Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pioneer Lodge during CMS and state inspections, most recent first.
Lack of Required RN Coverage: The facility failed to provide RN coverage for at least 8 continuous hours daily for a census of 23 residents. Review of nursing schedules and RN payroll records showed multiple days with no RN coverage for the required time, and Administrative Staff A confirmed the missing coverage. The facility did not provide an RN coverage policy.
Food items in the kitchen were found improperly stored, with many items missing dates or labels, several containers opened or unsealed, and some produce in poor condition. Surveyors also observed meat thawing above the stove while potatoes were cooking, and the lunch meat was soft and warm when touched. The CDM and admin staff stated they expected food to be sealed, labeled, dated, kept clean, and thawed appropriately.
CNA in-service training was not developed, implemented, or permanently maintained to ensure required topics and at least 12 hours per year for CNA staff. Review of personnel files showed multiple CNAs lacked calculated annual hours, and one CNA was missing ANE and social media training. An admin staff member stated staff were expected to have the required education and annual hours, and no policy for CNA in-service and annual training hours was provided.
Lack of Informed Consent for Psychotropic Medications: The facility failed to document informed consent for multiple residents receiving psychotropic medications, including antidepressants, antipsychotics, anxiolytics, and anticonvulsants used for psychotropic purposes. Record review showed no evidence that the resident and/or representative was informed of the potential adverse effects for several ongoing medication orders, and an RN stated consents were only completed when a new med was started.
Food Served Below Required Holding Temperature: Dietary staff prepared pureed sausage and potatoes, but after pureeing and holding, the temperatures dropped below the expected hot-holding level. An observation showed the food remained on the counter before being placed in the steam table, and later re-temping found the potatoes at 115 degrees F and the sausage at 120 degrees F when served to residents. Staff stated hot foods were expected to be held at 135 degrees F, and the facility policy did not include specific cooked or holding temperature requirements.
Wheelchair Foot Support Not Provided for Two Residents: Two residents with dementia and total or near-total dependence for mobility were observed in wheelchairs without footrests or a footboard, with their feet dangling or only touching the floor. Care plans directed staff to provide wheelchair assistance, and staff interviews confirmed the residents could not self-propel or adjust positioning. The facility’s restorative wheelchair mobility policy required proper positioning and foot support, but the residents were repeatedly observed without it.
Advance directive records were not accurately reflected for multiple residents. One resident had a Full Code order and CPR care plan instructions in the EMR despite a signed DNR form, another resident's DNR lacked required signatures, and a third resident had a DNR order even though the resident had signed a document declining DNR. An Administrative Nurse stated the SSD completed advance directive paperwork and the floor nurse documented the order in the EMR.
Failure to notify the resident’s representative of a significant weight loss occurred for a resident with schizophrenia, dementia, and heart disease. The resident had severe cognitive impairment, was on a pureed diet with thickened liquids and Mighty Shake supplements, and was documented as malnourished with a decline from 160 lbs to 140.6 lbs. The record lacked documentation that the family/rep was informed, and staff acknowledged the resident had been declining and losing weight.
Failure to provide written transfer notification: A resident with COPD, HF, schizophrenia, and dementia became barely responsive with rapid breathing and was sent to the hospital for evaluation. The EMR showed bed-hold information was sent to the guardian, but there was no documentation that the resident or representative received a written notice explaining the reason for the transfer; staff confirmed the required written notification was not done.
Failure to Implement Effective Fall Interventions: Two residents with cognitive impairment and fall risk had falls, but the facility did not consistently update or implement effective fall interventions afterward. One resident with severe cognitive impairment and a history of falls was given an intervention to remind her to use the call light, which the ADNS said was not appropriate because she could not retain the information. Another resident with bipolar disorder, COPD, osteoporosis, and moderate cognitive impairment fell while not wearing oxygen, yet the care plan was not updated after the fall; later she was observed short of breath in the bathroom without oxygen and with her walker outside the door.
Hand hygiene and shared equipment cleaning lapses were observed during resident care. A CMA and CNA cared for a resident who had been incontinent of a large soft stool, and the CNA removed and reapplied gloves multiple times without hand hygiene before continuing peri care, applying barrier cream, and dressing the resident. After the transfer, the mechanical lift was moved to another resident’s room without being sanitized, and the CNA stated the facility did not have sanitation wipes for the lift between residents.
