United Pioneer Home

Inspectors wroteBased on observation and interview, the facility did not ensure food was stored and prepared in a sanitary manner that prevents foodborne illness to the residents. This practice had the potential to affect all 40 residents within the facility.*Open food noted in cold storage, not labeled and dated.*Cook D did not have a hair net on mustache.

Inspectors wroteBased on record review and interview, the facility did not ensure residents/representatives were notified of the rate to reserve the resident's bed in the bed hold notice. This has the potential to affect 2 of 5 residents R9 received bed hold notices with no daily rate documented and no information on resident appeal rights. R5 received bed hold notices with no daily rate documented and no information on resident appeal rights. R3's bed hold notices did not have daily rate documented and no information on resident appeal rights. R15 received a verbal bed hold notice, but facility did not have any documentation that R15 received the daily rate or information on resident appeal rights. R16 received a bed hold notice but it did not have the daily rate documented nor information on resident appeal rights.

Inspectors wroteBased on observation, interview and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This affected residents (R) R29, R41, R17, R16, R21, and R15. Certified Nursing Assistant (CNA) G did not perform hand hygiene when passing water pitchers to R29, R41, R17, R16, and R21. CNA H did not perform hand hygiene when providing peri cares to R15. Maintenance F entered R16's droplet precaution room without donning PPE when cleaning R16's room.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure the resident's environment remains as free of accident hazards as possible. The facility did not use appropriate assist devices during transfer when needed to prevent accidents which affected resident (R) (R6). Certified Nurse Assistant (CNA) H did not use gait belt while transferring R6 from toilet to wheelchair.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure standards of practice were followed for providing respiratory services for 1 of 1 resident (R) reviewed for oxygen therapy (R15). Certified Nurse Assistant (CNA) H did not check portable oxygen tank before taking R15 to lounge for an activity according to facility policy. The facility did not implement new respiratory interventions after each episode of R15 found with no oxygen on.

Inspectors wroteBased on observation, record review and interview, the facility did not ensure that residents are free of significant medication errors for 1 of 12 residents (R12) reviewed for medication errors. R12 has a type 2 diabetes mellitus diagnosis. Facility staff administered short acting insulin 4 hours after Blood Glucose (BG) was taken. Facility staff did not follow standards of practice for insulin administration.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure the resident's environment remains as free of accident hazards as possible. The facility did not implement new interventions and increase supervision when needed to prevent accidents for 2 of 3 residents (R) (R1, R2) reviewed.-R1 is at risk for falls and fell on [DATE], 12/30/24, 01/01/25, 01/09/25, 05/13/25, 06/06/25, 08/04/25, 08/05/25, and the facility did not place new interventions or increase supervision to prevent further fall incidents. On 08/06/25, x-ray results revealed a left humeral head fracture. On 08/08/25, additional x-rays of left knee related to complaints of pain, revealed an acute transverse non-displaced fracture of the mid portion of the left patella. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not maintain an infection prevention program designed to provide a safe and sanitary environment to prevent the transmission of communicable disease and infection. This has the potential to affect all 33 residents residing in the facility. The facility did not implement Standard of Practice (SOP) for documentation of Infection Control Surveillance and Monitoring with isolation precaution type, start date, and stop date. Staff did not perform appropriate hand hygiene with glove use during cares provided to R19 and R16.

Inspectors wroteBased on interview and record review, the facility did not establish an Infection Prevention and Control Program (IPCP) that must include, at a minimum, the following elements: An antibiotic stewardship program that includes a system to monitor/review antibiotic use. This has the potential to affect all 33 residents residing in the facility. The facility did not follow a Standard of Practice (SOP) for antibiotic stewardship for antibiotic use for residents on the line list logs from January 2024 through June 2024 line lists. The facility did not implement a SOP for antibiotic stewardship to monitor/review antibiotic usage, outcome measures, and summarizing of antibiotic resistance. The facility did not outline and implement a SOP for antibiotic stewardship concerning mode and frequency of education for prescribing providers and nursing staff on antibiotic use and protocols. [...]

Inspectors wroteBased on interview and record review, the facility did not conduct a thorough investigation into the abuse or protect from future incidents through education for Resident (R) 16. The facility did not conduct a thorough investigation into the abuse as other residents were not interviewed to determine if other residents were affected. The facility did not protect residents from future incidents as education was not provided to staff after this incident occurred.

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure the Minimum Data Set (MDS) was documented accurately related to tube feeding for 2 (R2 and R11) of 13 residents reviewed for MDS resident assessments.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure activities of daily living were maintained for 1 out of 2 sampled residents (R31). R31 was not ambulated per recommendation of Physical Therapy (PT). This is evidenced by: The facility's policy titled, Restorative Nursing Program (08/2015) states in part, To promote each Residents ability to adapt and adjust to living as independently and safely as possible .To focus on achieving and/or maintaining the Residents optimal physical functioning in activities of daily living. R31 was admitted to the facility on [DATE]. R31's diagnoses included compression fracture of vertebra, low back pain, unspecified, adult failure to thrive, weakness, and muscle weakness (generalized). [...]

Inspectors wroteBased on observation, record review and interview, the facility did not implement a restorative program in attempt to improve or maintain resident's functional abilities for 1 of 2 residents (R19) reviewed for limited Range of Motion (ROM).

