Pioneer Trace Group LLC

Inspectors wroteBased on interview, record review, and review of the facility's document and polices, the facility failed to protect the residents' right to be free from mental and verbal abuse for 3 of 7 sampled residents, Resident (R) 1, R7, and R11. Resident (R) 2 had a history of verbal and physical outburst behaviors. Residents observed R2 throwing objects, physically hitting staff, and attempts were made to hit other residents and staff. This caused the residents psychosocial harm in which they made statements of being afraid, scared, walking on eggshells, and fear for their safety when R2 was around. Immediate Jeopardy (IJ) was identified on 05/21/2026 in the area of 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation and was determined to exist on 05/13/2026. Substandard Quality of Care (SQC) was also determined to exist. [...]

Inspectors wroteBased on interview, record review, review of the facility's investigation, and review of the facility's policy, the facility failed to ensure residents' care plans were revised to include interventions needed to provide person-centered care related to supervision and monitoring to ensure safety for 1 of 28 sampled residents, Resident (R) 5. Interviews with staff revealed that on 05/02/2026 at approximately 5:55 PM, staff observed the resident exiting the facility and they were able to intervene and return the resident back to the facility. However, the facility failed to revise the resident's care plan to include interventions that would increase the resident's supervision and/or monitoring. [...]

Inspectors wroteBased on observation, interview, record review, review of the website https://www.localconditions.com, review of the facility's investigation, and review of the facility's policies, the facility failed to have an effective system in place to ensure each resident received adequate supervision and monitoring. The facility failed to implement interventions and adequate supervision for 1 of 20 sampled residents to prevent unsafe wandering and elopement, Resident (R) 5. Review of the facility's investigation revealed R5 eloped from the facility on 05/02/2026 at approximately 8:11 PM and was found outside near the back facility entrance roadway by Dietary Aide 1, who was taking out trash. The investigation revealed R5 traveled approximately 286 feet from the facility entrance, in her wheelchair, over an uneven surface, without staff awareness or supervision. [...]

Inspectors wroteBased on observation, interview, review of the facility's job descriptions, and review of the facility's documents and policy, the facility failed to ensure that food was stored in a manner that minimized the risk of foodborne illness for all 78 current facility residents. Observation on 01/07/2026 and review of the facility's Food Temperature logs for 01/01/2026, 01/04/2026, 01/05/2026, and 01/06/2026 revealed the temperature in the facility's walk-in refrigerator/cooler was greater than 41 degrees Fahrenheit (F), the upper limit for the acceptable temperature.

Inspectors wroteBased on observation, interview, review of the facility's job descriptions, and review of the facility's documents and policy, the facility failed to ensure essential kitchen equipment was maintained and in safe operating condition for all 78 of the facility's current residents.

Inspectors wroteBased on interview, record review, and review of the facility's policies, the facility failed to ensure a resident was free from abuse due to misappropriation or exploitation for 1 of 38 sampled residents, Resident (R) 2.

Inspectors wroteBased on interview, record review, and review of the facility's document and policy, the facility failed to ensure appropriate coordination, oversight, communication, and continuity of care related to dialysis services for 1 of 38 sampled residents, Resident (R29). The facility failed to maintain an active contract with the dialysis provider and failed to ensure required dialysis communication was completed, sent, reviewed, and returned to the medical record to support continuity of care and monitor the resident's condition before and after dialysis treatments. This failure placed the resident at risk for unmet medical needs and complications related to dialysis services. [...]

Inspectors wroteBased on interview and review of the facility's policy, the facility failed to ensure all residents had the right to send and receive mail on Saturdays.

Inspectors wroteBased on interview and review of the facility's policies, the facility failed to establish written standards, policies, and procedures for a documented water management program based on nationally accepted standards for all residents (census 76). The facility did not have a water management program that included a description of the building's water systems where Legionella and other opportunistic waterborne pathogens could grow and spread, flow diagrams, measures to prevent growth, testing protocols, acceptable ranges, and established ways to intervene when control limits were not met.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policies, the facility failed to prepare food safely to prevent cross-contamination. Dietary Aide (DA) 2 was observed on 10/01/2024 preparing a puree brownie with gnats flying around the uncovered blender and gnats were observed flying in and around the trash can in the dining area. The deficiency had the potential to affect all residents that received meals from the kitchen.

Inspectors wroteBased on observation, interview, record review, review of facility policy, and review of the Centers for Medicare and Medicaid Services (CMS), Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to implement a person centered Comprehensive Care Plan (CCP) for each resident to meet a resident's medical, and nursing needs identified in the comprehensive assessment for one (01) of nineteen (19) sampled residents (Resident #69). Resident #69 had pressure ulcers/injuries to his/her right ankle and left heel, and the CCP, dated 10/23/19, revealed an intervention to provide heel protection. However, observation on 11/12/19, 11/13/19 and 11/14/19, revealed Resident #69 was in bed without heel protection.

Inspectors wroteBased on observation, interview, record review, review of the facility policy, and review of the Centers for Medicare and Medicaid Services (CMS), Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to ensure the Comprehensive Care Plan (CCP) was reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs for one (1) of nineteen (19) sampled residents (Resident #35). Resident #35 had a Physicians Order; dated 07/19/19 for heel boots when in bed; however, there was no documented evidence the CCP was revised to include the heel boots. Further, observations on 11/13/19 revealed the resident was in bed for approximately one (01) hour without heel boots on his/her feet.