Failure to monitor antibiotic use for a resident with recurrent UTIs. A resident with dementia, depression, intact cognition, and occasional urinary incontinence was treated twice with Keflex for UTI symptoms, but both C&S reports showed Keflex was not among the susceptible antibiotics. Staff expected the provider to review the C&S and order a susceptible antibiotic, yet the Keflex orders were not changed and there was no documentation explaining why.
Daily nursing staff postings did not include the actual hours worked by CNA, LPN, and RN staff, and the shift titles were difficult to read. Review of the postings showed the same missing documentation across multiple days, and an Administrative Nurse stated she had never documented the actual hours worked for the posted staff sheet.
Inaccurate PBJ staffing reporting showed excessively low staffing and missing 24-hour LN coverage on multiple days across several quarters, even though review of the Daily Nurse Staffing Form and payroll data showed the days were actually covered with appropriate staff. Administrative staff stated the PBJ report was submitted by an outside firm and expected it to be accurate.
Lack of Required RN Coverage
Penalty
Summary
The facility failed to provide RN coverage for at least eight continuous hours daily for a census of 23 residents. Review of the facility’s Daily Census Report showed 23 residents in the facility, and review of nursing schedules and RN payroll documents for 04/01/24 through 12/31/24 showed no RN coverage for eight continuous hours on multiple days, including 04/28/24, 05/11/24, 05/25/24, 06/01/24, 06/22/24, 06/23/24, 07/06/24, 07/07/24, 07/20/24, 07/21/24, 08/03/24, 08/04/24, 08/17/24, 08/18/24, 08/31/24, 09/01/24, 09/14/24, 09/15/24, 10/26/24, 10/27/24, 11/23/24, 11/24/24, and 12/21/24. During interview, Administrative Staff A stated the facility did not have RN coverage on the listed days and that the facility had identified the issue and had since improved. The facility did not provide a policy for RN coverage.
Food Storage and Thawing Deficiencies
Penalty
Summary
Food was not prepared and served under sanitary conditions in the facility’s main kitchen and food storage areas. During observation of the dry storage area, freezer, free-standing refrigerator, and three-bay refrigerator, multiple food items were found without dates or labels, including pasta in storage bins, frozen French toast sticks, English muffins, garlic bread, chicken patties, chicken legs, ground beef, pork sausage, pepperoni, unidentified meat, opened gallons of milk, tartar sauce, Parmesan cheese, lunch meat, shredded cheese, tomato sauce, red Jello, tomatoes, green peppers, and wilted lettuce. The three-bay refrigerator also had old dried blood on the bottom. Several food items were observed unsealed or in poor condition, including wrinkled tomatoes, wrinkled green peppers, and brown lettuce. Surveyors also observed three packaged bags of ground beef, one packaged bag of ground pork sausage, and two packaged bags of ham lunch meat thawing above the stove in a metal container while two pans of cut-up potatoes were cooking. The lunch meat was soft and warm when touched. During interview, Dietary Staff CC stated that food items in the freezer, dry storage, and refrigerator were required to be sealed, labeled, and dated, and that this was how he thawed meats on the menu. The Certified Dietary Manager and Administrative Staff A both stated they expected food to be stored, sealed, labeled, and dated properly, kitchen areas kept clean, and meats thawed appropriately. The facility policy stated that food items would be checked, dated, and stored properly, kitchen equipment would be kept clean, and defrosting would be completed in the refrigerator or in a cold-water bath.
CNA In-Service Training Deficiencies
Penalty
Summary
The facility failed to develop, implement, and permanently maintain an in-service training program for CNA staff that included the required topics and at least 12 hours per year. The facility reported a census of 23 residents, and five CNAs who had worked in the facility for more than 12 months were reviewed for required in-service training. Review of personnel files showed that CNA M, hired on 02/26/1997, lacked the total hours calculated for the 12 hours required; CNA N, hired on 10/24/23, also lacked the total hours calculated for the 12 hours required; and CNA O, hired on 08/29/17, lacked Abuse, Neglect, and Exploitation training and social media training, and CNA O's total hours were not calculated for the 12 hours required. During an interview on 09/23/25 at 09:00 AM, Administrative Staff A stated he expected staff to have the required education and the required 12 hours annually. The facility did not provide a policy for CNA staff required for in-service and annual training hours.
