Pioneer House

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement ordered measures to promote wound healing for one of four sampled residents (Resident 1), when staff did not ensure that low air loss (LAL) mattress (a specialized medical-grade support surface used to prevent and treat bedsores [pressure ulcers] by combining continuous airflow with pressure relief) air pump for Resident 1 was working or connected to the power outlet. This failure increased the potential for slower healing or worsening pressure ulcer in Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to implement measures to prevent an avoidable elopement for one of three sampled residents (Resident 1), when staff was unaware Resident 1 had left the facility unsupervised. This failure had the potential to negatively affect Resident 1's health and safety and could result to harm and injury.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement an effective discharge planning process for one of 3 Residents (Resident 1) when Resident 1 who was homeless was discharged without proper arrangements for home health nursing services to manage multiple burn wounds, food, or transportation to follow up medical appointments. A review of the admission record indicated the facility admitted Resident 1 in the fall of 2025 with multiple diagnoses which included aftercare for multiple burn wounds that had been surgically grafted (a procedure where healthy skin is taken from one part of the body and transplanted to cover another area where skin is damaged). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet professional standards of quality for three of 13 sampled residents (Resident 20, Resident 36 and Resident 2) when:Resident 20's medical record was not updated with the correct diagnosis;Resident 20's physician's order to wear a cervical collar was not followed;Resident 36's physician's order for weight monitoring was not followed; andResident 2's physician's order for daily weights was not followed. These failures resulted in an inaccurate medical record for Resident 20, Resident 36 and Resident 2 and had the potential for injury to Resident 20's neck.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were assisted with activities of daily living (ADL, basic self-care tasks) to maintain personal hygiene for two of 13 sampled residents (Resident 33 and Resident 23) when nail care was not performed. These failures increased the risk of infection and had the potential to diminish the residents' sense of dignity. 1. Resident 33 was admitted to the facility mid-2023 with diagnosis which included stroke with loss of movement to one side of the body, and high blood sugar. During a review of Resident 33's Minimum Data Set (MDS, federally mandated resident assessment tool) dated 9/29/25, the MDS indicated resident 33 could not perform personal hygiene (wash/dry face and hands) without full assistance from a staff member. During an observation and interview on 12/1/25 at 9:28 a.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of 13 sampled residents (Resident 4) were offered sufficient fluid intake to maintain proper hydration. This failure placed Resident 4 at risk for dehydration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication storage for a census of 49 when expired medications were available for residents use and medications were not stored properly. These failures had the potential for residents to receive ineffective medications and placed residents at risk for cross contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was prepared and stored in a safe and sanitary manner for a census of 48 residents who received food prepared from the kitchen, when:1. Trash can by the hand washing station was found without plastic liner with used gloves, paper towels and coffee creamer cups;2. Food debris was found on several kitchen utensils inside the plastic tray, while the bottom of the tray designated for storing clean kitchen utensils contained visible dirt and food debris;3. Several plastic water pitchers and metal pans were found stacked wet and stored at the clean and ready-to-use storage areas;4. Water collected in the plastic pan under refrigerator one's evaporator located on the top of the metal shelf used to store resident foods;5. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to follow proper infection control practices for two of 13 sampled residents (Resident 19 and Resident 23) when:1. Resident 23's tube feeding syringe (a large syringe used to administer nutrition through a tube placed in the stomach) was not labeled with a date, and2. Staff did not put on a gown while providing care to Resident 19 and Resident 23 who were on Enhanced Barrier Precautions (EBP, precautions taken to prevent the spread of disease and require the use of a gown and gloves). These failures had the potential to increase the spread of infection.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to implement an effective pest control program to prevent cockroach infestation in the kitchen, dining hall, and surrounding areas when multiple cockroaches were observed in these locations. This failure posed a potential health risk to the 49 residents due to exposure to pests.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate reconciliation of controlled medications for two of 13 sampled residents (Resident 56 and Resident 57) when random controlled medication audits did not reconcile. These failures resulted in the facility not having an accurate accountability of controlled substances and increased the potential for diversion. The controlled medication record for two random residents (Resident 56 and Resident 57) who received as needed controlled medications were requested for review during the survey. During a review of Resident 57's Medication Administration Record (MAR) dated 11/1-12/31/25, Resident 57 had orders for Hydromorphone (opioid analgesic) 4 mg to be given every two hours as needed for pain. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate supervision when they did not ensure one of three sampled residents (Resident 1) was wearing a wandering device (a wearable device, commonly referred to as a wander guard, with sensors that trigger alarms, used to prevent residents at risk of wandering from leaving a safe area unsupervised) according to Resident 1's physician orders (PO) and care plan (CP). This failure resulted in Resident 1 walking out of the facility unsupervised and without the facility's knowledge, which exposed the resident to cold temperatures, nightfall, and traffic, which could have resulted in serious injury, medical complications, and/or death.

