Pioneer Ridge Retirement Community

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure Resident (R) 1 remained free from verbal abuse and mistreatment when Licensed Nurse (LN) G used an expletive and other derogatory language toward R1. Findings Included:- R1's Electronic Medical Record (EMR) documented diagnoses of dementia with other behavioral disturbance (a progressive mental disorder characterized by failing memory, and confusion, with changes in their mood, personality, or actions), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Quarterly Minimum Data Set (MDS) dated 03/26/2026 for R1 documented a Brief Interview for Mental Status (BIMS) score of four, which indicated severe cognitive impairment. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide adequate supervision and failed to respond appropriately to alarms to prevent the elopement of Resident (R) 1, who was cognitively impaired, had a history of wandering and exit seeking, and was at risk for falls. On 04/26/26 at 01:44 AM, R1 pushed on the Blue-Hall emergency exit door, which sounded the alarm immediately when pushed, then opened after 15 seconds, and R1 exited the facility. Licensed Nurse (LN) G sat at the nurse's station with a clear view of the emergency exit door but did not look up or respond to the door alarm. At 02:05 AM, Certified Nurse Aide (CNA) M approached the nurse's station and asked LN G where the alarm was coming from, and LN G stated it was likely an exit door. CNA M and CNA N immediately started looking for the source of the alarm. [...]

Inspectors wroteThe facility had a census of 62 residents. The sample included 17 residents. Five Certified Nurse Aides (CNA) were reviewed for yearly performance evaluations and in-service training. Based on record review and interview, the facility failed to ensure one of the five reviewed CNA staff had the required yearly performance evaluations completed. This placed the residents at risk for inadequate care.

Inspectors wroteThe facility identified a census of 62 residents. The facility had one main kitchen and two dining areas. Based on observation, interview, and record review, the facility failed to ensure that staff members properly tested the dishwashing sanitization chemicals documented freezer and refrigerate temperatures. The facility also failed to staff donned hairnets and beard guards and maintain dairy food at the appropriate temperature.

Inspectors wroteThe facility identified a census of 62 residents. The facility identified nine residents on Enhanced Barrier Precautions (EBP- infection control interventions designed to reduce transmission of resistant organisms, which employ targeted gown and glove use during high contact care). The facility failed to identify Resident (R) 74, who had a percutaneous endoscope gastrostomy tube (PEG- a tube inserted through the wall of the abdomen directly into the stomach), and R1, R21, R48, and R6, who had a urinary catheter (a tube inserted into the bladder to drain the urine into a collection bag). Based on record review, observations, and interviews, the facility failed to implement signage or indicators within the physical environment to alert staff and visitors of the required EBP. [...]

Inspectors wroteThe facility identified a census of 62 residents. The sample included 17 residents. Based on interviews, observation, and record review, the facility failed to develop and implement the core elements of antibiotic stewardship to ensure an effective infection prevention and control program including antibiotic stewardship for the residents of the facility.

Inspectors wroteThe facility identified a census of 62 residents. The sample included 17 residents. Based on interviews, observation, and record review, the facility failed to designate a staff member with the required qualification and certification as the Infection Preventionist, who was responsible for the facility's Infection Prevention and Control Program.

Inspectors wroteThe facility reported a census of 62 residents. The Sample included 17 residents. Based on observations, record review, and interviews, the facility failed to ensure safe medication storage of three of its six medication carts. Findings Included:- On 12/01/25 at 07:08 AM, an inspection of the Blue Hall revealed an unlocked and unsupervised medication cart next to the medication storage room. The cart contained prescription medications, stock medications, insulin (a hormone that lowers the level of glucose in the blood), and treatment supplies for the residents on the hall. An inspection of the Blue Hall also revealed an unsecured, smaller treatment cart that contained stock medication and treatment supplies next to the medication cart. At 07:11 AM, Certified Medication Aide (CMA) M entered the hallway and secured both carts. [...]

Inspectors wroteThe facility identified a census of 62 residents. The sample included 17 residents, with five residents reviewed for immunizations. Based on interviews, observation, and record review, the facility failed offer or obtain informed declinations or a physician-documented contraindication for the Pneumococcal Conjugate Vaccine (PCV20 - vaccination for bacterial infections), and pneumococcal (type of bacterial infection) vaccination for Resident (R) 2, R4, and R8.

