Memorial Skilled Nursing Center 320 Cattle Call Dr.
Brawley, CA 92227
3/30/26 indicated the facility had 46 falls, of which 34 were unwitnessed (staff were not present to see what happened).On 4/28/26 at 12:12 P.M., an interview was conducted with UM 3. UM 1 was also present. UM 3 stated she was the facility's quality assurance (QA) nurse specifically tasked with keeping track of the falls in the facility since January 2026. UM 3 stated since Resident 1's fall was being investigated by the California Department of Public Health Licensing and Certification, she had identified a pattern related to falls happening due to a lack of supervision. UM 3 stated resident falls and lack of supervision should have been identified as the root cause in some of the unwitnessed falls including the falls of Resident 1 and Resident 2. UM 3 stated staffing issues were discussed during the monthly QA meetings, but staffing had not been identified as contributing to the lack of supervision. UM 3 stated staffing was not part of the facility's Quality Assurance and Program Improvement (QAPI) committee and was not an action item or program improvement project. UM 3 stated falls, supervision, and staffing should have been thoroughly looked at by the QA/QAPI committee.On 4/28/26 at 1:52 P.M., a joint interview and record review was conducted with UM 1. UM 1 stated the facility's QA/QAPI Committee met on 4/15/26 for the quarterly QAPI meeting and that staffing had been a part of the QAPI. UM 1 presented an undated document titled QAPI Performance Improvement Plan CNA and LVN [licensed vocational nurse] Staffing Stability.
The document indicated, Problem Statement The facility is experiencing staffing instability due to: Increased CNA/LVN call-offs, Employees out on Workers' Compensation, extended hiring process (~ 4 weeks), new hire turnover shortly after hire.
Impact: short staffing, increased workload, risk to resident care and regulatory compliance.On 4/28/26 at 2:55 P.M., a telephone interview was conducted with the interim director of nursing (DON).
The DON stated the issues with resident falls, supervision, and staffing should have been addressed and a focused part of the facility's QAPI.On 4/28/26 at 3:52 P.M., an interview was conducted with the facility's administrator (ADM). UM 1, UM 2, UM 3, and the DSD were also present.
The ADM stated residents' supervision needs should have been met.
The ADM stated there were many residents out in front of the nurses' stations as observed on 4/27/26 and he acknowledged staff had been performing other tasks which made it difficult for them to provide supervision.
The ADM stated he had not been aware that staffing was such an issue.
The ADM reviewed the facility's undated document titled QAPI Performance Improvement Plan CNA and LVN Staffing Stability.
The ADM stated this issue with staffing was discussed during every QA/QAPI meeting, but it was not actively being worked on by the QAPI committee.
The ADM stated it should have been an action item actively being worked on to gain the attention and support of the governing body.
The ADM stated falls were a QA/QAPI action item, but that supervision and staffing had not been identified as a contributing factor.
The ADM stated this should have been identified.A review of the facility's policy titled QAPI01 Quality Assurance and Performance Improvement (QAPI) Program revised 3/28/24, indicated, .The facility implements and maintains an 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 issues.Purpose to implement a process that identifies opportunities for improvement and leads to optimal achievement in clinical and operational outcomes, and overall quality of care.8.
The QAPI Committee evaluates.define issues, plan and implement action, and ensure monitoring and follow up.
management should have been individualized to meet his needs.On 5/4/26 at 3:40 P.M., a telephone
The MD stated Resident 1's health condition had been steadily declining which could be due to neck
pain.
The MD stated Resident 1 could have been experiencing discomfort from sitting in his wheelchair for five hours on 3/26/26.
