Pioneer Care and Rehab: Dementia Wandering Violations - MT
The facility knew about the wandering from the moment he arrived. Staff member C told inspectors the resident, identified only as resident #3, had been entering other residents' rooms since he came to the facility. He would not remember where his own room was. He would think he was already in it.
On November 14, 2025, the facility reported to the state that resident #3 had walked into resident #4's room and a physical altercation broke out when resident #4 tried to redirect him. Resident #4 was injured.
The facility's response was to place resident #3 on one-to-one observation. That lasted until December 1. Then they stepped it down to checks every fifteen minutes.
The nursing notes from the weeks that followed show how that worked out.
On December 3, staff recorded that resident #3 was attempting to enter other residents' rooms and had to be redirected. He was aggressive.
On December 12, he was up at 6 a.m., wandering the halls. He walked into another resident's room and sat down in that resident's wheelchair. When the resident returned and shut his door to keep him out, resident #3 banged on it. Walking away, he said he should kick the man's ass.
By December 21, an SBAR note recorded him wandering in and out of other residents' rooms. No intervention beyond the note appears in the record.
On December 22, the facility opened a new secured memory care wing and moved resident #3 into it. Staff member B told inspectors the fifteen-minute checks ran from December 1 until that date.
Six days later, on December 28, a nursing note described what happened when supervision fell short again. Resident #3 was wandering in and out of other residents' rooms and taking their personal items. He picked up a glass vase. Staff had to physically intervene to get it away from him. They redirected him to his room for dinner. He picked up his plate, walked to another resident's room, and dumped his food in the toilet. Then he started dumping other items down the toilet, including deodorant and toothbrushes, before staff could stop him.
Staff member D told inspectors on December 31 that resident #3 still wandered into other rooms on the secured unit, but had not had any further conflicts that she knew of, and that staff could usually redirect him.
Usually.
That word is doing a lot of work. Between the November altercation that injured resident #4 and the December 28 episode in which a man with dementia was holding a glass vase and had to be physically relieved of it, the facility had more than six weeks to develop a supervision plan that matched the actual risk. What the record shows instead is a step-down from one-to-one observation to fifteen-minute checks, followed by a move to a secured unit that did not prevent further intrusions.
Inspectors found the facility failed to consistently ensure resident #3 had adequate supervision to prevent him from entering other residents' rooms, placing him and the people living around him at elevated risk of verbal or physical confrontations. The deficiency was cited at a level of minimal harm or potential for actual harm.
The other residents whose rooms he entered, whose wheelchairs he sat in, whose doors he pounded on, whose belongings he took, are not named in the report. Neither is the resident who came home to find him in his chair and locked his door, only to hear the banging start.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pioneer Care and Rehabilitation from 2025-12-31 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
PIONEER CARE AND REHABILITATION in DILLON, MT was cited for violations during a health inspection on December 31, 2025.
The facility knew about the wandering from the moment he arrived.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.