Pioneer Ridge Retirement Community

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Jun 1, 2026

  Based on observation, record review, and interview, the facility failed to provide adequate supervision and failed to respond appropriately to alarms to prevent the elopement of Resident (R) 1, who was cognitively impaired, had a history of wandering and exit seeking, and was at risk for falls. On 04/26/26 at 01:44 AM, R1 pushed on the Blue-Hall emergency exit door, which sounded the alarm immediately when pushed, then opened after 15 seconds, and R1 exited the facility. Licensed Nurse (LN) G sat at the nurse's station with a clear view of the emergency exit door but did not look up or respond to the door alarm. At 02:05 AM, Certified Nurse Aide (CNA) M approached the nurse's station and asked LN G where the alarm was coming from, and LN G stated it was likely an exit door. […]

• Immediate jeopardy, isolatedF806Mar 19, 2025

  The facility reported a census of 61 residents, with 9 sampled. Based on observation, interview, and record review the facility failed to ensure the staff provided Resident (R) 1 a peanut-free meal, per his reported allergies upon admission. On 03/07/25 at 06:30 PM, the staff provided R1 a peanut butter cookie with his dinner and the staff failed to verify his documented allergies on his meal ticket. R1 had an anaphylaxis allergic reaction to the peanut butter that resulted in vomiting. The facility could not provide epinephrine to R1 to prevent further potential anaphylaxis-related symptoms and the facility transferred R1 to the hospital. R1 received the epinephrine at the hospital and was admitted to the hospital on 03/07/25 for anaphylaxis. […]

• Actual harm, isolatedF689Feb 7, 2023

  The facility reported a census of 49 residents. The sample included three residents at risk for falls. Based on record review, observations, and interviews, the facility failed to ensure staff provided care planned fall interventions for Resident (R) 1 to prevent a fall. On 01/26/22 at 01:34 PM, R1 fell from a Sit-To-Stand lift (mechanical device used to help mobility impaired residents transition from a seated to a standing position) when one staff member assisted in the transfer, instead of the care planned two staff assistance. Consequently, the inappropriately applied lift sling, separated on one side of the lift, and caused R1 to fall backwards, striking R1's head on the tile floor. […]

• No harm, potential for more than minimal, widespreadF730Dec 3, 2025

  The facility had a census of 62 residents. The sample included 17 residents. Five Certified Nurse Aides (CNA) were reviewed for yearly performance evaluations and in-service training. Based on record review and interview, the facility failed to ensure one of the five reviewed CNA staff had the required yearly performance evaluations completed. This placed the residents at risk for inadequate care.Findings included: - Review of the facility's performance evaluation and in-service records revealed the following:CNA N, hired 09/30/23, had no yearly performance evaluations provided upon request.On 12/03/25 at 09:30 AM, Administrator A stated the facility did not have a performance evaluation for CNA N.On 12/03/25 at 02:43 PM, Administrative Nurse D stated that yearly evaluations were completed… […]

• No harm, potential for more than minimal, widespreadF812Dec 3, 2025

  The facility identified a census of 62 residents. The facility had one main kitchen and two dining areas. Based on observation, interview, and record review, the facility failed to ensure that staff members properly tested the dishwashing sanitization chemicals documented freezer and refrigerate temperatures. The facility also failed to staff donned hairnets and beard guards and maintain dairy food at the appropriate temperature. Findings included:- During the initial tour of the kitchen and dining room area on 12/01/25 at 07:10 AM, an open undated gallon of milk sat in a brown tub without ice. Dietary Staff EE tempted the open milk, which was 46 degrees. The Milk was discarded. Dietary Staff EE lacked a hairnet when setting up the breakfast serving line. […]