Lack of Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to inform residents and/or their representatives about the risks related to psychotropic medications for R18, R6, R9, R5, and R15. Review of the EMR and paper records showed that R18 had an order for escitalopram oxalate 5 mg daily, R6 had orders for divalproex sodium 125 mg at bedtime and Seroquel 300 mg at bedtime, R9 had orders for alprazolam 0.25 mg each evening and Zoloft 25 mg, R5 had an order for risperidone 0.5 mg twice daily, and R15 had orders for Seroquel 100 mg at bedtime, divalproex sodium 125 mg at bedtime, olanzapine 20 mg at bedtime, escitalopram 20 mg, and clonazepam 0.5 mg twice a day. For each of these residents, the clinical record lacked evidence of informed consent related to the medications. During an interview on 09/22/25 at 03:01 PM, the Administrative Nurse stated that the facility did not complete consents for psychotropic medications unless the resident started a new medication. The facility policy titled Psychotropic Medication Use, dated 01/09/25, stated that every psychoactive medication would initiate a signed informed consent to ensure the physician had reviewed with the resident and/or resident representative the potential adverse effects of the order of any psychoactive medication.
Food Served Below Required Holding Temperature
Penalty
Summary
The facility failed to ensure that meals were served at safe and appetizing temperatures. During an observation on 09/22/25 at 10:42 AM, Dietary Staff DD prepared three servings of pureed sausage, onions, and peppers that had a cooked temperature of 165 degrees Fahrenheit, then pureed the food and found the temperature had dropped to 127 degrees Fahrenheit. Dietary Staff DD also prepared pureed potatoes that had a cooked temperature of 186 degrees Fahrenheit, and after pureeing, the temperature was 135 degrees Fahrenheit. The pureed sausage was placed in three separate divided dishes, covered with foil, and left on the counter until 11:00 AM, when the dishes were placed in the steam table. During a later observation on 09/22/25 at 11:30 AM, Dietary Staff DD re-temped the pureed food on the steam table and found the pureed potatoes were 115 degrees Fahrenheit and the pureed sausage was 120 degrees Fahrenheit. Dietary Staff DD served the pureed foods to residents at those recorded temperatures. During interviews, Dietary Staff BB stated she expected staff to serve all food items at the required holding temperature of 135 degrees Fahrenheit for hot food, and Administrative Staff A stated she expected dietary staff to serve food at the appropriate temperatures. The facility's Food Preparation and Handling policy stated that food items and products served to elders would be prepared using methods and techniques designed to preserve maximum nutritive value and be free of injurious organisms and substances, but the policy lacked temperature requirements for cooked and holding food.
Wheelchair Foot Support Not Provided for Two Residents
Penalty
Summary
The facility failed to provide footrests or a footboard for two residents who used wheelchairs and were unable to self-propel or adjust their positioning. R3 had diagnoses of dementia, depression, and pain, with an MDS showing a BIMS of zero, severe cognitive impairment, impairment to one lower extremity, and total dependence for all ADLs. R9 had diagnoses of dementia, depression, and osteoarthritis, with an MDS showing a BIMS of two, severe cognitive impairment, and total dependence for most ADLs, including transfers and wheelchair mobility. R3’s care plan directed staff to provide a high-back wheelchair and total staff assistance for locomotion via a manual high-back wheelchair, and R9’s care plan directed staff to provide total staff assistance for locomotion via a wheelchair. During multiple observations, both residents were seen seated in wheelchairs without footrests, with their feet dangling approximately two inches off the ground or with only the tips of their toes touching the floor. R3 was observed at the nurses’ station, being propelled to the shower room, and in the dining room without footrests; R9 was observed in her room and in the dining room without footrests. Staff interviews confirmed the condition of the wheelchairs and the residents’ inability to self-propel. CNA P stated R3 did not have foot pedals and could not self-propel or adjust herself, and that R9 never had foot pedals and her feet dangled all the time. CRA M reported R3 had previously had a footboard but was unsure why it was no longer in place, and said she looked at body positioning during restorative care but not the residents’ feet. LN G stated she did not really know of any residents without foot pedals who could not self-propel, and Administrative Nurse D stated she expected residents who could not self-propel independently would have footrests. The facility’s restorative wheelchair mobility policy stated residents using wheelchairs must be provided individualized measurements, proper positioning, and foot support, and that feet should not be allowed to dangle.
Advance Directive Documentation Not Consistent With Resident Records
Penalty
Summary
The facility failed to ensure that residents' advance directives were accurately reflected in the medical record. For one resident, the EMR contained a physician order for Full Code and the care plan instructed staff to provide CPR, while the same resident also had a DNR form signed by the resident and a physician. For another resident, the EMR contained a physician order for DNR, but the DNR document had only the physician's signature and lacked a witness, representative, and/or resident signature. A third resident had a DNR order in the EMR and the care plan stated the resident had a signed DNR in the record, but the resident had previously signed a document stating they did not agree to a DNR. The provider did not check off DNR and signed the acknowledgement on the form. During interview, the Administrative Nurse stated the Social Service Designee would complete the advance directive paperwork and the floor nurse would document the order in the EMR, and stated she expected all residents to have the correct paperwork completed, care planned, and ordered. The facility did not provide a policy on advance directives.