The MD stated LN 8 should have assessed if Resident 1 had been experiencing pain when he kept trying to get up from his wheelchair on 3/26/26.A review of the facility's policy titled Pain Management revised November 2016, indicated, . To ensure the assessment and management of the resident's pain to the extent possible when such services are required.Facility staff will help the resident attain or maintain their highest level of well-being while working to prevent or manage the resident's pain to the extent possible.If the resident cannot verbalize the intensity of their pain, the licensed nurse will assess the resident's pain based on non-verbal cues. (examples of non-verbal cues : grimacing, increased confusion, restlessness, distressed behavior, guarding of a body part, refusal of care and repositioning, not eating or sleeping, increased heart rate, blood pressure, or respirations) .
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Pioneers Memorial Skilled Nursing Center 320 Cattle Call Dr.
Brawley, CA 92227
carry out daily tasks), dementia, history of falling, and a fall with abrasion to the head.
Resident 29's MDS assessment dated [DATE], indicated the resident had a BIMS score 5 out of 15
A review of the facility provided list of residents falls from 1/1/26 through 3/30/26 indicated the following: -Resident 2 had an unwitnessed fall on 1/15/26 at 6
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Pioneers Memorial Skilled Nursing Center 320 Cattle Call Dr.
Brawley, CA 92227
worked for nursing staff were not available upon request.As a result, staffing information reflecting
given time. In addition, the facility was unaware of actual hours worked by its nursing staff.Findings:On 4/27/26 at 4:18 P.M., a joint interview and record review was conducted with the Director of Staffing Development (DSD).
The DSD stated she assisted with scheduling nursing staff while the staffer was on leave.
The DSD reviewed the facility's Daily Nurse Staffing Information dated 4/26/26 that was posted in the facility lobby.
The DSD stated the nursing hours posted was projected hours and not actual nursing hours worked.
The DSD stated she did not know the actual hours worked.
The actual nursing hours for 1/14/26 and 1/15/26 were requested from the DSD.On 4/28/26 at 2:20 P.M., a joint interview and record review was conducted with the DSD.
The nursing hours on 1/14/26 and 1/15/26 were provided and reviewed.
The DSD stated these were projected nursing hours.
The DSD stated the facility did not have access to actual nursing hours because a separate outside management company was handling that.
The DSD further stated the facility did not know if they were meeting the State required nursing hours.On 4/28/26 at 2:55 P.M., a telephone interview was conducted with the interim director of nursing (DON).
The DON stated the facility should have access to actual nursing hours worked and they should be posted as per regulation.
The DON stated the facility should also know if they were meeting State required nurse staffing hours.
The DON stated actual nursing hours worked should be readily available when requested.On 4/28/26 at 3:52 P.M. an interview was conducted with the administrator (ADM).
The unit manager (UM) 1, UM 2, UM 3, and the DSD were also present.
The ADM stated the facility should have access to actual nursing hours worked and they should be posted.A review of the facility's undated policy titled, Nursing Department - Staffing, Scheduling & Postings, indicated, .A.
The facility will post the following information on a daily basis.
The total number and actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: a.
Registered nurse b.
Licensed practical nurses or licensed vocational nurses.c.
Certified nurse aides.The facility will post the nurse staffing data as specified above, on a daily basis at the beginning of each shift.The facility will, upon oral or written request, make nurse staffing data available to the public.The facility will maintain the posted daily nurse staffing data for a minimum of 18 months.
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Pioneers Memorial Skilled Nursing Center 320 Cattle Call Dr.
Brawley, CA 92227
DSD stated the facility assessment did not describe a method for determining resident acuity which
facility assessment was unclear.On 4/28/26 at 2:55 P.M., a telephone interview was conducted with
stated staffing was a problem and had affected the facility's ability to provide the supervision residents needed.
The DON stated resident acuity should have been assessed and reviewed to determine staffing needs.
The DON stated a method for determining this should have been clear on the facility's facility assessment.On 4/28/26 at 3:52 P.M., an interview was conducted with the facility's administrator (ADM). UM 1, UM 2, UM 3, and the DSD were also present.
The ADM stated residents' supervision needs should have been met.
