Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pioneer Health Care Center during CMS and state inspections, most recent first.
Two residents in a facility were not protected from physical abuse by other residents. In one case, a resident with schizophrenia and dementia hit another resident, causing injury. In another incident, a resident with dementia and bipolar disorder pushed another resident, initially misidentified as the aggressor. The facility's failure to implement effective behavioral interventions and monitoring led to these incidents.
The facility failed to control a fly infestation, with flies observed in multiple resident rooms, landing on residents and their belongings. Staff noted the issue worsened due to weather and location, and efforts like keeping doors closed were insufficient. Glue fly traps were not maintained properly, and the nursing home administrator was unaware of the problem.
The facility failed to maintain a sanitary and comfortable environment in 28 of 55 rooms, with issues such as missing ceiling tiles, chipped plaster, sticky floors, and a strong odor of urine. Mice feces were found in dresser drawers, indicating a pest control problem. The maintenance supervisor acknowledged the ongoing mouse issue, and the nursing home administrator was unaware of the extent of the problem.
The facility failed to provide proper respiratory care for three residents requiring supplemental oxygen. One resident was found with an empty oxygen concentrator, another was receiving less oxygen than prescribed, and a third was using oxygen without a physician's order. Staff acknowledged these errors, which could lead to hypoxia and confusion.
A resident assessed as a supervised smoker obtained a lighter from a family member and attempted to burn a thread off a bandage, resulting in first and second-degree burns. The facility failed to prevent the resident from accessing the lighter, leading to the incident.
The facility failed to maintain a clean and sanitary kitchen environment, with issues such as dust, debris, and grime buildup. Additionally, food was not held at appropriate temperatures during lunch service, with hot foods and cold foods both outside safe temperature zones. These deficiencies were confirmed by the dietary supervisor and dietary aide.
The facility failed to complete annual performance reviews and provide regular in-service education based on the outcome of these reviews for five CNAs. Record reviews showed that these CNAs, hired between 2016 and 2022, did not have an annual performance review completed. The DON was unaware that performance reviews needed to include a regular in-service plan based on the outcome of these reviews.
A resident with multiple health conditions did not receive necessary daily oral and personal hygiene care, despite being cognitively intact and having a care plan specifying her needs. Staff interviews confirmed the oversight, with the CNA admitting to not providing the required care.
The facility failed to notify and document a resident's elevated blood sugar levels to the provider as directed on the physician's order. The resident had elevated blood sugar levels 19 times over a 45-day period, but there was no documentation indicating that the physician was notified. Staff interviews confirmed the failure to follow physician orders and facility policy.
A resident with COPD and chronic respiratory failure was observed receiving 3 LPM of oxygen instead of the physician-ordered 2 LPM. Staff were unaware of the correct flow rate until the physician's order was reviewed, leading to the resident receiving an incorrect oxygen flow rate for an extended period.
The facility failed to ensure proper labeling and storage of medications, including not discarding an expired Anoro inhaler, not dating an Anoro inhaler when opened, and not dating a Lantus insulin pen when opened. These issues were observed in two medication carts, with staff unaware of the importance of these practices.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse by other residents, as evidenced by two separate incidents. In the first incident, Resident #5, who has a history of schizophrenia and dementia with behavioral disturbances, physically assaulted Resident #4 by hitting her in the head. Resident #4, who suffers from bipolar disorder and delusional disorders, reported pain, redness, and swelling to her right eye following the incident. The facility's investigation confirmed the abuse, and it was noted that Resident #5 had a history of resident-to-resident aggression, yet the interventions in place were insufficient to prevent the incident. In the second incident, Resident #2, diagnosed with unspecified dementia and bipolar disorder, was found to have pushed Resident #6 after a review of facility cameras. Initially, it was alleged that Resident #6 was the aggressor, but further investigation revealed that Resident #2 was responsible for the physical altercation. Resident #6, who has severe cognitive impairments and a history of aggressive behavior, reported being pushed and experiencing pain, although no injuries were observed. The facility's failure to accurately monitor and manage Resident #2's behavior led to this incident. Both incidents highlight the facility's inability to effectively implement and follow through with behavioral care plans and interventions designed to prevent resident-to-resident abuse. The facility's policies and procedures for identifying and mitigating risk factors for abuse were not adequately executed, resulting in harm to the residents involved. The lack of effective monitoring and intervention strategies contributed to the occurrence of these abusive events.