Inspectors wroteBased on observation, interview and record review, the facility failed to protect the rights to be free from physical abuse for two of four sampled residents (Resident 2 and Resident 3), when: 1. Resident 1 entered Resident 2's room, touched Resident 2's belongings, ate his food, and swung her arms at Resident 2 when Resident 2 tried to intervene; and2. Resident 1 approached Resident 3 in the dining room and hit her on the back. These failures resulted in Resident 2 and Resident 3 sustaining pain and injury from physical contact and voicing their safety concerns.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to ensure one out of two sampled residents, Resident 1, was provided a therapeutic diet as ordered by the physician. This failure had the potential for Resident 1 to experience malnutrition and weight loss.

Inspectors wroteBased on interview and record review, the facility failed to provide a safe discharge for one of three sampled residents (Resident 1), when Resident 1 was discharged to a room and board facility (a home that offers housing accommodations, may offer meals, but does not provide personal care services) and did not have care needed for activities of daily living (ADL). This failure resulted in Resident 1 living in an unsafe environment that could not meet Resident 1's needs which prompted a transfer to the hospital.

Inspectors wroteBased on interview and record review, the facility failed to make sure that an inventory of personal belongings sheet was completed, and a copy was given upon admission to one of three sampled residents (Resident 1.) This failure had the potential for the resident ' s personal belongings being lost or stolen.

Inspectors wroteBased on interview and record review, the facility failed to protect two sampled residents (Resident 3 and Resident 2) from abuse, when, Resident 3 was verbally threatened and punched by Resident 1 in the face and neck and Resident 2 experienced multiple episodes of sexual inappropriateness from Resident 1, who had a known history of verbal aggression and sexual inappropriateness. These failures resulted in Resident 3's physical injury and emotional distress and feeling dirty for Resident 2.

Inspectors wroteBased on interviews and record reviews the facility failed follow physician orders for one resident out of five sampled residents (Resident 1) when Resident 1 ' s weight was not measured at admission. This failure had the potential for facility to be unable to recognize if Resident 1 experienced unexpected weight loss.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure one resident out of five sampled residents (Resident 1), who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain grooming and personal hygiene, when Resident 1 did not receive showers as scheduled. This failure had the potential for Resident 1 to experience a decrease in hygiene and psychosocial wellbeing.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure medications were stored in their original containers and in a safe manner for 16 sampled residents. This failure had the potential for medications to be incorrectly identified and misused.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was prepared and stored in a safe and sanitary manner for a census of 42 residents who received food prepared from the kitchen, when: 1. Expired half-gallon of milk, opened salad dressing and creamer containers without open dates labeled, and full egg crates without received or expiration dates labeled were found in the kitchen refrigerators; 2. No temperature monitoring logs for resident food freezer section and for the dry storage room; 3. Ice and water dispensers in the dining room were not clean; and, 4. Lids used for covering prepared food on the steam table were stored on top of the unclean oven top. These failures decreased the facility's potential to store, prepare, distribute, and serve food in accordance with professional standards for food service safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection prevention and control practices to help prevent the development and transmission of communicable diseases and infections when: 1. Housekeeping staff dipped contaminated gloves into mop bucket sanitizing solution; 2. Laundry room did not contain a hand washing station, and laundry room staff did not use gown for handling dirty laundry, did not sanitize equipment after handling dirty laundry, did not perform hand hygiene after glove removal, did not perform hand hygiene between resident room visits, and hung contaminated clothes hangers back on the clean linens cart; 3. Facility unable to provide evidence of timely corrective action following positive legionella tests in the water systems; 4. [...]