The ADM stated staffing was discussed each month during quality assurance meetings, but that he had not been aware that staffing was such an issue.
The ADM stated based on the survey findings, the facility assessment should have identified and assessed the resident needs related to supervision.
The ADM stated the facility should have had a method to determine resident acuity in order to sufficiently staff according to resident needs.
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Pioneers Memorial Skilled Nursing Center 320 Cattle Call Dr.
Brawley, CA 92227
in accordance with accepted professional standards.
interview and record review, the facility failed to ensure a licensed nurse/unit manager (UM) 2
1).As a result of this deficient practice, UM 2's falsified documentation misrepresented the facility's investigation into Resident 1's fall and fall aftercare.Findings:A review of Resident 1's Face Sheet indicated the resident was admitted on [DATE] and re-admitted on [DATE] with diagnoses to include unspecified dementia (progressive brain disorder causing cognitive decline, memory loss, confusion, and behavioral changes), impulse disorder (mental health condition characterized by inability to resist urges or impulses that may harm oneself), anxiety disorder, and a history of falling.A review of Resident 1's IDT Progress Note-Falls dated 4/13/26 at 10:48 A.M., indicated the IDT was composed of the director of rehabilitation, social services director, the director of staff development, infection preventionist, quality assurance nurse, and the MDS coordinator.
The IDT note further indicated, .Resident experienced an unwitnessed fall in front of the nurse's station.IDT reviewed the incident and contributing factors, including fall risk status, environment and current care plan.
The following interventions will be implemented/reinforced: 30-minute rounding and floor mats.On 4/13/26 at 3:23 P.M., a joint interview and record review was conducted with the director of staff development (DSD).
The DSD stated that an IDT meeting was supposed to be conducted after a resident fell in the facility.
The DSD stated that there was no IDT conducted to investigate Resident 1's fall on 3/26/26.
The DSD reviewed Resident 1's IDT Progress Note-Falls dated 4/13/26.
The IDT note indicated the DSD had attended and participated in the IDT meeting.
The DSD stated she was not aware of this IDT meeting on 4/13/26 and she was not present during the IDT meeting. On 4/27/26 at 7:29 A.M., a joint interview and record review was conducted with UM 2. UM 2 stated the IDT team met after each fall to investigate the fall, determine its cause, to gather as much information as possible, and to make proper care plans with interventions that were relevant to the residents' needs. UM 2 reviewed documentation of the IDT conducted on 4/13/26 to investigate Resident 1's fall that occurred on 3/26/26. UM 2 stated Resident 1's IDT meeting actually did not occur, and his fall was not investigated. UM 2 stated she was the author of Resident 1's fall IDT note dated 4/13/26. UM 2 stated the IDT members were too busy to conduct Resident 1's fall IDT meeting. UM 2 stated she was aware surveyors were looking into Resident 1's fall and that the IDT for the resident's fall needed to be done. UM 2 stated Resident 1's fall IDT never happened and, It's falsified. UM 2 stated documentation of an IDT meeting should be factual and accurate, reflecting what occurred.On 4/28/26 at 2:38 P.M., an interview was conducted with the administrator (ADM).
The ADM stated falsifying resident documentation was unacceptable.
The ADM stated his main objective as an administrator of the facility was to promote telling the truth.
The ADM stated, We don't lie. We take our lumps and learn from them.On 4/28/26 at 2:55 P.M., a telephone interview was conducted with the interim director of nursing (DON).
The DON stated IDT notes and other clinical documentation should be true and accurate.The facility's policy titled Alert Charting Documentation revised 1/1/12 did not provide guidance related to documenting accurately and truthfully in resident's clinical records.
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Pioneers Memorial Skilled Nursing Center 320 Cattle Call Dr.
Brawley, CA 92227
corrective plans of action.
Improvement (QAPI) committee failed to identify concerns related to lack of supervision and adequate
deficiencies to remain uncorrected and placed the facility's residents' safety at risk.Cross reference
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.