Fly Infestation Due to Ineffective Pest Control
Penalty
Summary
The facility failed to implement an effective pest control program, resulting in a fly infestation throughout the long-term care living environment. Observations made during the survey revealed that flies were present in multiple resident rooms, often landing on residents, their personal belongings, and even their food. Residents were observed swatting flies away from their faces and food, indicating a significant nuisance and potential hygiene issue. Glue fly ribbons were noted in several rooms, but they were full of dead flies, suggesting inadequate maintenance and replacement. Interviews with staff members, including registered nurses, licensed practical nurses, and housekeeping staff, confirmed the presence of a worsening fly problem, particularly in residents' rooms. Staff attributed the increase in flies to recent weather conditions, such as high rainfall, and the facility's location. Efforts to mitigate the issue included keeping doors closed to prevent flies from entering, but these measures were insufficient to control the infestation effectively. The maintenance supervisor acknowledged the fly problem and mentioned that glue fly traps were placed in some rooms, but they were not being changed frequently enough. The nursing home administrator was unaware of the fly issues until the survey, indicating a lack of communication and oversight regarding the pest control program. This deficiency highlights the facility's failure to maintain a pest-free environment, as recommended by the CDC guidelines for environmental infection control in healthcare facilities.
Facility Fails to Maintain Sanitary and Comfortable Environment
Penalty
Summary
The facility failed to maintain a sanitary, orderly, and comfortable environment for residents in 28 of 55 rooms. Observations revealed numerous deficiencies, including missing ceiling tiles, chipped and peeling plaster, and sticky floors. Many rooms had a strong odor of urine, and some had puddles of urine under the beds. The walls and ceilings in several rooms were damaged, with unfinished repair work and missing baseboards. Additionally, the window blinds in some rooms were broken, and the floors were cluttered with trash and debris. The presence of mice feces was noted in the drawers of dressers in multiple rooms, indicating a significant pest control issue. The maintenance supervisor acknowledged that mice were an ongoing problem due to the building's age and heat vents providing easy access. Despite the implementation of a new housekeeping program called 'safety culture,' the cleaning issues persisted, with sticky floors and urine stains being common across many rooms. The environmental tour conducted with the maintenance supervisor highlighted the lack of work orders for the identified damages, suggesting a failure in the facility's maintenance and repair processes. The nursing home administrator was unaware of the fly issues and expressed surprise at the ongoing mouse problem and the presence of droppings, indicating a lack of awareness and oversight regarding the facility's environmental conditions.
Deficiencies in Oxygen Administration for Residents
Penalty
Summary
The facility failed to provide proper respiratory care for three residents who required supplemental oxygen. Resident #3, who had a diagnosis of COPD, was observed with an empty portable oxygen concentrator, despite a physician's order for continuous oxygen at 2 LPM. The resident's oxygen saturation level was at 90%, and she reported feeling 'loopy,' indicating potential hypoxia. The staff, including RN #2, acknowledged that the portable oxygen concentrator should have been refilled regularly to prevent such occurrences. Resident #2, diagnosed with chronic respiratory failure and COPD, was found to be receiving oxygen at 2 LPM, contrary to the physician's order of 3 LPM. This discrepancy was observed on two separate occasions, and RN #1 confirmed the error, adjusting the oxygen flow to the correct level. The incorrect oxygen administration could have led to confusion and hypoxia, as noted by the staff. Resident #7, with a history of respiratory arrest and COPD, was using oxygen without a physician's order. The resident's care plan included continuous oxygen at 10 LPM, but the oxygen concentrator was set at 3 LPM. LPN #1 confirmed the absence of a physician's order for the oxygen therapy. The assistant director of nursing emphasized the importance of having a physician's order for oxygen use and ensuring that oxygen is administered as prescribed to prevent adverse outcomes.
Failure to Prevent Resident from Obtaining Lighter Leads to Burns
Penalty
Summary
The facility failed to ensure that Resident #13, who had been assessed as a supervised smoker, did not have access to a lighter. This failure resulted in Resident #13 obtaining a lighter from a family member during a visit. The resident attempted to use the lighter to burn a dangling thread off a bandage on her leg, which led to the bandage catching fire. The incident occurred in the resident's room, and the fire was extinguished by a certified nurse aide (CNA) who heard the resident's screams and responded promptly. Despite the CNA's quick actions, the resident sustained first and second-degree burns and was transferred to the emergency department for treatment. The facility's failure to prevent the resident from obtaining a lighter directly led to this incident. The resident had a history of hemiplegia on the right side and cerebral infarction, which contributed to her need for assistance with personal care and supervision. The care plan for Resident #13 included interventions to ensure she did not have access to smoking materials and required staff supervision during smoking breaks. However, the facility did not implement adequate measures to prevent family members from providing the resident with a lighter, leading to the accident. Interviews and record reviews confirmed that the facility had not been notified of any previous incidents involving the resident having a lighter, indicating a lapse in communication and monitoring. The incident highlights the facility's failure to maintain a safe environment for the resident, resulting in significant harm.
