
Report
TheVardellReport
Pioneers Memorial Skilled Nursing Center
Skilled nursing facility and nursing facility
320 Cattle Call Dr.
Brawley, CA 92227

TheVardellReport
Skilled nursing facility and nursing facility
320 Cattle Call Dr.
Brawley, CA 92227
Life by Vardell Presents
The deeper story, beautifully organized. Available records, historical context, and questions worth asking.
This report is free. Vardell does not certify, grade or endorse; it shows what the record documents.
The Essentials
Across 7 inspections from December 2022 to April 2026, state surveyors documented 65 findings at Pioneers Memorial Skilled Nursing Center; 63 have a recorded correction and 2 await one; CMS lists 5 enforcement actions in the window.
* Partial year, through October 1, 2026.
| Year | Inspections | Findings | Of which, actual harm (level G or above) |
|---|---|---|---|
| 2022 | 1 | 10 | 0 |
| 2023 | 0 | 0 | 0 |
| 2024 | 3 | 31 | 2 |
| 2025 | 2 | 15 | 0 |
| 2026 | 1 | 9 | 2 |
Chronology
Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.
9 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
2 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
13 findings
Enforcement Action
Civil money penalty, $11,482 imposed April 28, 2026. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of January 10, 2025, the nearest before the penalty date.
Enforcement Action
Civil money penalty, $11,482 imposed April 28, 2026. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of January 10, 2025, the nearest before the penalty date.
Enforcement Action
Civil money penalty, $11,482 imposed April 28, 2026. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of January 10, 2025, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
29 findings
Enforcement Action
Civil money penalty, $52,435 imposed February 20, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of February 20, 2024, the nearest before the penalty date.
Enforcement Action
Denial of payment imposed February 20, 2024. Status: Closed, May 6, 2024. CMS does not tie a penalty to a survey; listed with the standard health inspection of February 20, 2024, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
10 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.
Context
A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.
Inspectors cited F689 in February 2024, December 2024, April 2025 and April 2026. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F657 in February 2024, October 2024 and April 2026. This citation covers whether care plans are written on time and revised by a team that includes the resident’s caregivers. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F684 in February 2024, January 2025 and April 2025. This citation covers whether residents receive the treatment their orders, preferences and goals call for. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F812 in December 2022, February 2024 and January 2025. This citation covers how food is stored, prepared and served. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F880 in December 2022, February 2024 and January 2025. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F578 in December 2022 and February 2024. This citation covers residents’ right to accept or refuse treatment and to make an advance directive. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F656 in December 2022 and February 2024. This citation covers whether each resident has a written care plan that meets their needs, with goals that can be measured. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F676 in February 2024 and January 2025. The agency describes it this way: Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F693 in February 2024 and January 2025. The agency describes it this way: Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F695 in December 2022 and January 2025. This citation covers oxygen, breathing treatments and other respiratory care. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F697 in February 2024 and April 2026. The agency describes it this way: Provide safe, appropriate pain management for a resident who requires such services. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F726 in February 2024 and January 2025. The agency describes it this way: Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F732 in February 2024 and April 2026. The agency describes it this way: Post nurse staffing information every day. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F867 in February 2024 and April 2026. The agency describes it this way: Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
F911 was cited in December 2022, February 2024 and January 2025. The agency describes it this way: Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. The most serious was level B (potential for minimal harm). The February 2024 citation has no recorded correction date; its status reads “Waiver has been granted.” The record does not show whether the problem was fixed.
F912 was cited in December 2022, February 2024 and January 2025. The agency describes it this way: Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. The most serious was level B (potential for minimal harm). The February 2024 citation has no recorded correction date; its status reads “Waiver has been granted.” The record does not show whether the problem was fixed.
For Your Next Visit
Bring these to the tour. Each one comes from something in the record; the reason is under the question.
What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?
Accident Hazards and Supervision: cited in four inspections, most seriously at level G.
How often are care plans revised, and who takes part in the review?
Care Plan Timing and Review: cited in three inspections, most seriously at level D.
How do nurses make sure a doctor’s orders are carried out, and how are families told when something is missed?
Quality of Care: cited in three inspections, most seriously at level G.
May we see the kitchen, and what do your own sanitation checks look like week to week?
Kitchen and Food Safety: cited in three inspections, most seriously at level E.
Who leads infection control here, and how often are hand-hygiene and isolation practices audited?
Infection Control: cited in three inspections, most seriously at level E.
How are a resident’s advance directive and treatment wishes recorded and shared with every shift?
Treatment Choices and Advance Directives: cited in two inspections, most seriously at level D.
How is a care plan written and reviewed here, and how do families take part in it?
Care Plans: cited in two inspections, most seriously at level E.
What changed after F676 was cited, and how do you check it now?
Citation F676: cited in two inspections, most seriously at level F.
What changed after F693 was cited, and how do you check it now?
Citation F693: cited in two inspections, most seriously at level D.
Who manages oxygen and breathing treatments on each shift, and how is the equipment checked?
Respiratory Care: cited in two inspections, most seriously at level D.
What changed after F697 was cited, and how do you check it now?
Citation F697: cited in two inspections, most seriously at level D.
What changed after F726 was cited, and how do you check it now?
Citation F726: cited in two inspections, most seriously at level D.
What changed after F732 was cited, and how do you check it now?
Post nurse staffing information every day: cited in two inspections, most seriously at level F.
What changed after F867 was cited, and how do you check it now?
Citation F867: cited in two inspections, most seriously at level F.
What changed after F911 was cited, and how do you check it now?
Citation F911: cited in three inspections, most seriously at level B. The February 20, 2024 citation has no recorded correction date.
What changed after F912 was cited, and how do you check it now?
Citation F912: cited in three inspections, most seriously at level B. The February 20, 2024 citation has no recorded correction date.
How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?
Insufficient nursing staff was cited in April 2026.
What led to the 2026 fine, and has it been paid?
An $11,482 civil money penalty was imposed April 28, 2026. CMS publishes the fine, not whether it has been paid. The record holds five enforcement actions in the window.
The Evidence
Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the California state survey agency.
California state survey agency
Inspection Dec 15, 2022 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Feb 20, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Oct 11, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Dec 18, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Jan 10, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Apr 28, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Apr 28, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Centers for Medicare & Medicaid Services
Published Oct 1, 2026 · Retrieved Nov 1, 2026
Centers for Medicare & Medicaid Services · 555557
Published Oct 1, 2026 · Retrieved Nov 1, 2026
Record windowDecember 15, 2022 – October 1, 2026
Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.
Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.