Cycle 1
Health 2025-01-08 · Fire 2025-01-08
2 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Pelican Rapids, MN
Pelican Valley Health Center
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
211 East Mill Avenue, Pelican Rapids, MN
(218) 863-2991
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
28
Certified beds
Average residents
28
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1986-12-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.16
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.68
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
2.96
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
4.80
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
1.84
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.84
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
0.51
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
1.41
CMS adjusted RN staffing hours
Adjusted total hours
5.84
CMS adjusted total nurse staffing hours
Case-mix index
1.12
Higher values indicate more complex resident acuity
RN turnover
22%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
140
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
81.86
Composite VBP score used to determine payment impact.
Payment multiplier
1.0262
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
7.80
Baseline 25.00% · Performance 31.82% · Measure score 7.80 · Achievement 7.80 · Improvement 0
Adjusted total nurse staffing
8.58
Baseline 4.98 hours · Performance 5.52 hours · Measure score 8.58 · Achievement 8.58 · Improvement 6.23
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.17% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 34 · Observed rate 5.88% · Lower 95% interval 6.73% |
| Discharge to community | 64.82% |
50.57%
14.2 pts better
|
No Different than the National Rate · Eligible stays 28 · Observed rate 71.43% · Lower 95% interval 50.26% |
| Medicare spending per beneficiary | 0.61 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 14 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 7.21% |
8.2%
1 pts worse
|
Numerator 8 · Denominator 111 |
| Staff flu vaccination coverage | 26.61% |
42%
15.4 pts worse
|
Numerator 29 · Denominator 109 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
97.3%
1.8 pts better
|
93.4%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 96.3% · 4Q avg 99.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
96.1%
3.9 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.5% |
3.9%
0.4 pts better
|
3.3%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.4% · Q3 3.6% · Q4 7.4% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.0% |
4.3%
3.3 pts better
|
11.4%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% |
| Percentage of long-stay residents who lose too much weight | 3.3% |
4.1%
0.8 pts better
|
5.4%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 8.7% · Q3 0.0% · Q4 4.5% · 4Q avg 3.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 3.2% |
12.4%
9.2 pts better
|
19.6%
16.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 0.0% · Q3 0.0% · Q4 4.5% · 4Q avg 3.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 2.5% |
17.5%
15 pts better
|
16.7%
14.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 5.0% · Q4 0.0% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 22.8% |
22.5%
0.3 pts worse
|
16.3%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 22.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.6% |
18.6%
5 pts better
|
14.9%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 22.7% · Q3 0.0% · Q4 19.0% · 4Q avg 13.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
2.3%
2.3 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.7% |
2.6%
0.1 pts worse
|
1.7%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 3.6% · Q3 3.6% · Q4 0.0% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.4% |
24.8%
3.6 pts worse
|
19.8%
8.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.0% · Q2 34.6% · Q3 20.2% · Q4 27.4% · 4Q avg 28.4% |
| Percentage of long-stay residents with pressure ulcers | 0.0% |
5.4%
5.4 pts better
|
5.1%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 58.8% |
88.6%
29.8 pts worse
|
81.7%
22.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 58.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.9%
1.9 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-08 · Fire 2023-11-08
4 health deficiencies
Top issue: Infection Control (3 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-02-22 · Fire 2023-02-22
3 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-01-08
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-01-29
D · Potential for more than minimal harm
2025-01-08
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-01-29
D · Potential for more than minimal harm
2025-01-08
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-01-29
F · Potential for more than minimal harm
2023-11-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-12-12
F · Potential for more than minimal harm
2023-11-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-12-12
F · Potential for more than minimal harm
2023-11-08
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-12-12
F · Potential for more than minimal harm
2023-11-08
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-12-12
F · Potential for more than minimal harm
2023-11-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-12-12
E · Potential for more than minimal harm
2023-11-08
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-12-12
D · Potential for more than minimal harm
2023-11-08
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2023-12-12
D · Potential for more than minimal harm
2023-11-08
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-12-12
C · Minimal harm
2023-11-08
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-12-12
C · Minimal harm
2023-02-22
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-04-05
C · Minimal harm
2023-02-22
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-04-05
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-01-08
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-01-29
E · Potential for more than minimal harm
2025-01-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-29
F · Potential for more than minimal harm
2023-11-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-12
F · Potential for more than minimal harm
2023-11-08
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-12-12
D · Potential for more than minimal harm
2023-11-08
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-12-12
D · Potential for more than minimal harm
2023-11-08
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-12-12
D · Potential for more than minimal harm
2023-02-22
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-04-05
D · Potential for more than minimal harm
2023-02-22
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-04-05
D · Potential for more than minimal harm
2023-02-22
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2023-04-05
Penalties and ownership
What sits behind the stars
Ownership
Pelican Valley Health Center
5% Or Greater Direct Ownership Interest · Organization
Ahlf, Tyler
Corporate Director · Individual
Ahlf, Tyler
W-2 Managing Employee · Individual
Anderson, Mark
Operational/Managerial Control · Individual
Bratlien, Richard
Corporate Officer · Individual
Bruggeman, Susan
Corporate Director · Individual
Erickson, Shannon
Corporate Director · Individual
Evenson, Brian
Corporate Officer · Individual
Gugisberg, Marnie
Operational/Managerial Control · Individual
Knorr, Bradley
Corporate Director · Individual
Knute Nelson
Operational/Managerial Control · Organization
Patterson, Patrick
Corporate Director · Individual
Sjostrom, Mark
Corporate Officer · Individual
Slotten, David
Corporate Officer · Individual
Urman, Angela
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Valley Care And Rehab Llc
Barnesville, MN
5-star overall rating with 4-star inspections with $7,446 in total fines with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Mn Veterans Home Fergus Falls
Fergus Falls, MN
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Emmanuel Nursing Home
Detroit Lakes, MN
3-star overall rating with 2-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
Jump out