Inspectors wroteBased on interview and record review, the facility did not ensure 1 of 5 residents (R8) were free from unnecessary medications. -R8 was prescribed lorazepam (anti-anxiety) without a documented diagnosis. -R8 was prescribed lorazepam as needed (PRN), beyond the 14-day limit, without a documented rationale. -R8's record did not include interventions to reduce or eliminate the need for administration of medication. -R8's record did not indicate adequate monitoring of anti-anxiety medication, including signs or symptoms to warrant administration of medication, and side effects of the medication.

Inspectors wroteBased on observation, record review and interview, the facility did not ensure drugs and biologicals used in the facility are labeled in accordance with current accepted professional principles for 1 of 26 medications reviewed during medication administration observation. This had the potential for harm to affect Resident (R)30. This is evidenced by: R30 was admitted to facility on 12/08/23 with a pertinent diagnosis of diabetes mellitus II. R30 has a prescription order for insulin Glargine Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine) inject 28 unit subcutaneously one time a day related to type 2 diabetes. On 07/10/24 at 7:50 AM, Surveyor observed Licensed Practical Nurse (LPN) F complete medication administration of insulin to R30. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not revise the care plan with accurate information for safety interventions when the call light was removed for 2 of 2 residents (R) reviewed. (R2 and R3).

Inspectors wroteBased on observation, interview and record review, the facility did not ensure residents were safe in their environment to prevent the risk of falling. This occurred for 3 of 3 residents (R) reviewed for falls, (R1, R2, and R3). The facility staff did not ensure R1 had pressure alarm pad while R1 was sitting in recliner as care planned. The facility staff did not ensure brakes were locked on EZ-stand lift during R2's transfer from recliner to bathroom. The facility staff did not ensure R3's recliner leg rest was down, and recliner unplugged as care planned.

Inspectors wroteBased on observations, interviews and kitchen temperature log review, the facility did not ensure the dishwashers were maintained and in safe operating condition. This has the potential to affect all 32 residents. The dishwasher did not reach manufacturer recommended temperatures to effectively sanitize dishes.

Inspectors wroteBased on record review and interview, the facility did not consult with the resident's physician when the resident had a change in condition for 1 of 1 residents reviewed (R27). Physician was not notified of R27's increased pain after a fall with a resident that has a history of fractured cervical vertebra. This is evidenced by: R27 was admitted to the facility on [DATE] and has diagnoses that include fracture of 6th cervical vertebra, anxiety, traumatic brain injury (TBI), fibromyalgia and major depressive disorder. Surveyor reviewed nursing description of fall with injury that occurred on 05/08/23 at 3:10 PM that read in part: .[R27] was seen by [Licensed Practical Nurse (LPN) N] lying on floor in front of [R27] wheelchair in hallway between hall and dining room. [LPN N] evaluated [R27]. [LPN N] observed [R27's] glasses crooked to the side of resident's face, nose bleeding. [...]

Inspectors wroteBased on observations, interviews and record review, the facility did not ensure residents received care per professional standards of practice. The LPN moved R27 after a significant fall, who had a history of cervical fracture after a fall with injury before Registered Nurse (RN) assessment was completed. Facility did not ensure a resident with chronic wounds received care per professional standards of practice to include weekly wound assessments with description of wound and measurements. This affected 1 of 3 residents looked at for wounds. (R8) This is evidenced by: Example 1 The facility policy, entitled Falls Protocol, dated 05/2019, reads in part If a resident had fallen or is observed on the floor without a witness to the event, nursing staff will evaluate for possible injuries to the head, neck, spine and extrmidies [sic]. [...]

Inspectors wroteBased on observation, record review and interview, the facility did not initiate interventions to prevent weight loss for 1 of 1 resident (R17) reviewed for weight loss. R17 had a significant weight loss from 01/01/23 to 07/01/23 and no interventions were documented in the medical chart.

Inspectors wroteBased on observations, interviews and record review, the facility did not ensure residents using psychotropic drugs received a gradual dose reduction (GDR), had indication for use, or monitoring for adverse side effects for 1 of 3 residents (R27) reviewed for psychotropic medications. Facility did not have a clinical rationale for not attempting a GDR for R27's antipsychotic medication, or documentation of behaviors for indication for use, or monitoring of side effects for adverse effects of the medication. This is evidenced by: R27 was admitted to the facility on [DATE] and has diagnoses that include fracture of 6th cervical vertebra, anxiety, traumatic brain injury (TBI), fibromyalgia and major depressive disorder. R27 has a doctor's order for Risperidone tablet 0.5 MG by mouth two times a day. On 04/04/23, the pharmacist made a recommendation for a GDR. [...]

Inspectors wroteBased on observations and interviews, the facility did not distribute and serve food in accordance with professional standards for food service safety. This had the potential to affect 3 residents who are on a pureed diet. Facility did not check temperature of pureed foods or document temperature of pureed food.

Inspectors wroteBased on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. This affected 3 of 12 sampled residents. Staff did not wear proper personal protective equipment (PPE) when doing wound care for a resident (R) on enhanced barrier precautions (EBP) and did not sanitize bandage scissors prior to cutting dressings. This affected 1 of 3 residents observed for wound care. (R8) Staff did not perform hand hygiene prior to putting on gloves during medication administration for R27. Staff did not perform hand hygiene between glove changes during cares during 1 of 3 observations of cares. This affected R4.