Inspectors wroteThe facility reported a census of 62 residents. The Sample included 17, with two residents reviewed for dignity. Based on observations, record review, and interviews, the facility failed to ensure a dignified care environment for Resident (R) 1 and R21 during meal service. Findings Included:- On 12/02/25 at 12:22 PM, an observation was completed in the main dining room for meal service. R1 (a cognitively impaired resident who was physically dependent on staff assistance) sat in his Broda chair (specialized wheelchair with the ability to tilt and recline) at the table closest to the kitchen entry door. R1 had a Foley catheter (an indwelling urinary catheter with a tube inserted into the bladder to drain urine into a collection bag). R1's urinary collection bag was hung directly under his wheelchair. R1's urinary collection bag was visible and was one-third full with bright yellow urine. [...]

Inspectors wroteThe facility identified a census of 62 residents. The sample included 17 residents, with one reviewed for privacy. Based on observation, record review, and interviews, the facility failed to secure protected health information (PHI) for Resident (R) 62. Findings Included:On 12/01/25 at 07:15 AM, an inspection of the Red Hall revealed an unsecured and unsupervised treatment cart outside R62's room. The cart contained stock medications, treatment supplies, and insulin for residents on the hall. The cart laptop was open and contained R62's picture and protected health information (PHI) within direct view. On 12/01/25 at 07:18 AM, Licensed Nurse (LN) J opened R62's door and exited the room into the hallway. LN J stated she was not sure if the medication carts were supposed to be locked, but would lock them during the survey inspection. [...]

Inspectors wroteThe facility identified a census of 62 residents. The sample included 17 residents, with five reviewed for abuse and/or neglect. Based on the record review and interview, the facility failed to ensure Resident (R) 37, R58, R61, R67, and R73 were free from abuse when their medication was misappropriated from the facility's medication cart.

Inspectors wroteThe facility identified a census of 62 residents. The sample included 17 residents, with one resident reviewed for hospitalization. Based on observation, record review, and interviews, the facility failed to provide a written notice of transfer/discharge as soon as practicable, and the facility also failed to provide a bed hold notice with the required information for Resident (R) 50.

Inspectors wroteThe facility identified a census of 62 residents. The sample included 17 residents with five reviewed for care plan. Based on observation, record review, and interviews, the facility failed to implement a comprehensive care plan for Resident (R) 54 related to his activities of daily living (ADL). Findings Included: - R54's Electronic Medical Records (EMR) noted diagnoses of Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), benign prostatic hyperplasia (BPH- non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency, and urinary tract infections), dysphagia (difficulty swallowing), and dementia (a progressive mental disorder characterized by failing memory and confusion). [...]

Inspectors wroteThe facility identified a census of 62 residents. The sample included 17 residents with five reviewed for care plan revisions. Based on observation, record review, and interviews, the facility failed to revise Resident (R) 38 and R27's care plans to reflate changes in their care. Findings Included: - R38's Electronic Medical Records (EMR) noted diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), limited mobility, muscle weakness, and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R38's Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of zero, indicating severe cognitive impairment. The MDS noted she could independently complete bathing, dressing, bed mobility, and transfers. [...]

Inspectors wroteThe facility identified a census of 62 residents. The sample included 17 residents, with one reviewed for quality of care. Based on observation, record review, and interviews, the facility failed to ensure the physician order was followed for a daily weight for R45 to monitor for congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid).

Inspectors wroteThe facility identified a census of 62 residents. The sample included 17 residents, with two residents reviewed for treatment/services to prevent/heal pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to ensure pressure-reducing measures were placed on Resident (R) 2, and further failed to ensure R2's Low air loss (LAL) mattress (medical device that uses continuous airflow through small holes in the surface to reduce moisture, keep skin cool and dry, and redistribute pressure to prevent and treat pressure ulcers) was set at the proper weight. [...]

Inspectors wroteThe facility identified a census of 62 residents. The sample included 17 residents, four residents were sampled for accidents and hazards. Based on observation, record review, and interviews, the facility failed to provide Resident (R) 2's fall interventions as directed by her care plan.

Inspectors wroteThe facility identified a census of 62 residents. The sample included 17 residents, with one resident reviewed for respiratory care. Based on interviews, observation, and record review, the facility failed to ensure there was physician indication for oxygen administration for Resident (R) 27.

