Pioneer House

In the surveyor’s words

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

• Actual harm, isolatedF689Nov 24, 2025

  Based on observation, interview, and record review, the facility failed to provide appropriate supervision when they did not ensure one of three sampled residents (Resident 1) was wearing a wandering device (a wearable device, commonly referred to as a wander guard, with sensors that trigger alarms, used to prevent residents at risk of wandering from leaving a safe area unsupervised) according to Resident 1's physician orders (PO) and care plan (CP).This failure resulted in Resident 1 walking out of the facility unsupervised and without the facility's knowledge, which exposed the resident to cold temperatures, nightfall, and traffic, which could have resulted in serious injury, medical complications, and/or death. […]

• No harm, potential for more than minimal, widespreadF802Oct 12, 2023

  Based on observation, interview, and record review, the facility failed to ensure one dietary personnel was competent to carry out the functions of the food and nutrition service when the Dietary Aide (DA) 1 was unable to practice correct hand hygiene practices during dishwashing with the dish machine performed by one person and unable to verbalize the process of manual (3-compartment sink) dishwashing (cross refer to F812, finding number 5). These failures had the potential to cause food borne illness in a potentially compromised population of 42 out of 44 residents who received food from the facility kitchen. […]

• No harm, potential for more than minimal, widespreadF812Oct 12, 2023

  Based on observation, interview, and record review, the facility failed to ensure food was prepared, stored, served, or distributed in accordance with professional standards of food serve safety when: 1. food items with missing or incorrect labeling and dating were found, 2. food items with opened packages were found not covered to prevent cross contamination (the unintentional transfer of bacteria and/or substances from one food to another), 3. food items that were expired were found and available for use, 4. ice machine was not clean located in the dining room, 5. Dietary Aide (DA) 1 was not able to verbalize the process of manual (3-compartment sink) dishwashing, and not practicing handwashing during dishwashing when perform by one person, 6. […]

• No harm, potential for more than minimal, widespreadF814Oct 12, 2023

  Based on observation, interview, and record review, the facility failed to provide a clean environment for the residents and visitors when one garbage dumpster and one food waste bin, located outside the facility, were not secure with the dumpster lids closed. This failure had the potential for an unsafe environment for the residents and visitors due to possible pest infestation and spread of diseases in the facility. Findings: During the kitchen initial tour observation on 10/9/23, at 11:14 a.m., one dumpster garbage bin and one food waste bin located outside nearby facility kitchen were not securely closed by the lids, and there were bags of trash inside both of bins. […]

• No harm, potential for more than minimal, widespreadF761Nov 11, 2022

  Based on observation, interview and record review, the facility failed to ensure safe and secure labeling and storage of medications and biologicals (vaccines and drugs) for a census of 27, when: 1. Expired medication was found in medication cart 1, expired medications and biologicals were found in the medication room, and an expired box of topical ointments was found in the house supply storage room; 2. An opened medication found in medication cart 1, and an opened medication and an opened vial of tuberculin skin test [TST] in the medication room refrigerator, had no open dates; 3. A medication supplement was inappropriately stored in the refrigerator; 4. The medication room ceiling above the stored medications and biologicals was leaking; and 5. […]