Removal Plan
- A sweep of the supervised smokers for lighters was completed. No lighters were found.
- Staff were re-educated on safe smoking practices, ensuring supervised smokers did not have lighters and the facility smoking policy.
- The social services assistant (SSA) completed an audit of all the smokers to re-determine if the smoker was supervised or unsupervised. The facility implemented smoking aprons for all smokers regardless of smoking status.
- The facility reached out to families to provide education on the importance of not providing smoking supplies to the smoking residents. Families were educated to give the smoking supplies to the nurses.
- The one unsupervised smoker in the facility was re-educated on the importance of keeping control of his lighter and not giving it to supervised smokers. The unsupervised smoker was receptive to the re-education understanding the severity of the situation and agreed not to share his lighter with supervised smokers.
- Housekeeping staff were educated to be more critical and observant for lighters when in a smoker's room. Education included, if a lighter was found, it was to be given to the nurse on duty immediately.
- Nursing staff were educated if staff turned in a lighter from a supervised smoker to notify the DON.
- Resident #13 was moved to a different hall with more staff monitoring. Resident #13 was provided with a vape pen in lieu of cigarettes and the vape pen supplies were kept locked up by the facility.
- The facility completed a care conference with the family. During the conference, the family admitted they had given Resident #13 the lighter. The resident's family was educated on the importance of not providing the resident with a lighter.
- Audits of smokers were started and continued weekly to ensure lighters were not in the possession of supervised smokers and if found, family education was conducted.
- All audits and education were to be reviewed during weekly interdisciplinary team (IDT) meetings and during monthly quality assurance and performance improvement (QAPI) meetings.
Facility Fails to Maintain Sanitary Kitchen and Proper Food Temperatures
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, as observed during an initial tour and a follow-up visit. Specific issues included chipped paint and dust on the shelf below the three-compartment sink, dust and debris buildup on exposed plumbing pipes and around the hand-washing sink, dark greasy substances on the outside of the kitchen steamer, and dirt and grime buildup under and around the hand-washing sink. These observations were confirmed by the dietary supervisor, who acknowledged the need for better cleaning to avoid foodborne illness and contamination of food preparation surfaces. Additionally, the facility failed to hold food at appropriate temperatures during lunch service. Observations revealed that hot foods on the steam table and cold foods in a plastic bowl with ice cubes did not maintain safe temperature levels. For example, the country fried steak was at 116 degrees Fahrenheit, and the chocolate pudding was at 67 degrees Fahrenheit, both outside the safe temperature zones. The dietary aide and dietary supervisor confirmed the importance of maintaining proper food temperatures to prevent harmful bacteria growth and potential illness among residents.
Failure to Complete Annual Performance Reviews and Provide In-Service Education
Penalty
Summary
The facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for five of five staff reviewed. Specifically, the facility had not completed annual performance reviews and/or provided regular in-service education based on the outcome of the reviews for certified nurse aides (CNAs) #9, #11, #12, #13, and #14. Record reviews showed that these CNAs, hired between 2016 and 2022, did not have an annual performance review completed. Additionally, the CNAs did not have an in-service education plan based on the outcome of the review. During an interview, the director of nursing (DON) stated she was not aware that performance reviews needed to include a regular in-service plan based on the outcome of these reviews.
Failure to Provide Daily Oral and Personal Hygiene
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for Resident #8, a 67-year-old with diagnoses including acute embolism, thrombosis, unspecified fracture, and multiple sclerosis. Despite being cognitively intact and requiring only set-up or clean-up assistance for oral hygiene and moderate assistance for personal hygiene, the resident reported not receiving necessary oral and personal hygiene care on multiple occasions. Specifically, the resident was not provided with a toothbrush or assistance to wash her hands and face in the morning, which made her feel incomplete and bewildered. The resident's care plan documented her need for moderate assistance and her preference for morning hygiene routines, but these were not consistently followed by the staff. Interviews with staff, including a registered nurse (RN), a certified nurse aide (CNA), and the Director of Nursing (DON), confirmed that the resident should have received daily personal and oral hygiene care. However, the CNA responsible for the resident admitted to never providing the required care. The DON acknowledged the oversight and noted that the resident had varying levels of independence depending on her physical condition. Despite the resident's care plan and a posted note specifying her hygiene preferences, the staff failed to adhere to these guidelines, resulting in the deficiency.