Inspectors wroteThe facility identified a census of 62 residents. The sample included 17 residents, with one resident reviewed for dialysis (a procedure where impurities or wastes are removed from the blood), and end-stage renal disease (ESRD- a terminal disease of the kidneys). Based on observation, record review, and interviews, the facility failed to provide standards of care related to Resident (R) 7's dialysis.

Inspectors wroteThe facility identified a census of 62 residents. The sample included 17 residents, with two residents reviewed for hospice services. Based on observation, record review, and interviews, the facility failed to ensure collaboration between the nursing home and hospice services to identify hospice-supplied services, supplies, medication, and equipment for Resident (R) 3 and R1.

Inspectors wroteThe facility identified a census of 62 residents. The sample included 17 residents. Based on interviews, observation, and record review, the facility failed to post the previous state inspection information in a location accessible to residents and visitors.

Inspectors wroteThe facility identified a census of 67 residents. The sample included three residents. Based on observations, record review, and interviews, the facility failed to report an allegation of abuse between staff and Resident (R) 1 to the State Agency (SA) as required. This deficient practice placed R1 at risk for unidentified and ongoing abuse.

Inspectors wroteThe facility reported a census of 61 residents, with 9 sampled. Based on observation, interview, and record review the facility failed to ensure the staff provided Resident (R) 1 a peanut-free meal, per his reported allergies upon admission. On 03/07/25 at 06:30 PM, the staff provided R1 a peanut butter cookie with his dinner and the staff failed to verify his documented allergies on his meal ticket. R1 had an anaphylaxis allergic reaction to the peanut butter that resulted in vomiting. The facility could not provide epinephrine to R1 to prevent further potential anaphylaxis-related symptoms and the facility transferred R1 to the hospital. R1 received the epinephrine at the hospital and was admitted to the hospital on [DATE] for anaphylaxis. This deficient practice placed R1 in immediate jeopardy and any resident with a food allergy at risk to their health and safety. Findings Included: [...]

Inspectors wroteThe facility identified a census of 61 residents. The sample included nine, with one reviewed for competent staffing. Based on interviews and record reviews, the facility failed to ensure staff possessed the appropriate skills and knowledge to identify the available epinephrine (medication used to alleviate symptoms of severe allergic reactions) during Resident (R) 1's anaphylaxis episode. This deficient practice placed R1 and all residents with allergies at risk for impaired quality of care.

Inspectors wrote- R29's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of hemiparesis (muscular weakness of one half of the body), hemiplegia (paralysis of one side of the body), and cerebrovascular accident (CVA-stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) affecting the dominate right side. The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented R29 was independent with transfers, changes in position, and ambulation was not tested. The MDS documented R29 had no falls during the observation period. The Quarterly MDS dated 08/08/24 documented a BIMS score of 14 which indicated intact cognition. [...]

Inspectors wroteThe facility identified a census of 45 residents. The sample included 13 residents with five reviewed for immunization status. Based on record reviews, and interviews, the facility failed to obtain consent or declinations for the Pneumococcal Conjugate Vaccine (PCV20- vaccination for bacterial infections) pneumococcal (type of bacterial infection) vaccination for Resident (R) 32, R10, R46, and R34. This placed the residents at increased risk for complications related to pneumonia.

Inspectors wroteThe facility identified a census of 45 residents. The sample included 13 residents. One resident was sampled for reasonable accommodations of resident needs. Based on observation, record review, and interview, the facility failed to ensure Resident (R)45 had a call light within her reach. This deficient practice left R45 vulnerable to unmet care needs due to the inability to call for staff assistance.

Inspectors wroteThe facility identified a census of 45 residents. The sample included 13 residents with two residents reviewed for hospitalization. Based on observation, record review, and interviews, the facility failed to provide written notice for a facility-initiated transfer as soon as practicable for Resident (R) 31. This deficient practice placed R31 at risk of uninformed choices and miscommunication regarding care needs.

Inspectors wroteThe facility identified a census of 45 residents. The sample included 13 residents with two residents reviewed for hospitalization. Based on observations, record review, and interview the facility failed to provide a bed hold notice with the required information to Resident (R) 31 and/or their legal representative when R31 transferred to the hospital. This deficient practice placed R31 at risk for impaired ability to return to the facility or her same room.

