Pioneer Care and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Pioneer Care and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Dec 20, 2022

  Based on interview and record review, the facility failed to identify risks and hazards related to a resident's previous falls and medical history, and implement interventions, for the prevention of falls or risks/hazards, for 1 (#8) of 4 sampled residents; and, the resident had a fall and sustained significant injuries from the fall, to include a punctured lung. After being admitted to the hospital, it was determined by the physician and responsible party, that end of life care was in the best interest of the resident, due to the extent of the injuries and status. Findings include: An Immediate Jeopardy was announced on [DATE] at 2:30 p.m., for F689 Accidents and Hazards, with the severity and scope of J, which would be lowered to a G upon removal of the immediacy of harm. […]

• Actual harm, isolatedF689May 8, 2025

  Based on interview and record review, the facility failed to identify and implement beneficial interventions to prevent further falls for a resident with dementia, limited safety awareness, and who was at risk for falls. The resident used psychotropic medications and the care plan contained only minimal fall interventions and the resident had an unwitnessed fall and had head lacerations. The resident had subsequent falls and sustained a fractured hip for 1 (#10) of 17 sampled residents. Findings include. Review of resident #10's nursing note, dated 4/28/25 at 7:06 p.m., showed: - found resident sitting on his floor at 1700 (5:00 p.m.). Assessed for injury. ROM provided. […]

• Actual harm, isolatedF760Dec 5, 2024

  Based on interview and record review, the facility failed to crush medications as ordered by the physician, for 1 (#1) of 5 sampled residents with a diagnosis of difficulty swallowing. This resulted in the resident being transferred to the emergency department and hospitalized for aspiration pneumonia. Findings include: During an interview on 12/4/24 at 2:37 p.m., staff member G said resident #1 was at risk for choking and the resident eats in the dining room. She had never witnessed resident #1 to have problems with swallowing but the resident has her food cut up into small bites. […]

• Actual harm, isolatedF689Aug 27, 2024

  Based on observation, interviews, and record reviews, the facility failed to ensure an ongoing systemic approach was utilized for managing a resident with a known history of elopement attempts, by failing to ensure the resident was evaluated timely and as needed throughout his stay, for future elopement prevention as the resident continued to attempt to elope; and the facility failed to ensure staff were made aware of the resident's risk for elopement and process utilized for residents who were an elopement risk, and resident #1 eloped, sustained an injury, and was hospitalized for monitoring, for 1 (#1) of 12 sampled residents. […]

• Actual harm, isolatedF689May 21, 2024

  Based on observation, interview, and record review, the facility failed to identify the root cause of falls for the implementation of individualized interventions; and failed to ensure resident care plans were updated with interventions addressing the residents' current medical, physical, and cognitive limitations for 2 (#s 42 and 49) of 2 residents sampled for falls. Findings include: 1. During an observation and interview on 5/21/24 at 9:42 a.m., resident #42 was attempting to stand up out of his wheelchair. He was part way in the door of his room. He stepped forward and tripped on the foot pedals of his wheelchair. A member of the survey team reached out to catch resident #42 to keep him from falling to the ground. Resident #42 stated he needed to get his dresser packed. […]