Failure to Notify Physician of Elevated Blood Sugar Levels
Penalty
Summary
The facility failed to notify and document Resident #29's elevated blood sugar levels to the provider as directed on the physician's order. Resident #29, over the age of 65, was admitted with diagnoses including type II diabetes mellitus with diabetic autonomic polyneuropathy, chronic obstructive pulmonary disease, hyperlipidemia, and anxiety disorder. The resident was cognitively intact and required staff supervision for various activities. The physician's order specified that blood glucose levels should be checked at bedtime and the provider should be notified if levels were less than 60 mg/dl or greater than 350 mg/dl. However, the facility did not follow this order on multiple occasions when the resident's blood sugar levels exceeded 350 mg/dl, as documented in the medication administration record (MAR) for March and April 2024. There was no documentation indicating that the physician was notified of these elevated levels, which occurred 19 times over a 45-day period. Interviews with staff, including a registered nurse (RN) and the director of nursing (DON), confirmed that the elevated blood sugar levels were not reported to the physician as required. RN #1 acknowledged that there should have been documentation in the resident's medical record indicating that the physician was notified. The DON also confirmed that the staff should have notified the provider and documented the action in the nursing progress note. Both staff members emphasized the importance of following physician orders to prevent serious health complications for the resident. The facility's diabetic care policy, revised in November 2020, stated that the physician would order parameters for monitoring and reporting blood sugar levels, and these parameters should be incorporated into the medication administration record and care plan. Despite this policy, the facility failed to adhere to the physician's orders and the care plan, which included evaluating the resident, documenting, and reporting to the physician. The resident's care plan also noted noncompliance with her diabetic diet, which may have contributed to the elevated blood sugar levels. However, the primary issue was the facility's failure to notify the physician as required by the physician's order and facility policy.
Failure to Administer Correct Oxygen Flow Rate
Penalty
Summary
The facility failed to ensure that a resident's supplemental oxygen was administered according to the physician's order. Resident #40, who had diagnoses including COPD and chronic respiratory failure with hypoxia, was observed multiple times receiving 3 liters per minute (LPM) of oxygen via nasal cannula, despite the physician's order specifying 2 LPM. The resident himself confirmed that the physician had ordered continuous oxygen at 2 LPM. The discrepancy between the physician's order and the actual oxygen administration was also noted in the resident's care plan, which incorrectly indicated 3 LPM of oxygen. Staff interviews revealed that the registered nurse (RN) was unaware of the correct oxygen flow rate until the physician's order was reviewed. The RN then adjusted the oxygen flow to 2 LPM and verified the resident's oxygen saturation level, which was 92% on the correct flow rate. The Director of Nursing (DON) confirmed that the facility's policy required a physician's order for oxygen administration, including the rate, route, and frequency, and emphasized the importance of matching the care plan with the physician's order to prevent potential health complications. The deficiency was identified as a failure to follow the physician's order for oxygen therapy, leading to the resident receiving an incorrect oxygen flow rate for an extended period.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored in accordance with accepted professional standards. Specifically, the facility did not discard an expired Anoro inhaler, did not date an Anoro inhaler when it was opened, and did not date a Lantus insulin pen when it was opened. These deficiencies were observed in two medication carts during the survey. The west medication cart contained two Anoro inhalers, one of which was expired and the other was not dated. The registered nurse (RN) responsible for the cart was unaware of the expiration and the importance of dating the inhalers. Similarly, the south medication cart contained an open Lantus insulin pen without an open date, and the licensed practical nurse (LPN) responsible for the cart was also unaware of the missing date and its significance for medication safety. The director of nursing (DON) confirmed the importance of dating medications when opened and discarding them when expired to ensure their safety and effectiveness for residents. The observations and interviews revealed a lack of adherence to professional guidelines for medication labeling and storage, which could potentially compromise the safety and efficacy of the medications administered to residents.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 11 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Rocky Ford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Crowley County Nursing Center | 12.1 mi | ★★★★★ | 0 | 0 |
| Bluestem Village | 15.9 mi | — | 0 | 0 |
| Fowler Health Care | 17.3 mi | ★★★★★ | 11 | 0 |
| Bent County Healthcare Center | 26.7 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.