Inspectors wroteThe facility identified a census of 45 residents. The sample included 13 residents with three residents reviewed for treatment and services to prevent and heal pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 45's offloading boots were applied to her heels to prevent pressure ulcers. The facility also failed to ensure that R29's pressure-relieving cushion was in his wheelchair. This placed R45 and R29 at increased risk for worsening pressure ulcers and the development of new pressure ulcers. Findings Included: [...]

Inspectors wroteThe facility identified a census of 45 residents. The sample included 13 residents with two residents reviewed for positioning and mobility. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 45's palm splint was applied. This deficient practice placed the resident at risk for discomfort and decreased range of motion (ROM- the full movement potential of a joint, usually its range of flexion and extension).

Inspectors wroteThe facility identified a census of 45 residents. The sample included 13 residents with one resident observed for bowel and bladder. Based on observation, record reviews, and interviews the facility failed to assess, identify, and implement interventions related to Resident(R)31's incontinence. This deficient practice placed R31 at risk of impaired dignity and increased risk for urinary tract infections (UTI).

Inspectors wroteThe facility identified a census of 45 residents. The sample included 13 residents with two residents reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to ensure Resident(R) 21's continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) mask was stored in a sanitary manner. This placed R21 at an increased risk for respiratory infection and complications.

Inspectors wroteThe facility identified a census of 45 residents. The sample included 13 residents with three residents reviewed for accidents. Based on observation, record review, and interviews, the facility failed to ensure that Residents (R)12 and R46 had a documented safety assessment for the use of side rails that addressed entrapment, consent for the use of the side rails, and failed to ensure the resident and/or responsible party were advised of the risks and/or benefits of the use of the side rails. This placed the residents at risk for uninformed decisions and impaired safety related to the risks associated with the use of side rails. Findings Included: [...]

Inspectors wroteThe facility identified a census of 45 residents. The sample included 13 residents with six residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to notify Resident (R)21's physician according to the physician-ordered parameters for blood glucose monitoring. This deficient practice placed R21 at risk for delayed treatment of hyperglycemia (greater than the normal amount of glucose in the blood) and unnecessary medication complications.

Inspectors wroteThe facility had a census of 45 residents. The sample included 13 residents with six reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure Resident (R)34 and R32 had a stop date for as-needed (PRN) lorazepam (anxiety medication). This placed the residents at risk for adverse effects from psychotropic (alters mood or thoughts) medication.

Inspectors wroteThe facility identified a census of 45 residents. The sample included 13 residents. Based on observation, record review, and interviews, the facility failed to ensure that physician-ordered laboratory test results for Resident (R) 31 were included in R31's clinical record. This deficient practice could result in unnecessary tests and delayed treatment.

Inspectors wroteThe facility identified a census of 45 residents. The sample included 13 residents with two residents reviewed for hospice (a type of health care that focuses on the terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) services. Based on observation, record review, and interview, the facility failed to ensure a coordinated plan of care, which coordinated care and services provided by the facility with the care and services provided by hospice, was developed and available for Resident (R)45. This placed the resident at risk for inappropriate end-of-life care. Finding Included: [...]

Inspectors wroteThe facility identified a census of 45 residents. The facility identified five residents on Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact care). Based on record reviews, observations, and interviews, the facility failed to implement signage or indicators within the physical environment to alert staff and visitors of the required EBP and personal protective equipment (PPE) for Resident (R) 7 and R32. The facility additionally failed to store respiratory equipment in a sanitary manner. These deficient practices placed the residents at risk for infectious diseases.

Inspectors wroteThe facility identified a census of 51. The sample included 13 residents. Based on interviews and record review, the facility failed to provide activities on the weekends which reflected the residents' interests, and preferences. This placed the residents at risk for boredom, isolation, and decreased quality of life.

Inspectors wroteThe facility identified a census of 51 residents with one kitchen. Based on observation, record review, and interviews, the facility failed to maintain sanitary dietary standards related to food storage. This deficient practice placed the residents who received food from the facility kitchen at risk related to food borne illnesses and food safety concerns.

