Pioneer Trace Group LLC

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 day and documented according to state-specific requirements. Further review revealed federal standards required that refrigerated food be stored below 41 degrees Fahrenheit (F).Review of the Job Description for the Cook, signed 11/01/2016, revealed duties included inspection of all equipment for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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. Further review revealed federal standards required that refrigerated food be stored below 41 degrees Fahrenheit (F).Review of the Job Description for the Cook, signed 11/01/2016, revealed duties included inspection of all equipment for proper functioning and safety before and during use; to follow established safety and infection control procedures; to plan, direct, and supervise the food service program including food storage, inspection of all equipment and systems regularly for proper functioning and safety; and to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of the facility's policies, the facility failed to ensure a resident was free from abuse due to misappropriation or exploitation for 1 of 38 sampled residents, Resident (R) 2. The findings include:Review of the facility's policy titled, Controlled Substances, revised date 12/2011, revealed nursing staff must count controlled drugs at the end of each shift. The policy stated the nurse coming on duty and the nurse going off duty must make the count together and must document and report any discrepancies to the Director of Nursing Services.Review of the facility's policy titled, Controlled Medication Storage, dated [DATE], revealed at each shift change, a physical inventory of all controlled medication(s), including the emergency supply, was conducted by two licensed nurses and was documented on the controlled medication accountability record per facility procedure.Review of the facility's policy titled Abuse Prevention, revised [DATE], revealed that misappropriation of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, record review, and review of the facility's document and policy, the facility failed to ensure appropriate coordination, oversight, communication, and continuity of care related to dialysis services for 1 of 38 sampled residents, Resident (R29). The facility failed to maintain an active contract with the dialysis provider and failed to ensure required dialysis communication was completed, sent, reviewed, and returned to the medical record to support continuity of care and monitor the resident's condition before and after dialysis treatments. This failure placed the resident at risk for unmet medical needs and complications related to dialysis services.The findings Include:Review of the facility's policy titled, Hemodialysis Access Care, revised September 2010, revealed the general medical nurse was expected to document in the resident's medical record every shift and obtain and maintain reports from the dialysis nurse post-dialysis. The facility was unable to provide evidence of an active contract or written agreement with the dialysis provider for R29, who was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and review of the facility's policy, the facility failed to ensure all residents had the right to send and receive mail on Saturdays. The findings include: Review of the facility's policy titled, Residents Rights, revised 07/01/2014 revealed the resident had the right to privacy in written communications, including the right to send and promptly receive mail. During the Resident Council meeting on 10/01/2024 at 10:00 AM, Resident (R) 46 stated residents did not receive or send mail on Saturdays at the facility. R46 stated he did receive packages unopened the day they were delivered to the facility. The rest of the resident attendees confirmed there was no Saturday mail delivery. In an interview with the Business Office Manager (BOM) on 10/03/2024 at 12:21 PM, she stated she was unaware it was against residents' rights not to have their mail being delivered on Saturdays. The BOM stated her work schedule was Monday through Friday 7:30 AM to 4:00 PM, and she was not on the campus during the weekends to sort the mail and give it to the Activities Department. In an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and review of the facility's policies, the facility failed to establish written standards, policies, and procedures for a documented water management program based on nationally accepted standards for all residents (census 76). The facility did not have a water management program that included a description of the building's water systems where Legionella and other opportunistic waterborne pathogens could grow and spread, flow diagrams, measures to prevent growth, testing protocols, acceptable ranges, and established ways to intervene when control limits were not met. The findings include: Review of the facility's policy titled, Infection Control Policy, dated 02/02/2021, revealed the policy's purpose is to prevent, detect, investigate, and control infections in the facility and maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and general public. Review of the facility's policy titled, Prevention of Legionella Growth and Exposure, dated 06/2017, revealed the facility had an established water management program in an effort…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of the facility's policies, the facility failed to prepare food safely to prevent cross-contamination. Dietary Aide (DA) 2 was observed on 10/01/2024 preparing a puree brownie with gnats flying around the uncovered blender and gnats were observed flying in and around the trash can in the dining area. The deficiency had the potential to affect all residents that received meals from the kitchen. The findings include: Review of the facility's policy titled, Resident Rights, revised on 08/01/2013, revealed the facility must care for its residents in a manner and in an environment that promoted maintenance or enhancement of each of the resident's quality of life. Review of the facility's policy titled, Food and Preparation and Service, revised 07/01/2014, revealed the food services employees shall prepare and serve food in a manner that complied with safe preparation and handling. Review of the facility's policy titled, Pest Control, revised 05/01/2008…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, review of facility policy, and review of the Centers for Medicare and Medicaid Services (CMS), Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to implement a person centered Comprehensive Care Plan (CCP) for each resident to meet a resident's medical, and nursing needs identified in the comprehensive assessment for one (01) of nineteen (19) sampled residents (Resident #69). Resident #69 had pressure ulcers/injuries to his/her right ankle and left heel, and the CCP, dated 10/23/19, revealed an intervention to provide heel protection. However, observation on 11/12/19, 11/13/19 and 11/14/19, revealed Resident #69 was in bed without heel protection. The findings include: Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated October 2016, revealed the Comprehensive Care Plan is an interdisciplinary communication tool and must include measurable objectives and time frames and must describe the services to be furnished to attain or maintain the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, review of the facility policy, and review of the Centers for Medicare and Medicaid Services (CMS), Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to ensure the Comprehensive Care Plan (CCP) was reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs for one (1) of nineteen (19) sampled residents (Resident #35). Resident #35 had a Physicians Order; dated 07/19/19 for heel boots when in bed; however, there was no documented evidence the CCP was revised to include the heel boots. Further, observations on 11/13/19 revealed the resident was in bed for approximately one (01) hour without heel boots on his/her feet. The findings include: Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated October 2016, revealed the care plan must be reviewed and revised periodically, and the services provided or arranged should be consistent with each resident's written plan of care.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.