Pioneer House
Inspection Findings
F-Tag F0600
F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
stated that Resident 1 often wandered around unsupervised, entering other residents' rooms, and that he [Resident 4] often had to stay in his room's entrance monitoring to make sure that Resident 1 did not enter.
Resident 4 further stated that the facility did not provide enough staff to sufficiently supervise Resident 1.
During an interview on 9/5/25 at 11:18 a.m. with Certified Nursing Assistant (CNA 1), CNA 1 indicated Resident 1 was known to have wandered and had aggressive behavior, and she was on special monitoring by staff, but she was not monitored at all times. CNA 1 further stated she had to get Resident 1 out of other residents' rooms on a daily basis. During an interview on 9/5/25 at 11:56 a.m. with LN 3, LN 3 confirmed that Resident 1 was known to wander around and had instances of aggression towards other residents. LN 3 stated that direct care staff were busy providing care to other residents, and the facility did not provide sufficient staff to monitor Resident 1 at all times. During an interview on 9/5/25 at 1:59 p.m. with the Director of Nursing (DON), DON confirmed that Resident 1 was known to be moving around and entering different residents' rooms, and she had prior incidents of aggressive behavior. The DON confirmed that Resident 1 was seen physically touching Resident 3 in the dining room yesterday. The DON further stated that she expected residents to be free from physical and verbal abuse. During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, the P&P indicated, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to:. b. other residents.
Event ID:
Facility ID:
If continuation sheet
PIONEER HOUSE in SACRAMENTO, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in SACRAMENTO, CA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from PIONEER HOUSE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.