Cycle 1
Health 2025-02-21 · Fire 2025-02-21
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Viborg, SD
Pioneer Memorial Nursing Home
3-star overall rating with 3-star inspections with $32,536 in total fines with 1 recent health deficiencies
315 North Washington St, Viborg, SD
(605) 326-5161
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
46
Certified beds
Average residents
44
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2004-04-01
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
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
0.62
Registered nurse staffing · state 0.80 · national 0.68
LPN hours / resident day
0.28
Licensed practical nurse staffing · state 0.49 · national 0.87
Aide hours / resident day
2.84
Nurse aide staffing · state 2.61 · national 2.35
Total nurse hours
3.74
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
0.90
RN + LPN hours · state 1.28 · national 1.54
Weekend hours
3.26
Weekend nurse staffing · state 3.32 · national 3.43
Weekend RN hours
0.34
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.79
CMS adjusted RN staffing hours
Adjusted total hours
4.75
CMS adjusted total nurse staffing hours
Case-mix index
1.08
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
53%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,989
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
25.08
Composite VBP score used to determine payment impact.
Payment multiplier
0.9837
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
0
Baseline 48.89% · Performance 64.71% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
5.02
Baseline 4.42 hours · Performance 4.51 hours · Measure score 5.02 · Achievement 5.02 · Improvement 0.11
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 11 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 8 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 15 · 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 2 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 82 |
| Staff flu vaccination coverage | 97.44% |
42%
55.4 pts better
|
Numerator 76 · Denominator 78 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 1 · 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 10 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.5
0.5 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.7 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.5 |
1.9
1.4 pts better
|
1.8
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.4 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
95.4%
4.6 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
96.9%
3.1 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 | 7.8% |
5.1%
2.7 pts worse
|
3.3%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 2.9% · Q3 9.8% · Q4 11.9% · 4Q avg 7.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.0% |
4.6%
2.6 pts better
|
11.4%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 0.0% · Q3 2.5% · Q4 2.4% · 4Q avg 2.0% |
| Percentage of long-stay residents who lose too much weight | 2.3% |
5.5%
3.2 pts better
|
5.4%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 7.4% · Q3 0.0% · Q4 0.0% · 4Q avg 2.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.7% |
17.8%
4.1 pts better
|
19.6%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 14.8% · Q3 11.8% · Q4 15.8% · 4Q avg 13.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 33.0% |
25.1%
7.9 pts worse
|
16.7%
16.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 29.2% · Q3 37.5% · Q4 31.2% · 4Q avg 33.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
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 | 19.7% |
21.3%
1.6 pts better
|
16.3%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 19.7% · Q4 14.1% · 4Q avg 19.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 24.8% |
21.6%
3.2 pts worse
|
14.9%
9.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.6% · Q2 26.9% · Q3 31.2% · Q4 14.3% · 4Q avg 24.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.5% |
2.0%
1.5 pts worse
|
1.0%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 2.9% · Q3 4.0% · Q4 1.8% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.0% |
3.3%
1.3 pts better
|
1.7%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 0.0% · Q3 0.0% · Q4 2.4% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.0% |
25.8%
0.2 pts worse
|
19.8%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.8% · Q2 33.1% · Q3 21.4% · Q4 24.2% · 4Q avg 26.0% |
| Percentage of long-stay residents with pressure ulcers | 4.9% |
4.6%
0.3 pts worse
|
5.1%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 3.5% · Q3 6.3% · Q4 3.1% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.2% |
83.2%
10 pts better
|
81.7%
11.5 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 93.2% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-31 · Fire 2023-10-31
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-09-29 · Fire 2022-09-29
0 health deficiencies
No concentrated health issue counts in this cycle.
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2022-09-29
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2022-09-29
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-02-21
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 2025-03-14
J · Immediate jeopardy
2023-10-31
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-11-22
J · Immediate jeopardy
2023-10-31
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-11-22
Penalties and ownership
What sits behind the stars
$32,536
2023-10-31
Fine
Fine · fine $32,536
Fine
Ownership
Pioneer Memorial Hospital & Health Services
5% Or Greater Direct Ownership Interest · Organization
Christensen, Paul
Operational/Managerial Control · Individual
Christiansen, Anne
Operational/Managerial Control · Individual
Christiansen, Anne
Corporate Officer · Individual
Christiansen, Anne
W-2 Managing Employee · Individual
Gerdes, Issac
Operational/Managerial Control · Individual
Gerdes, Issac
Corporate Director · Individual
Gerdes, Issac
W-2 Managing Employee · Individual
Johnson, Gabriel
Operational/Managerial Control · Individual
Larsen, Kimberly
Operational/Managerial Control · Individual
Lee, Troy
Operational/Managerial Control · Individual
Nyhaug, Connie
Operational/Managerial Control · Individual
Parsons, Melanie
Operational/Managerial Control · Individual
Penning, Ryan
Operational/Managerial Control · Individual
Pioneer Memorial Hospital & Health Services
Operational/Managerial Control · Organization
Poncelet, Chris
Operational/Managerial Control · Individual
Rudd, Tonya
Operational/Managerial Control · Individual
Rudd, Tonya
Corporate Director · Individual
Rudd, Tonya
W-2 Managing Employee · Individual
Stanage, Lisa
Operational/Managerial Control · Individual
Surprenant, Luke
Operational/Managerial Control · Individual
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#3
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