Inspection Reports for
Pioneer Care and Rehabilitation

F 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia: the facility failed to ensure adequate supervision of a resident with dementia who wandered into other residents' rooms, causing a physical altercation and risk of harm.

F 0865 Have a plan that describes the process for conducting QAPI and QAA activities: the facility lacked an effective antibiotic stewardship program, did not receive drug regimen reviews from May 2024 through April 2025, and had an outdated QAPI plan not reviewed for over two years.

F 0578 Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive: the facility failed to ensure POLST forms were complete and valid for residents #9, #16, #20, and failed to ensure resident #22's code status was consistently correct.

F 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities: the facility failed to report two injuries of unknown origin and an allegation of resident-to-resident abuse for residents #10, #47, and #53.

F 0627 Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge: the facility failed to complete required education, notifications, and documentation for an AMA discharge for resident #55.

F 0628 Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies: the facility failed to provide transfer discharge notice and bedhold documentation for resident #3 during hospitalization.

F 0655 Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted: the facility failed to develop and implement a baseline care plan within 48 hours for resident #10.

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason: the facility failed to provide needed dining assistance and adaptive equipment for resident #3.

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: the facility failed to identify and implement interventions to prevent falls for resident #10, who sustained multiple falls and a fractured hip related to increased Ativan dosing.

F 0692 Provide enough food/fluids to maintain a resident's health: the facility failed to accurately monitor meal intake and address suspected weight scale errors for resident #22, who experienced severe weight loss.

F 0695 Provide safe and appropriate respiratory care for a resident when needed: the facility failed to obtain timely physician orders and follow-up for resident #44 experiencing chest pain and respiratory distress, resulting in hospital transfer.

F 0697 Provide safe, appropriate pain management for a resident who requires such services: the facility failed to provide effective pain management and monitoring for resident #35, resulting in overmedication and adverse effects.

F 0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures: the facility failed to ensure pharmacist reviews were completed and documented for residents #10, #3, #22, #24, and #35, including lack of gradual dose reductions for psychotropic medications.

F 0760 Ensure that residents are free from significant medication errors: the facility failed to prevent a medication error for resident #12 who received two fentanyl patches simultaneously.

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs: the facility failed to secure medication carts and controlled substance drawers during medication administration.

F 0841 Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility: the facility's medical director was not responsive to nursing staff, delaying care for resident #20 with bradycardia and other medical issues.

F 0865 Have a plan that describes the process for conducting QAPI and QAA activities: the facility failed to maintain an effective antibiotic stewardship program, lacked current QAPI plan updates, and had staffing and infection preventionist deficiencies.

F 0880 Provide and implement an infection prevention and control program: the facility failed to ensure staff performed hand hygiene during medication pass and failed to implement enhanced barrier precautions and signage for residents #21 and #44.

F 0881 Implement a program that monitors antibiotic use: the facility failed to use antibiotics appropriately for resident #35, including prolonged antibiotic use, concurrent antibiotics for the same infection, and failure to identify Clostridium difficile infection.

F 0882 Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home: the facility lacked a designated infection preventionist at the time of survey.

F 0943 Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation: the facility failed to provide adequate abuse education to administrative staff, resulting in failure to identify and report abuse allegations for residents #10 and #53.

F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist: the facility failed to consistently have physician ordered medications available, causing one resident to miss multiple doses of Methadone between December 2024 and February 2025.

F 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently: the facility failed to ensure services were delivered in a manner encouraging residents to report concerns without fear of retaliation, resulting in decreased resident morale, increased depression, and reduced participation in activities for multiple residents.

F 0760 Ensure that residents are free from significant medication errors: the facility failed to crush medications as ordered for a resident with difficulty swallowing, leading to aspiration pneumonia and hospitalization.

F 0880 Provide and implement an infection prevention and control program: a staff member assisted a resident with drink service in a manner that cross-contaminated coffee between residents.

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: the facility failed to timely evaluate and monitor a resident at risk for elopement, resulting in the resident eloping, sustaining injury, and being hospitalized. Staff were not consistently aware of the resident's elopement risk or use of Wanderguard alarms.

F 0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely: the facility failed to maintain cleanliness and safety, including visibly dirty linens, stained toilets, damaged doorknobs, and sharp metal on baseboard heaters posing safety hazards.

F 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals: the facility failed to update care plans for residents with repeated behaviors and falls, resulting in continued incidents without revised interventions.

