Cycle 1
Health 2025-08-06 · Fire 2025-08-06
11 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fergus Falls, MN
Pioneer Care Center
4-star overall rating with 3-star inspections with 11 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1131 South Mabelle Avenue, Fergus Falls, MN
(218) 998-1500
Overall
4 / 5
CMS overall stars
Health inspections
3 / 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
105
Certified beds
Average residents
89
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1987-04-11
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
0.97
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.32
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
3.23
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
4.52
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
1.29
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
4.05
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
0.60
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
1.00
CMS adjusted RN staffing hours
Adjusted total hours
4.65
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
38%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,912
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
38.11
Composite VBP score used to determine payment impact.
Payment multiplier
0.9912
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.21
Baseline 16.90% · Performance 18.55% · Measure score 6.21 · Achievement 6.21 · Improvement 0
Healthcare-associated infections
0
Baseline 5.35% · Performance 7.81% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
5.06
Baseline 41.91% · Performance 42.98% · Measure score 5.06 · Achievement 5.06 · Improvement 0
Adjusted total nurse staffing
3.97
Baseline 4.67 hours · Performance 4.21 hours · Measure score 3.97 · Achievement 3.97 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.15% |
10.72%
1.6 pts better
|
No Different than the National Rate · Eligible stays 98 · Observed rate 5.1% · Lower 95% interval 6.12% |
| Discharge to community | 51.59% |
50.57%
1 pts better
|
No Different than the National Rate · Eligible stays 93 · Observed rate 49.46% · Lower 95% interval 43.69% |
| Medicare spending per beneficiary | 0.83 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 54 · Denominator 54 |
| Falls with major injury | 1.85% |
0.77%
1.1 pts worse
|
Numerator 1 · Denominator 54 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 24 · Denominator 48 |
| Discharge mobility score | 27.08% |
50.94%
23.9 pts worse
|
Numerator 13 · Denominator 48 |
| Pressure ulcers or injuries, new or worsened | 3.7% |
2.29%
1.4 pts worse
|
Numerator 2 · Denominator 54 · Adjusted rate 5.88% |
| Healthcare-associated infections requiring hospitalization | 7.81% |
7.12%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 59 · Observed rate 8.47% · Lower 95% interval 4.66% |
| Staff COVID-19 vaccination coverage | 7.92% |
8.2%
0.3 pts worse
|
Numerator 16 · Denominator 202 |
| Staff flu vaccination coverage | 27.93% |
42%
14.1 pts worse
|
Numerator 62 · Denominator 222 |
| Discharge function score | 56.25% |
56.45%
0.2 pts worse
|
Numerator 27 · Denominator 48 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 36 · Denominator 36 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 52.38% |
25.2%
27.2 pts better
|
Numerator 11 · Denominator 21 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.7
0.7 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.8 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.2 |
2.0
0.2 pts worse
|
1.8
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 1.9 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
97.3%
2.4 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.9% · Q3 100.0% · Q4 100.0% · 4Q avg 99.7% |
| 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 | 1.8% |
3.9%
2.1 pts better
|
3.3%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.3% · Q3 2.5% · Q4 0.0% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.8% |
4.3%
1.5 pts better
|
11.4%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 4.1% · Q3 2.9% · Q4 0.0% · 4Q avg 2.8% |
| Percentage of long-stay residents who lose too much weight | 3.6% |
4.1%
0.5 pts better
|
5.4%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 2.8% · Q3 4.5% · Q4 1.6% · 4Q avg 3.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.2% |
12.4%
0.8 pts worse
|
19.6%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.0% · Q2 12.3% · Q3 10.6% · Q4 13.1% · 4Q avg 13.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.2% |
17.5%
1.3 pts better
|
16.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.3% · Q2 12.1% · Q3 19.3% · Q4 22.6% · 4Q avg 16.2% · 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 | 20.6% |
22.5%
1.9 pts better
|
16.3%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.2% · Q2 20.2% · Q3 34.3% · Q4 20.8% · 4Q avg 20.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.2% |
18.6%
0.6 pts worse
|
14.9%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.9% · Q2 22.9% · Q3 20.0% · Q4 17.2% · 4Q avg 19.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
2.3%
1.4 pts better