Failure to Notify Representative of Significant Weight Loss
Penalty
Summary
The facility failed to notify the resident’s representative of a significant change in weight for a resident with schizophrenia, dementia, and heart disease. The resident’s Quarterly MDS documented a BIMS score of zero, indicating severe cognitive impairment, and noted a significant weight loss. The care plan identified nutritional problems related to weight loss, severe cognitive impairment, and dependence on staff for eating and drinking, and the physician orders included a pureed diet with thickened liquids and Mighty Shake supplementation. The resident’s record also documented malnutrition on the Mini Nutritional Evaluation and a decline in weight from 160 pounds to 140.6 pounds. The clinical record lacked documentation that the resident’s representative was notified of the weight loss. During observation, the resident was seen sitting at the table with eyes closed while staff assisted with lunch, and a nurse stated that when the resident closes his eyes, he is done with the meal. A CNA stated that staff weighed residents and recorded the weights, and the nurse reviewed the weights to determine who had lost weight. An administrative nurse stated the resident had been declining and losing weight and that the nurse should have notified the family of the change. The facility policy required the nurse to notify the resident and representative of non-immediate changes on the shift the change occurred unless otherwise directed by the physician.
Failure to Provide Written Transfer Notification
Penalty
Summary
The facility failed to provide Resident 1 with a written notification of transfer to the resident and/or the resident’s representative as soon as practicable. Resident 1 had diagnoses of COPD, heart failure, schizophrenia, and dementia. On 08/24/25 at 07:00 AM, a Health Status Note documented that Resident 1 was barely responsive with rapid breaths, and the provider ordered the resident sent to the hospital for evaluation. The record showed a Health Status Note on 08/26/25 at 01:40 PM stating that the bed hold was sent to the guardian, but the EMR lacked documentation of a written notification to the resident and/or representative explaining the reason for the hospital transfer. During interviews on 09/23/25, nursing and administrative staff stated that bed hold information was provided by Social Service Staff X or Administrative Staff A, and that the Ombudsman notification was provided monthly for discharges and transfers. Administrative Nurse D and Administrative Staff A both confirmed that the required written notification to the resident and/or representative of the reason for transfer to the hospital was not done for the resident’s transfer.
Failure to Implement Effective Fall Interventions
Penalty
Summary
The facility failed to implement interventions to prevent further falls after falls for two residents. One resident had diagnoses including anxiety, hallucinations, history of falls, and cognitive decline, with a BIMS score of 7 indicating severe cognitive impairment and a history of two or more falls in the prior quarter. The resident’s care plan identified high fall risk related to confusion, incontinence, lack of awareness of safety needs, vision and hearing problems, and wandering, with interventions such as placing the wheelchair by the bed, using anti-roll back brakes, a bed alarm, frequent checks, and lowering the bed. After a fall in which the floor alarm sounded and the resident was found on the floor beside the bed with a skin tear, the only documented intervention added was to remind the resident to use the call light, which the Administrative Nurse stated was not appropriate because the resident could not retain the information. The second resident had diagnoses including bipolar disorder, anxiety, COPD, and osteoporosis, with a BIMS score of 10 indicating moderate cognitive impairment and a care plan identifying fall risk and independence with a walker. After a fall while standing and putting in dentures, the resident’s oxygen saturation was 89 percent and the resident was not wearing oxygen. The care plan was not updated after that fall. Later, the resident was observed in the bathroom without oxygen, short of breath, with the walker outside the bathroom door. Staff interviews showed CNA staff were not involved in determining fall interventions, and the LN and Administrative Nurse stated that the charge nurse was supposed to develop interventions at the time of the fall, with the MDS nurse ensuring they were entered into the computer and communicated to staff. The facility policy stated that falls are to be documented on the care plan with interventions based on causal factors identified through root cause analysis.