Inspectors wroteBased on interviews and record reviews the facility failed to ensure one out of 16 sampled residents (Resident 21), maintained their right to retain and use personal possessions when staff were aware Resident 21's cell phone was taken without his permission. This failure resulted in the unrecovered loss of Resident 21's personal cell phone.

Inspectors wroteBased on interviews and record reviews the facility failed to investigate and report an allegation of abuse for one out of 16 sampled residents (Resident 21), when Resident 21 notified a Licensed Nurse (LN) of an allegation of sexual and physical abuse, which included an injury of unknown origin. This failure caused Resident 21 to feel unsafe within the facility.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure one out of 16 sampled residents (Resident 21), was provided with an environment that supported Resident 21's quality of life when Resident 21 received meals in polystyrene containers with plastic utensils. This failure resulted in Resident 21's lack of self-worth, self-esteem, and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure facility corridors had firmly secured handrails for the two out of two facility corridors (Unit A and Unit B corridors). This failure had the potential to result in increased falls and potential for injury to the residents that used the corridors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 44 sampled residents' (Resident 2 and Resident 4), call lights were within reach and easily accessible. This failure placed Resident 2 and Resident 4 at risk of not being able to ask staff for assistance.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was kept free from sexual abuse when a resident (Resident 4) was found in Resident 1's room touching her genital area (private parts). This failure violated Resident 1's right to be free from sexual abuse and had the potential to negatively impact Resident 1's psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), in a census of 43, was free from abuse when Resident 2 punched him in the face. This failure caused Resident 1 to sustain a nosebleed.

Inspectors wroteBased on observation, interview, and record the review, the facility failed to prevent physical abuse for 2 of 5 (Resident 2, Resident 3) sampled residents when: 1. Resident 1 threw a container of water at Resident 2, hit Resident 2 on the shoulder, and pushed a wheelchair into Resident 2's bed while Resident 2 was in bed; 2. Resident 1 pushed a wheelchair into Resident 3. This failure resulted in physical injury to Resident 1 and Resident 3 and emotional distress to Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to report to the Department a physical altercation between two residents (Resident 1 and Resident 3) that caused physical injury to both residents, within the regulatory time frame. This failure had the potential to cause harm to other residents without proper reporting.

Inspectors wroteBased on interview and record review, the facility failed to provide Social Services (SS) follow up for three days following abuse allegations for 3 of 5 sampled residents (Resident 1, Resident 2, and Resident 3). This failure had the potential for Resident 1, Resident 2, and Resident 3 to not receive competent and sufficient psychosocial support.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one dietary personnel was competent to carry out the functions of the food and nutrition service when the Dietary Aide (DA) 1 was unable to practice correct hand hygiene practices during dishwashing with the dish machine performed by one person and unable to verbalize the process of manual (3-compartment sink) dishwashing (cross refer to F812, finding number 5). These failures had the potential to cause food borne illness in a potentially compromised population of 42 out of 44 residents who received food from the facility kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was prepared, stored, served, or distributed in accordance with professional standards of food serve safety when: 1. food items with missing or incorrect labeling and dating were found, 2. food items with opened packages were found not covered to prevent cross contamination (the unintentional transfer of bacteria and/or substances from one food to another), 3. food items that were expired were found and available for use, 4. ice machine was not clean located in the dining room, 5. Dietary Aide (DA) 1 was not able to verbalize the process of manual (3-compartment sink) dishwashing, and not practicing handwashing during dishwashing when perform by one person, 6. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a clean environment for the residents and visitors when one garbage dumpster and one food waste bin, located outside the facility, were not secure with the dumpster lids closed. This failure had the potential for an unsafe environment for the residents and visitors due to possible pest infestation and spread of diseases in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the rights for dignity, privacy and homelike environment were promoted for six of 21 sampled residents (Resident 35, Resident 10, Resident 43, Resident 29, Resident 32, and Resident 146) to maintain and enhance the residents' self-esteem and self-worth and incorporate the residents' preferences, and choices, when: 1. Resident 35's finger nails were long with brownish discoloration under the nails with flaking nail polish; 2. The urinary catheter bag was not covered for Resident 10; 3. Window blind sheet was missing in the room of Resident 29; 4. Several items including loose pieces of metal panels, metal boxes and three large framed paintings, and a meal tray not picked up for two days, were found in Resident 32's room; 5. There was no wall clock or television for Resident 10 and Resident 43; and 6. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation of needs and preferences for four of 21 sampled residents (Resident 446, Resident 29, Resident 10, and Resident 43) when: 1. Water was not within reach for Resident 446; 2. Diet request for double protein portions was not provided to Resident 29; 3. The call light device was broken and not working in Resident 10 and Resident 43's room; and 4. There was no wall clock or television in Resident 10 and Resident 43's room. These failures had the potential to result in the residents' not attaining their needs and not maintaining their highest practicable physical, mental, emotional, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement comprehensive care plans for three out of 21 sampled residents (Resident 300, Resident 1, and Resident 32), when: 1. No care plan developed or implemented on medication for Resident 300's skin rash; 2. No care plan developed or implemented after teeth extraction for Resident 1; and 3. No care plan was developed or implemented for Resident 32's psychotropic medication. These failures had the potential to result in residents not attaining their highest practicable physical, mental and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to follow physician's orders in accordance with the professional standards of quality care for two of 21 sampled residents (Resident 1 and Resident 13), when: 1. Resident 1 was not weighed daily; and 2. Out of range blood sugar levels were not reported to the physician for Resident 13. These failures had the potential to result in the residents not obtaining their highest practicable well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure accurate accountability and effective storage of controlled medications (those with high potential for abuse or addiction) when random controlled medication audits of the Medication Administration Record (MAR) and Controlled Drug Record (CDR) for two out of three residents (Residents 2 and 31) did not reconcile to indicate they were given to the residents. 2. Implement a system to accurately document and secure emergency medications (E-Kit) for a census of 44. These failures resulted in the facility not having accurate accountability of controlled medications and potential for abuse or misuse of these medications, the potential for emergency medications to be unavailable when needed, and the potential for not meeting the residents' therapeutic needs or worsening of their medical conditions.