Inspectors wroteThe facility identified a census of 51 residents. Based on observations, record review, and interviews, the facility failed to ensure proper infection control standards were followed related to hand hygiene, medical equipment storage/cleaning, and catheter care. This deficient practice placed the residents at risk for complications related to infectious diseases. Findings Included: - On 07/17/23 the facility reported no residents were on transmission-based precautions. On 07/17/23 at 0709 AM an inspection of the Blue Hall revealed an oxygen tank (cylindrical tank used to provide supplemental oxygen), tubing, and nasal cannula (tubing that delivers oxygen directly through both nostrils of the nose) stored on the back of a wheelchair outside Resident (R)45's room. The nasal cannula and tubing hung down the back of the wheelchair and rested against the back of wheelchairs seat. [...]

Inspectors wroteThe facility identified a census of 51. The sample included 13 residents with two reviewed for dignity. Based on interviews and record review, the facility failed to provide dignified care for Residents (R)206 and R30. This deficient practice placed the residents at risk for decreased psychosocial well-being. Findings Included: [...]

Inspectors wroteThe facility identified a census of 51 residents. The sample included 13 residents with three residents reviewed for beneficiary notices review. Based on observation, record review, and interviews, the facility failed to provide Resident (R)6 with an Notice of Medicare Non-coverage (NOMNC CMS-form 10123) and Advanced Beneficiary Notice (ABN CMS-10055) with Medicare-Part A days remaining. This deficient practice placed R6 at risk for delayed care and missed services. Findings Included: - A review of R6 EMR revealed an Medicare End of Stay Minimum Data Set (MDS) completed on 04/14/23 noting she was being discharge for Medicare part A services but expected to remain in the facility. A review of R6's EMR indicated her last covered day for Medicare part A services was 04/15/23. On 07/19/23 R6's Beneficiary Notification Review was completed. [...]

Inspectors wroteThe facility identified a census of 51 residents. The sample included 13 residents. Based on observation, record review, and interviews, the facility failed to complete an accurate Minimum Data Set (MDS) assessment for Resident (R) 9 for special treatment and programs when the MDS documented she received dialysis (a process of removing excess water, solutions, and toxins from the blood) during the look back period. This deficient practice placed R9 at risk for inappropriate care planning and care needs.

Inspectors wroteThe facility identified a census of 51 residents. The sample included 13 residents with two residents reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to revise Resident (R) 42's comprehensive care plan to include administration of oxygen. This deficient practice placed R42 at risk for the potential alteration of continuous care among nursing home staff, that could result in adverse consequences related to respiratory distress and adverse side effects.

Inspectors wroteThe facility identified a census of 51 residents. The sample included 13 residents. Based on observation, record review and interview, the facility failed to ensure that physician ordered daily weights were obtained and monitored for Resident (R) 45 who had congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid). This deficient practice placed R45 at risk for unwanted weight/fluid gain and possible complications.

Inspectors wroteThe facility identified a census of 51 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to ensure care planned fall interventions were followed for Resident (R) 1 after a fall on 06/25/23. This deficient practice placed R1 at risk for additional falls and possible injury.

Inspectors wroteThe facility identified a census of 51 residents. The sample included 13 with two reviewed for nutrition. Based on observation, interviews, and record review, the facility failed to provide consist weekly weight monitoring as identified on Resident (R)14's nutritional care plan. This deficient practice placed R14 at risk for complication related to weight loss and malnutrition (condition that develops when the body is deprived of vitamins, minerals and other nutrients).

Inspectors wroteThe facility identified a census of 51 residents. The sample included 13 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure the physician was notified when antihypertensive medication (class of medication used to treat hypertension (high blood pressure) was not administered for Resident (R) 39 and blood sugars were outside of parameters for R7. This deficient practice placed these residents at risk for unnecessary medication use and possible unwarranted side effects.

Inspectors wroteThe facility identified a census of 51 residents. The sample included 13 residents with five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure Resident (R) 9 did not receive antipsychotic (class of medications used to treat psychosis and other mental emotional conditions) for an extended duration when staff failed to change a scheduled dose in response to a physician ordered gradual dose reduction (GDR) and failed to ensure the as needed (PRN) antipsychotic medication did not extend for a duration longer than 14 days without physician visit and rationale. The facility further failed to ensure an appropriate indication, or the required physician documentation, for continued use for R36's Seroquel (antipsychotic medication). [...]

Inspectors wroteThe facility identified a census of 51 residents. Based on interview, and record review the facility failed to submit accurate staffing hours to the federal regulatory agency through Payroll Based Journaling (PBJ), when the facility failed to accureately submit staffing hour data for all nursing personnel as required.