Hand Hygiene and Shared Equipment Cleaning Lapses
Penalty
Summary
The facility failed to use adequate hand hygiene during resident care and failed to disinfect shared equipment after use. During observation, a CMA and a CNA transferred a resident to bed using a mechanical lift after the resident had been incontinent of a large soft stool. The CMA washed the resident’s buttocks, removed gloves, washed hands, then put on new gloves and continued care. The CNA performed front peri care, removed gloves, put on new gloves without hand hygiene, and applied barrier cream. The CNA then removed gloves and applied clean gloves again without hand hygiene before dressing the resident. After the transfer, the mechanical lift was removed from the resident’s room and placed into another resident’s room without any sanitation completed by either staff member. The CNA stated the facility did not have sanitation wipes to wipe off the mechanical lift between residents and said she would normally wash her hands after removing gloves before putting on new gloves, but she was nervous. The Administrative Nurse stated staff were expected to use appropriate hand hygiene, including after removing soiled gloves before putting on clean gloves, and that reusable shared equipment such as mechanical lifts should be sanitized after each use. The facility’s policies on hand hygiene and cleaning reusable resident care equipment required hand decontamination after glove removal and cleaning between uses of shared items.
Failure to Monitor Antibiotic Use for UTI Treatment
Penalty
Summary
The facility failed to ensure staff adhered to antibiotic stewardship principles by monitoring the appropriate use of antibiotics prescribed for a resident with a history of UTIs. The resident had diagnoses of dementia and depression, a BIMS score of 15 indicating intact cognition, required moderate assistance with toileting hygiene, and was occasionally incontinent of urine. Her care plan identified her as having a history of UTIs and being at risk for UTIs, with staff instructed to monitor and report signs and symptoms such as frequency, urgency, foul-smelling urine, painful urination, fever, nausea, vomiting, loss of appetite, and behavioral changes. The resident had two UTI episodes in which Keflex was ordered and administered. In February, she complained of painful urination and upset stomach, a urine sample was sent to the lab, and Keflex 500 mg twice daily for seven days was ordered and given even though the culture and sensitivity report later showed Keflex was not among the susceptible antibiotics. In August, she again reported UTI symptoms including low back pain and burning with urination, and Keflex 500 mg three times daily for five days was ordered and administered. The culture and sensitivity report again showed Keflex was not on the list of susceptible antibiotics, and the provider documented there were no orders after the report was received. Staff interviews indicated they expected the physician to follow the C&S report and order a susceptible antibiotic, but there was no documentation explaining why the Keflex orders were not changed.
Daily Nursing Staff Posting Missing Actual Hours Worked
Penalty
Summary
The facility failed to ensure the daily staff posting included the actual hours worked by nursing staff as required. During an observation on 09/21/25 at 11:00 AM, the daily staff posting document did not document actual hours worked, and the titles for CNA, LPN, and RN above the shift columns were difficult to read. Review of the daily staff posting documents from 09/21/25 to 09/23/25 showed the same lack of documentation of actual hours worked. During an interview on 09/22/25 at 03:50 PM, Administrative Nurse D stated she had never documented the actual hours worked for the posted staff sheet. The facility did not provide a policy for posted nursing staff.
Inaccurate PBJ Staffing Reporting
Penalty
Summary
The facility failed to electronically submit accurate direct care staffing information through Payroll-Based Journaling (PBJ) based on payroll and other verifiable and auditable data. The facility reported a census of 23 residents, and the PBJ Staffing Data Report for FY 2024 Quarter 3 documented excessively low staffing. For FY 2024 Quarter 4, the report showed the facility did not have licensed nursing coverage for 24 hours on multiple days in July, August, and September 2024. For FY 2025 Quarter 2, the report again showed no 24-hour licensed nursing coverage on multiple days in January, February, and March 2025. Review of the Daily Nurse Staffing Form and Payroll Data Sheets showed the listed days were actually covered with the appropriate staff and that licensed nursing coverage was present for 24 hours each day. The record also noted no concerns with low weekend staffing. During interview, Administrative Staff A stated the PBJ report was submitted by an outside firm and said she expected the report to be completed accurately, while also noting concerns with FY Quarter 1 and that improvement had started to be seen. The facility policy on Payroll Based Journal, dated 08/18/25, stated it outlines procedures for maintaining accurate and timely staff employment and payroll records in accordance with PBJ reporting requirements.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near Coldwater
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Protection Valley Manor | 9.8 mi | ★★★★★ | 0 | 0 |
| Hill Top House | 25.7 mi | ★★★★★ | 0 | 0 |
| Haviland Operator, Llc | 27.1 mi | ★★★★★ | 5 | 0 |
| Western Skilled Nursing And Therapy | 33.5 mi | ★★★★★ | 0 | 0 |
| Minneola District Hospital Ltcu | 39.2 mi | ★★★★★ | 0 | 0 |
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