Pioneer Care Center

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF761Aug 6, 2025

  Based on observation, interview and document review, the facility failed to ensure medications were labeled appropriately to include administration directions, insulin pens were dated and not expired and failed to dispose of expired eye drops per manufacturer recommendation's for 9 of 9 residents (R47, R69, R92, R36, R40, R73, R19, R10, R13) reviewed during medication storage and administration. Finding include: R47's medication review report signed [DATE], included orders for Thera Tears (for dry eyes) solution 0.25%, install one drop in both eyes four times a day for dry eyes. During an observation and interview on [DATE] at 3:31 p.m., a bottle of Thera Tears 0.25% eye drops was in R47's medication drawer. The bottle had no name, label, or date opened. […]

• No harm, potential for more than minimal, patternF812Aug 6, 2025

  Based on observation, interview, and document review, the facility failed to ensure food stored in the refrigerators and freezers were labeled, dated and discarded properly. This deficient practice had the potential to affect all 89 residents who received food from the refrigerators, freezers and the kitchen.Findings include:On 8/4/25 at 9:44 a.m., during the kitchen tour with the cook the following concerns were identified.Walk in cooler-half container of sour cream without notation of an opened date and an expiration date of 6/20/25.Fridge in kitchen-1/4 container of mustard with an expiration date of 7/28/25.-1/2 bottle of barbeque sauce without notation of an opened date and no expiration date.During an interview on 8/4/25 at 10:20 a.m., cook verified the above findings during the… […]

• No harm, potential for more than minimal, patternF567Mar 24, 2022

  Based on interview and document review, the facility failed to ensure residents had access to petty cash on weekends and holidays for 1 of 1 resident (R65) who had a personal funds deposited with the facility. This had the potential to effect all 27 residents who utilized a personal funds account. Findings include: On 3/21/22, at 1:40 p.m. R65 verified she had a personal funds account with the facility. R65 stated she has not had any problems getting money out her account, except for on weekends and holidays. R65 indicated the facility had a debit card that all residents could use however facility staff had to be with you to have access to the pin number to even use the debit card. On 3/24/22, at 12:49 p.m. […]

• No harm, potential for more than minimal, isolatedF554Aug 6, 2025

  Based on observation, interview, and document review, the facility failed to ensure proper implementation of the self-administration of medication (SAM) assessments for 2 of 2 residents (R36, R1), reviewed for medication administration. Findings include: R36's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R36 was cognitively intact and diagnoses of diabetes, heart failure, and arthritis and required the assistance of one staff with activities of daily living (ADL's) for transfers and toileting. R36's physician orders dated 8/4/25, revealed the following: - Lidocaine External Patch 4%, apply to back topically two times a day for pain. […]

• No harm, potential for more than minimal, isolatedF604Aug 6, 2025

  Based on observation, interview and document review, the facility failed to comprehensively assess the use of a low bed as a potential restraint for 1 of 1 resident (R32) reviewed for restraints.Findings include: R32's significant change Minimum Data Set (MDS) assessment dated [DATE], identified R32 had severe cognitive impairment and diagnosis of Parkinson's, hypertension (elevated blood pressure) and arthritis. R32 required extensive assistance for activities of daily living (ADL's) which included bed mobility, transfers, and toileting. R32 had no impairment of upper or lower extremities, had a history of falls, and required a wheelchair for mobility. MDS indicated R32 did not use any restraints. […]