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 1.4% · Q4 1.3% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.2% |
2.6%
1.6 pts worse
|
1.7%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 3.4% · Q3 6.3% · Q4 3.9% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.4% |
24.8%
1.4 pts better
|
19.8%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 28.0% · Q3 17.6% · Q4 26.4% · 4Q avg 23.4% |
| Percentage of long-stay residents with pressure ulcers | 1.3% |
5.4%
4.1 pts better
|
5.1%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 2.0% · Q3 0.9% · Q4 1.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.7% |
88.6%
9.1 pts better
|
81.7%
16 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.4% · Q2 95.7% · Q3 97.4% · Q4 98.9% · 4Q avg 97.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.8% |
14.0%
4.2 pts better
|
12.0%
2.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.8% · Observed 9.1% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
1.9%
0.9 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.6% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.7% |
82.7%
13 pts better
|
79.7%
16 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.2% |
23.1%
5.9 pts better
|
23.9%
6.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.2% · Observed 15.9% · Expected 22.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-24 · Fire 2024-07-24
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2023-09-13 · Fire 2023-09-13
8 health deficiencies
Top issue: Infection Control (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-08-06
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-11-13
F · Potential for more than minimal harm
2024-07-24
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-08-30
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-08-06
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-09-03
E · Potential for more than minimal harm
2025-08-06
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 2025-09-03
D · Potential for more than minimal harm
2025-08-06
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-09-03
D · Potential for more than minimal harm
2025-08-06
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2025-09-03
D · Potential for more than minimal harm
2025-08-06
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-09-08
D · Potential for more than minimal harm
2025-08-06
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2025-09-03
C · Minimal harm
2025-08-06
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-09-03
D · Potential for more than minimal harm
2025-05-27
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-05-27
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-05-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-05-16
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-06-07
D · Potential for more than minimal harm
2024-07-24
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-08-16
D · Potential for more than minimal harm
2024-07-24
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-08-16
D · Potential for more than minimal harm
2024-07-24
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-08-16
D · Potential for more than minimal harm
2024-01-09
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-01-30
D · Potential for more than minimal harm
2023-09-13
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-10-05
D · Potential for more than minimal harm
2023-09-13
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-10-05
D · Potential for more than minimal harm
2023-09-13
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-10-05
D · Potential for more than minimal harm
2023-09-13
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 2023-10-05
D · Potential for more than minimal harm
2023-09-13
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-10-05
D · Potential for more than minimal harm
2023-09-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-05
D · Potential for more than minimal harm
2023-09-13
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-10-05
Penalties and ownership
What sits behind the stars
Ownership
Cook, Nicki
W-2 Managing Employee · Individual
Demuth, Suzanne
Corporate Officer · Individual
Denzel, Bonnie
Corporate Officer · Individual
Ellig, Joe
Corporate Officer · Individual
Freeman, Janet
Corporate Officer · Individual
Johnson, Nathan
Operational/Managerial Control · Individual
Johnson, Nathan
Corporate Director · Individual
Johnson, Nathan
W-2 Managing Employee · Individual
Kacer, Cindy
W-2 Managing Employee · Individual
Monke, Dean
Corporate Officer · Individual
Sethre, John
Corporate Officer · Individual
Tollerson, Brad
Corporate Officer · Individual
Underwood, Margaret
Corporate Officer · Individual
Watkins, Sara
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Lb Broen Home
Fergus Falls, MN
3-star overall rating with 4-star inspections with 6 recent health deficiencies with 5 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
Good Samaritan Society - Battle Lake
Battle Lake, MN
5-star overall rating with 5-star inspections with 1 recent health deficiencies
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