Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Manor Nursing Home during CMS and state inspections, most recent first.
A resident’s MDS was coded to show antibiotic use in Section N, but MAR review for the surrounding months showed no evidence the resident was receiving an antibiotic. The MDS Coordinator confirmed the resident was not taking an antibiotic during the assessment period and that it should not have been coded that way.
Care plans for two residents were not comprehensive. One resident had ongoing constipation with repeated PRN bowel med use, but the care plan did not include constipation or related interventions. Another resident had depression documented on the MDS and was receiving sertraline, but the care plan did not reflect the diagnosis or any interventions tied to the antidepressant treatment.
Care plan not updated after antidepressant change. A resident’s care plan still listed citalopram and related monitoring interventions even after the provider discontinued the medication due to possible contribution to tremors. The DON confirmed the care plan had not been revised to reflect the change.
The facility failed to accurately code the MDS for a resident's ADLs and two residents' medication use. A resident's MDS inaccurately showed independence in ADLs despite needing total assistance, while two residents were incorrectly coded for aspirin use as an anticoagulant instead of an antiplatelet. These errors were confirmed by staff interviews.
A resident with Congestive Heart Failure and chronic respiratory failure experienced a significant decline in condition, with oxygen saturation dropping to 73%. Despite facility policy requiring physician notification within one hour of such changes, the physician was not informed. The resident was later found deceased, and while family and other parties were notified, the physician was not.
The facility failed to update the comprehensive care plans for two residents to include hospice services, despite policy requirements. Resident 33, with multiple health conditions, and Resident 30, admitted to hospice care, both lacked documentation of hospice services in their care plans. The ADON confirmed these omissions, which were contrary to the facility's care plan policy.
Inaccurate MDS Coding for Antibiotic Use
Penalty
Summary
The facility failed to accurately code antibiotic use on the Minimum Data Set for Resident 11. The resident was admitted to the facility on an unspecified date, and the MDS dated 10/16/2025 indicated in Section N that the resident was taking an antibiotic at the time of the assessment. However, review of the resident’s Medication Administration Records for September and October 2025 showed no evidence that the resident was receiving an antibiotic during that timeframe. During an interview on 12/30/2025 at 4:00 PM, the MDS Coordinator confirmed that Resident 11 was not taking an antibiotic during the 10/16/2025 MDS assessment period and that it should not have been coded as such.
Care plans did not reflect ongoing constipation and depression needs
Penalty
Summary
The facility failed to ensure that the care plans for 2 residents were comprehensive and reflected their ongoing needs. One resident had a diagnosis of constipation on the care plan, but the record showed repeated use of bowel medications in December 2025, including Dulcolax suppository, Milk of Magnesia, and Senna, with multiple administrations throughout the month. Despite this ongoing problem and treatment pattern, the care plan did not include constipation as an active problem or identify interventions to address it. The DON confirmed that the resident had ongoing constipation and that this issue and the need for interventions were not included in the care plan. Another resident’s quarterly MDS dated 12/11/2025 identified a diagnosis of depression and indicated the resident was taking antidepressant medication. The medication orders also showed sertraline with a start date of 9/17/2025. However, the resident’s undated care plan did not include depression or any interventions related to the diagnosis or antidepressant treatment. The DON confirmed that the care plan did not reflect the resident’s depression or the need for an intervention related to the diagnosis and treatment.
Care Plan Not Updated After Antidepressant Discontinued
Penalty
Summary
The facility failed to review and revise the care plan for one resident’s antidepressant medication use. The resident’s care plan contained problem sections dated 4/23/2025 and 7/10/2025 that identified depression, anxiety, confusion from Parkinson’s disease, and use of scheduled citalopram/Celexa, with interventions to monitor for side effects and adverse reactions. A record review of the resident’s progress note showed that during a provider visit on 12/12/2025, the provider ordered citalopram discontinued because it could be contributing to the resident’s tremors. During interview on 12/30/2025, the DON confirmed the care plan still reflected the resident as taking citalopram despite the medication having been discontinued and confirmed the care plan should have been updated with the medication change.
Inaccurate MDS Coding for ADLs and Medication Use
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Sets (MDS) for three residents, affecting their care planning. Resident 16's MDS inaccurately reflected their need for assistance with activities of daily living (ADLs). Despite progress notes indicating that Resident 16 required total assistance with dressing, grooming, oral care, and toileting, and extensive assistance with eating, the MDS inaccurately recorded the resident as independent in these areas. This discrepancy was confirmed by the MDS Coordinator during an interview. Additionally, the facility incorrectly coded the use of aspirin for two residents, Residents 10 and 27, in their MDS. The MDS inaccurately categorized aspirin as an anticoagulant instead of an antiplatelet, as per the guidelines in the MDS 3.0 Resident Assessment Instrument (RAI) User's Manual. Interviews with the MDS nurse confirmed the coding errors, and it was noted that the facility lacked an MDS policy, relying solely on the RAI manual for MDS accuracy.
Failure to Notify Physician of Resident's Decline
Penalty
Summary
The facility failed to notify the physician of a significant decline in the condition of a resident, identified as Resident 45, who was admitted with Congestive Heart Failure and chronic respiratory failure. The facility's policy required informing the resident's physician within one hour of a significant change in condition. However, during a review of Resident 45's records, it was found that the physician was not notified of the resident's decline, which was documented in the progress notes. The notes indicated that the resident's oxygen saturation had dropped to 73%, prompting an increase in oxygen flow by the LPN, but no notification to the physician was recorded. Interviews conducted with the LPN and the Assistant Director of Nursing confirmed that the physician was not informed of the resident's condition change. The resident was found deceased later that evening, and while the family, funeral home, and other relevant parties were notified, the physician was not. This oversight was a clear violation of the facility's policy on notifying physicians of significant changes in a resident's condition.
Failure to Update Care Plans with Hospice Services
Penalty
Summary
The facility failed to ensure that comprehensive care plans were updated to include hospice care services for two residents, Resident 30 and Resident 33, out of a sample of 12 residents. The facility's policy, last reviewed in March 2023, mandates that services provided or arranged by the facility should be included in the comprehensive care plan. However, record reviews revealed that Resident 33, who was admitted to hospice services on August 6, 2024, with conditions such as abnormal weight loss, multiple myeloma, pressure ulcer, chronic pain, and atrial fibrillation, did not have hospice services documented in their care plan. This was confirmed by an interview with the Assistant Director of Nursing (ADON), who acknowledged the oversight. Similarly, Resident 30, admitted to the facility on February 21, 2023, and to hospice care as noted in a progress note dated September 5, 2024, also had no mention of hospice services in their comprehensive care plan. The ADON confirmed in an interview that Resident 30's care plan had not been revised to reflect the hospice care admission, which was a requirement according to the facility's care plan policy. These deficiencies highlight a failure to integrate hospice care into the residents' care plans as required by the facility's agreements and policies.
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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.
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Nursing homes near Hay Springs
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oglala Sioux Lakota Nursing Home | 11.9 mi | ★★★★★ | 9 | 0 |
| Crest View Care Center | 19.1 mi | ★★★★★ | 19 | 0 |
| Gordon Countryside Care | 26.4 mi | ★★★★★ | 8 | 0 |
| Hemingford Care Center | 32.2 mi | ★★★★★ | 23 | 0 |
| Ponderosa Villa | 37.1 mi | ★★★★★ | 9 | 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.