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable: the facility failed to ensure a resident's dignity and clean appearance by not offering clothing protectors during meals despite observable food debris on clothing.

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: the facility failed to identify root causes of falls, update care plans with individualized interventions, and provide adequate supervision, resulting in multiple falls and injuries for residents.

F 0740 Ensure each resident must receive and the facility must provide necessary behavioral health care and services: the facility failed to provide behavioral health services or mental health evaluations for residents with documented behavioral concerns and depression.

F 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life: the facility failed to provide medical social services for a resident with behavioral concerns, relying only on medication changes without counseling or referrals.

F 0803 Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident: the facility failed to follow diet textures for residents, serving inappropriate food textures without speech therapy approval, and failed to provide a controlled carbohydrate diet with double protein, resulting in increased blood sugars and risk of delayed healing.

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards: the facility failed to label and date food stored in the freezer, including waffles, fish sticks, and meats, risking food safety.

F 0825 Provide or get specialized rehabilitative services as required for a resident: the facility delayed physical therapy services for 47 days after admission for a post-stroke resident, delaying progress toward standing and discharge.

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations: the facility failed to offer pneumococcal vaccinations to a resident and had not documented vaccination or declination status.

F 0887 Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status: the facility failed to offer COVID-19 vaccinations to a resident and had not documented vaccination or declination status.

F 0622 Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged: the facility failed to document the basis for a resident's immediate transfer and discharge, did not provide required documentation or discharge notices, and did not attempt to find alternate placement as the resident's behaviors became unmanageable.

F 0623 Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights: the facility failed to provide proper discharge notification and appeal rights to the resident and representative during an immediate facility-initiated discharge.

F 0626 Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy: the facility failed to allow the resident to return after hospitalization and refused the transfer back, lacking physician documentation and proper discharge procedures.

F 0602 Protect each resident from the wrongful use of the resident's belongings or money: the facility failed to ensure resident cash was protected from theft or misuse, with $2,000 missing from a resident's money envelope and no determination of where it went.

F 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities: the facility failed to report a suspected misappropriation of resident money to the State Survey Agency within the required time frame, and the incident was only investigated after an outside complaint.

F 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals: the facility failed to revise the care plan to include a deep brain stimulator for the treatment of Parkinson's symptoms for one resident.

F 0726 Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being: the facility failed to address and obtain services for a resident with an implanted deep brain stimulator, and staff were unaware of the device and did not respond to concerns about it.

F 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals: the facility failed to update or revise the care plan for resident #28 related to wandering incidents and did not include interventions such as stop signs to prevent wandering.

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable: the facility failed to assist resident #52 with showers, resulting in the resident not receiving showers for over nine days and feeling unclean.

F 0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift: the facility failed to provide adequate staffing to respond to call lights timely for residents #17, #52, and #55, causing incontinence and discomfort, and failed to provide showers for residents #50 and #52 as scheduled.

F 0575 Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency: the facility failed to post correct Ombudsman information, resulting in residents not knowing how to contact the Ombudsman.

F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured: the facility failed to implement care plans reflecting residents' individualized shower preferences, causing poor hygiene for two residents.

F 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals: the facility failed to update or revise the care plan for a resident who wandered, despite multiple grievances and incidents.

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable: the facility failed to assist a resident with showers as needed, resulting in poor hygiene and resident distress.

F 0692 Provide enough food/fluids to maintain a resident's health: the facility failed to identify and address severe weight loss in a resident, including failure to provide nutritional supplements and appropriate food preparation.

F 0700 Try different approaches before using a bed rail. If a bed rail is needed, the facility must assess safety risk, review risks and benefits, obtain informed consent, and correctly install and maintain the bed rail: the facility failed to evaluate and obtain consent for bedrail use for six residents.

F 0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift: the facility failed to provide adequate staffing to respond timely to call lights, resulting in resident incontinence and discomfort, and failed to provide showers for some residents.

F 0727 Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis: the facility failed to maintain 24-hour licensed nursing coverage on multiple dates.

F 0865 Have a plan that describes the process for conducting QAPI and QAA activities: the facility failed to maintain documentation showing a consistent, comprehensive, and effective quality assurance and performance improvement program.

F 0880 Provide and implement an infection prevention and control program: the facility failed to ensure proper hand hygiene during medication administration and wound care, and failed to implement a consistent infection surveillance program including tracking and trending infections.