Pioneer Trace Group LLC

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600May 27, 2026

  Based on interview, record review, and review of the facility's document and polices, the facility failed to protect the residents' right to be free from mental and verbal abuse for 3 of 7 sampled residents, Resident (R) 1, R7, and R11. Resident (R) 2 had a history of verbal and physical outburst behaviors. Residents observed R2 throwing objects, physically hitting staff, and attempts were made to hit other residents and staff. This caused the residents psychosocial harm in which they made statements of being afraid, scared, walking on eggshells, and fear for their safety when R2 was around.Immediate Jeopardy (IJ) was identified on 05/21/2026 in the area of 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation and was determined to exist on 05/13/2026. […]

• Immediate jeopardy, isolatedF657May 27, 2026

  Based on interview, record review, review of the facility's investigation, and review of the facility's policy, the facility failed to ensure residents' care plans were revised to include interventions needed to provide person-centered care related to supervision and monitoring to ensure safety for 1 of 28 sampled residents, Resident (R) 5.Interviews with staff revealed that on 05/02/2026 at approximately 5:55 PM, staff observed the resident exiting the facility and they were able to intervene and return the resident back to the facility. However, the facility failed to revise the resident's care plan to include interventions that would increase the resident's supervision and/or monitoring. […]

• Immediate jeopardy, isolatedF689May 27, 2026

  Based on observation, interview, record review, review of the website https://www.localconditions.com, review of the facility's investigation, and review of the facility's policies, the facility failed to have an effective system in place to ensure each resident received adequate supervision and monitoring. The facility failed to implement interventions and adequate supervision for 1 of 20 sampled residents to prevent unsafe wandering and elopement, Resident (R) 5.Review of the facility's investigation revealed R5 eloped from the facility on 05/02/2026 at approximately 8:11 PM and was found outside near the back facility entrance roadway by Dietary Aide 1, who was taking out trash. […]

• No harm, potential for more than minimal, widespreadF812Jan 8, 2026

  Based on observation, interview, review of the facility's job descriptions, and review of the facility's documents and policy, the facility failed to ensure that food was stored in a manner that minimized the risk of foodborne illness for all 78 current facility residents. Observation on 01/07/2026 and review of the facility's Food Temperature logs for 01/01/2026, 01/04/2026, 01/05/2026, and 01/06/2026 revealed the temperature in the facility's walk-in refrigerator/cooler was greater than 41 degrees Fahrenheit (F), the upper limit for the acceptable temperature.The findings include:Review of the undated policy titled, Preventing Foodborne Illness - Food Handling, revealed the functioning of the refrigerator and food temperatures were to be monitored at designated intervals throughout the… […]

• No harm, potential for more than minimal, widespreadF908Jan 8, 2026

  Based on observation, interview, review of the facility's job descriptions, and review of the facility's documents and policy, the facility failed to ensure essential kitchen equipment was maintained and in safe operating condition for all 78 of the facility's current residents.The findings include:Review of the undated policy titled, Preventing Foodborne Illness - Food Handling, revealed the functioning of the refrigerator and food temperatures were to be monitored at designated intervals throughout the day and documented according to state-specific requirements. […]