Pioneer House
PIONEER HOUSE in SACRAMENTO, CA — inspection on September 5, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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.
Facility ID:
Frequently Asked Questions
More Reports
Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.