Inspectors wroteBased on observation, interview, and record review, the facility had a 10.53% error rate when four medication errors out of 38 opportunities were observed during a medication pass for two of six residents (Residents 31 and 299). This failure resulted in medications not given in accordance with the prescriber's orders and potential to affect the residents' clinical conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. Prepared medications were properly stored and labeled, and administered at the time of preparation; 2. Controlled medications were stored in accordance with facility policy and procedure; 3. Expired and discontinued medications were not available for resident use; and 4. Opened biologicals, eye drops, and inhalation solutions were dated once opened, to ensure they were not used beyond the discard date, and appropriately labeled with a pharmacy label or name to correctly identify which resident they were for. The deficient practices had the potential for residents to receive medications with unsafe or reduced potency from being used past their expiration date or improper storage, and diversion or misuse of medications from not being securely stored.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the menu was followed for the therapeutic diet (a modification of a regular diet, tailored to fit the nutritional needs of a particular person. It could be part of a treatment or medical condition and is normally prescribed by a physician) during the lunch meals on 10/10/23 and 10/11/23 when: 1. Five residents (Resident 1, 6, 9, 14, and 19) with small portion diets who got the incorrect portion size with their meals, 2. [...]

Inspectors wrote4. During a medication administration observation by the Health Facility Evaluator Nurse (HFEN) and the Pharmacy Consultant (PC) on 10/9/23 at 8:21 a.m. with LN 1, LN 1 prepared medications for Resident 299 which included megestrol (medication used to treat loss of appetite and weight loss) 40 milligrams/milliliter (mg/mL, unit of measurement), 10 milliliter (mL, unit of measurement). During preparation, LN 1 drew 10 mL from the bottle with a syringe. After measuring the medication, LN 1 placed the syringe directly on the medication cart. LN 1 then entered Resident 299's room and administered the medication directly into the resident's mouth with the syringe. During an interview on 10/10/23 at 9:53 a.m., with the Director of Nursing (DON), the DON indicated staff were expected to not place a syringe used to measure medication directly on top of the medication cart. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an informed consent was obtained when the dose of quetiapine (a medication used to balance hormones that help regulate mood, behaviors, and thoughts) was increased for one of 44 residents (Resident 32). This failure increased the potential for Resident 32's Responsible Party (RP) to not be informed of the risks and benefits of the medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 21 sampled resident's (Resident 300) responsible party (RP, person in charge of making decisions) was notified of change in services. This failure had the potential to not allow the responsible party (RP) to appeal the decision in a timely manner.

