Inspection Reports for
Pioneer Care and Rehabilitation

The complaint investigation found that resident #3 entered resident #4's room causing a physical altercation and minor injuries. The resident was known to wander into other rooms despite supervision measures, placing residents at risk for verbal or physical altercations.

The facility failed to provide necessary supervision to resident #3 with dementia, who continued to enter other residents' rooms despite being on 1-to-1 observation and later placed in a secured memory care unit. This failure increased the risk of emotional distress and physical injury to resident #3 and other residents, resulting in a physical altercation and minor injuries.

The facility failed to have an antibiotic stewardship program, did not receive timely medication deliveries or drug regimen reviews from the pharmacy from May 2024 through April 2025, and lacked a current QAPI plan which had not been reviewed or revised for over two years. Additionally, the facility did not have a certified infection preventionist at the time of the survey.

The complaint investigation revealed multiple deficiencies including failure to complete treatment wishes documentation, failure to report abuse and injuries, inadequate discharge planning, failure to develop baseline care plans, inadequate dining assistance, failure to prevent falls related to medication, inaccurate monitoring of weight loss, delayed respiratory care orders, ineffective pain management, incomplete pharmacist medication reviews, medication errors, unsecured medication carts, ineffective medical director oversight, lack of infection preventionist, inadequate antibiotic stewardship, failure to follow infection control practices, and inadequate abuse education. Some allegations were substantiated while others were not reported or investigated properly.

The facility failed to timely complete and implement treatment wishes documentation, failed to report suspected abuse and injuries, failed to ensure proper discharge planning and documentation, failed to develop baseline care plans timely, failed to provide adequate dining assistance, failed to prevent falls related to medication use, failed to monitor severe weight loss accurately, failed to provide timely respiratory care orders, failed to manage pain effectively, failed to ensure pharmacist medication regimen reviews, failed to prevent medication errors, failed to secure medication carts, failed to ensure effective medical director oversight, failed to maintain an effective infection prevention program, failed to implement antibiotic stewardship, and failed to provide adequate staff education on abuse and neglect.

The complaint investigation found substantiated issues with medication availability leading to missed doses for resident #1, and concerns about retaliation and negative impact on resident mood and participation linked to the new administrator's actions.

The facility failed to consistently have physician-ordered medications available, resulting in missed doses for one resident. Additionally, the administration's actions led to resident concerns about retaliation, increased depression, and decreased participation in activities.

The complaint investigation found that a resident with difficulty swallowing was given medications whole instead of crushed as ordered, leading to aspiration pneumonia and hospitalization. The investigation also identified improper infection control practices during drink service that could spread pathogens.

The facility failed to crush medications as ordered for a resident with difficulty swallowing, resulting in aspiration pneumonia and hospitalization. Additionally, the facility failed to ensure proper infection control during drink service, risking cross-contamination between residents.

The complaint investigation was substantiated as the resident eloped, sustained injury, and was hospitalized. The facility failed to timely evaluate the resident's elopement risk and failed to ensure staff awareness of the resident's risk and safety protocols.

The facility failed to ensure timely evaluation and monitoring of a resident at risk for elopement, failed to implement adequate interventions to prevent elopement, and failed to ensure staff were adequately informed about the resident's elopement risk and related safety procedures. The resident eloped by taking a vehicle from the facility parking lot, resulting in injury and hospitalization.

The facility was found deficient in multiple areas including failure to maintain a clean and safe environment, failure to update care plans after resident falls, inadequate behavioral health and medical social services, failure to follow prescribed diet textures and controlled carbohydrate diet, failure to provide timely physical therapy, and failure to offer pneumococcal and COVID-19 vaccinations to a resident.

The complaint alleged that resident #2 was sent to the hospital and the facility refused to allow the resident to return, with hospital staff told the resident had been discharged and would only be accepted back if sedated sufficiently. The complaint was submitted to the State Survey Agency on 2/13/24.

The facility failed to document the basis for an immediate transfer and discharge of resident #2, did not provide required discharge notices or documentation, failed to notify the resident or representative properly, and did not allow the resident to return to the facility after hospitalization, resulting in improper discharge and transfer practices.

The complaint investigation found that $2,000 was missing from resident #4's money envelope. The facility replaced $2,500 but did not report the incident to the State Survey Agency within the required timeframe. A police investigation was initiated in December 2023 due to an outside complaint, not from the facility's reporting.

The facility failed to protect resident cash from theft or misuse and failed to timely report suspected misappropriation of resident money to the State Survey Agency. An investigation revealed $2,000 missing from a resident's funds, which was replaced by the facility, but the missing money was never properly reported.

The facility failed to revise the care plan to include the resident's deep brain stimulator and failed to address and obtain appropriate services for the resident with the implanted device. Staff were unaware of the device, and communication with the physician and director of nursing regarding the resident's care was inadequate.

The facility was found deficient in multiple areas including failure to post correct Ombudsman information, incomplete care plans for resident hygiene and wandering, inadequate assistance with showers, failure to address severe weight loss, lack of bedrail evaluations and consents, inadequate staffing leading to delayed call light responses, failure to maintain 24-hour licensed nursing coverage, insufficient QAPI documentation, and poor infection control practices including improper hand hygiene and lack of infection surveillance.

The visit was complaint-related based on grievances filed by residents about wandering behavior, lack of shower assistance, and long call light wait times. The complaint was substantiated with findings of deficient care planning, inadequate assistance, and staffing shortages.

The facility failed to update or revise the care plan for a resident who wandered, failed to assist a resident with showers as needed, and failed to provide adequate staffing to respond timely to call lights, resulting in resident discomfort and incontinence. Multiple grievances and facility-reported incidents supported these findings.