Inspectors wroteBased on interview and record review, the facility failed to ensure a transfer notice for one of 21 sampled residents (Resident 26) was sent to the Office of the State Long Term Care Ombudsman (resident advocate) as required when Resident 26 was transferred to the hospital. This failure had the potential to deny Resident 26 access to an advocate who could inform residents of their options and rights.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a comprehensive assessment was performed in accordance with regulatory time frames for three of 21 sampled residents (Resident 29, Resident 146 and Resident 300), when the admission MDS (Minimum Data Set, an assessment tool) assessments were not completed. This failure had the potential to result in the residents not attaining their highest practicable physical, mental and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a comprehensive assessment was performed in accordance with regulatory time frames for one of 21 sampled residents (Resident 10), when the significant change of condition MDS (Minimum Data Set, an assessment tool) assessment was not completed. This failure had the potential to result in Resident 10 not attaining the highest practicable physical, mental and psychosocial well-being.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a baseline care plan (BCP, document that outlines care needs) for one of 21 sampled residents (Resident 300) within 48 hours of the resident's admission. This failure had the potential to place the resident at risk for unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to review and revise the comprehensive care plan for one of 21 sampled residents (Resident 13), when the care plan did not reflect the removal of the urinary catheter (a tube used to empty the bladder and collect urine). This failure had the potential to result in Resident 13's receiving outdated care and placing the resident at risk for not meeting her highest practicable well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure orders were followed for three of 21 sampled residents (Resident 15, Resident 298, and Resident 300) when thin liquids were served instead of thickened liquids (beverage that is specifically designed for people who have difficulty swallowing; helps prevent choking by moving slower than thin liquids). These failures had the potential to increase the risk of choking.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly apply bed rails for one of 21 sampled residents (Resident 300), when Resident 300 did not have a side rail assessment, risk for entrapment assessment or informed consent for the use of the two 1/2 bed rails. This failure had the potential to cause Resident 300 restricted exiting from the bed, increased risk of injury, increased depression, and entrapment.

Inspectors wroteBased on interview and record review, the facility failed to ensure the pharmacist identified an irregularity for an antipsychotic (medication used to treat hallucinations [seeing or hearing things that are not there] and delusions [fixed beliefs with no basis in reality] medication during the monthly drug regimen review for one of 21 sampled residents (Resident 32). This failure had the potential for Resident 32 to receive unnecessary medication, or inappropriate medication dosage, which had potential for increased risk and exposure to side effects such as sedation, memory loss, falls and abnormal involuntary movements.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 21 sampled residents (Resident 32) was free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behaviors) when Resident 32's antipsychotic was increased without documented clinical rationale and was given in excess for the indication for use. This failure resulted in unnecessary medication for Resident 32, which had the potential for increased risk and exposure of side effects associated with psychotropic medications such as sedation, memory loss, falls and abnormal involuntary movements.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food of appropriate nutritive content was provided for one of 21 sampled residents (Resident 29), when the resident did not receive and consume food as prescribed by the physician. This failure had the potential to result in the resident not attaining the treatment and plan of care in accordance with his goals and preferences.

Inspectors wroteBased on observation, and interview, the facility failed to ensure essential equipment was working for two of 21 sampled residents (Resident 10 and Resident 43), when the residents' call light button devices did not work. This failure had the potential to result in the residents not being able to ask staff for assistance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, sanitary, functional and comfortable homelike environment for three of 21 sample residents (Resident 32, Resident 10 and Resident 43), when: 1. Several items including loose pieces of metal panels, metal boxes and large framed paintings, and a meal tray not picked up for two days, were found in Resident 32's room; 2. The call light device was broken and not working in Resident 10 and Resident 43's room; These failures had the potential to result in the residents not attaining their highest practicable physical, mental and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide safety and supervision for one of three sampled residents (Resident 1), when the resident walked out of the building, seen and not prevented by staff, and was found unattended and unsupervised four blocks away from the facility. This failure had the potential to result in accidents, falls and injury.