Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
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 Mn Veterans Home Fergus Falls during CMS and state inspections, most recent first.
A resident with dementia and a history of sundowning, verbal aggression, and wandering was in his room when another cognitively impaired, behaviorally aggressive resident entered unsupervised, moved belongings, allegedly grabbed the resident by the neck, and threw him to the floor, leaving with the resident’s cane. Staff later found the resident on the floor with bruising and swelling to his elbow and additional bruising to his buttock and opposite elbow. The aggressive resident had a well-documented pattern of wandering into other rooms, taking items, and becoming physically aggressive when confronted, and his care plan directed frequent monitoring of his whereabouts due to these behaviors. Despite this, he was able to enter another resident’s room and, even after the incident, continued to wander into other rooms without adequate supervision, demonstrating a failure to protect residents from physical abuse.
A resident with severe cognitive and physical impairments fell and sustained a head injury when staff failed to properly secure a lift sling to a ceiling lift during a transfer. The improper attachment of the sling strap was not double-checked, leading to the strap detaching and the resident falling to the floor. The resident required emergency evaluation and pain management as a result of the incident.
A resident with severe cognitive impairment fell from a ceiling lift during a transfer when a sling strap was not fully secured, resulting in head and arm injuries. After the incident, the same lift was used for additional transfers, and staff involved continued to perform transfers before receiving retraining or competency checks, contrary to facility policy requiring removal of equipment and staff restriction pending investigation. This failure exposed other residents needing total body lift transfers to potential harm.
A resident with severe cognitive impairment and a history of COPD, hypertension, and stroke was allowed to smoke independently, despite observations of unsafe smoking practices leading to burn-holes in their clothing. The facility's smoking assessments inaccurately reported no visible holes, and staff conducted assessments through a window rather than directly observing the resident in the smoking room. The facility's policy required individualized smoking interventions, but the deficiency in implementing these interventions was evident.
A resident with type two diabetes received insulin without the pen being primed, contrary to manufacturer's instructions. The RN administered 12 units of Semglee insulin without performing the necessary airshot to remove air bubbles, which is essential for accurate dosing. The RN, consultant pharmacist, and DON acknowledged the importance of this step, which was not followed as per the facility's medication administration policy.
Failure to Supervise Aggressive Resident Leads to Resident-to-Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and monitoring to prevent resident-to-resident physical abuse. One resident with dementia, cognitive impairment, and a history of sundowning, verbal aggression, and wandering was seated in his recliner with his room door open when another resident entered his room. The intruding resident, who also had dementia and severe cognitive impairment, was known to wander into other residents’ rooms, touch and take belongings, and had a documented history of verbal and physical aggression toward staff and residents. On the day of the incident, staff later observed this resident exiting the victim’s room carrying the victim’s cane. The victim reported that the other resident came into his room and began moving his belongings. He stated that he got up from his recliner, approached the intruder, and told him to stop. He reported that the other resident then placed his hands around his neck, choked him, and threw him to the floor, taking his cane when leaving the room. Staff responded after hearing the victim yelling and found him on the floor against the wall inside his doorway, with bruising and swelling to his elbow and later bruising to his buttock and the opposite elbow. The victim continued to report pain in his elbow, arm, lower back, and right hand following the incident, and documentation identified contusions and bruising related to the fall caused by the physical aggression of the other resident. The aggressive resident’s record showed a long-standing pattern of wandering into other residents’ rooms, taking or moving their belongings, and provoking or engaging in altercations when confronted. Progress notes documented multiple prior episodes in which he entered peers’ rooms, took walkers or other items, upset other residents, and on several occasions became physically aggressive, including throwing closed-fist punches at a peer and threatening or attempting to hit staff and residents. His care plan directed staff to monitor his whereabouts frequently due to his wandering into private spaces, his tendency to touch and take others’ belongings, and his potential to return aggression when peers became upset with him. Despite these known behaviors and care plan directives, he was able to enter the victim’s room unsupervised, interact with the victim’s belongings, and allegedly choke and throw the victim to the floor, resulting in injury. Following this incident, he continued to wander into other resident rooms unsupervised, demonstrating that the facility did not provide adequate supervision and monitoring to protect residents from physical abuse.
Failure to Ensure Safe Transfer Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when staff failed to properly attach a lift sling to a ceiling lift bar during a transfer of a resident with severe cognitive and physical impairments. The resident, who had diagnoses including non-traumatic brain dysfunction, Alzheimer's disease, aphasia, seizure disorder, and muscle weakness, was fully dependent on staff for all activities of daily living and transfers. During a transfer from bed to wheelchair, two nursing assistants attached the sling straps to the ceiling lift, but one of the straps was not fully secured. As the resident was lifted, a strap detached, causing the resident to fall from the lift, landing on a floor mat and sustaining a large contusion and hematoma to the back of the head, as well as a skin tear to the forearm. The resident required evaluation in the emergency department and experienced pain requiring medication. The incident was substantiated through staff interviews, reenactments, and document review. It was determined that the left leg sling strap was not properly hooked to the lift bar, and staff did not perform a double-check to ensure all straps were secure before initiating the lift. The facility's procedures and competency checklists did not explicitly require a double-check of sling strap security prior to lifting, and staff involved in the incident did not verify the connections after the resident was slightly lifted off the bed. Additionally, after the fall, the same ceiling lift was used to transfer the resident and another individual before the equipment was inspected, contrary to facility policy requiring removal of equipment from service after an adverse event. Observations and interviews revealed that the sling and lift were appropriate for the resident's care plan at the time, but the failure to ensure proper attachment and verification of the sling straps directly led to the resident's fall and injury. The staff involved did not intentionally cause harm, but the lack of adherence to safety protocols and insufficient verification of equipment setup resulted in actual harm to the resident.
Failure to Protect Residents During Investigation of Lift Transfer Accident
Penalty
Summary
A deficiency occurred when the facility failed to provide sufficient protection to other residents during the investigation of an accident involving a resident who fell from a ceiling lift during a transfer. The resident involved had severely impaired cognition, disorganized thinking, and physical behavioral symptoms directed toward others, and was dependent on staff for all transfers. During a transfer from bed to wheelchair, the resident fell from the ceiling lift after one of the sling straps became detached, resulting in the resident landing on the floor mat and sustaining a hematoma to the back of the head and a skin tear to the forearm. The incident was witnessed by staff, and it was determined that the sling strap was not fully secured to the lift bar, which led to the fall. Following the incident, the same ceiling lift was used to transfer the resident from the floor to the wheelchair, and then to transfer another resident, before any inspection or removal of the equipment from service. Staff involved in the incident continued to work on the floor and performed additional transfers with the ceiling lift before receiving re-education or competency checks. The facility's policies required that any lift or sling involved in an adverse event be immediately removed from service pending inspection, but this was not followed. Interviews revealed that staff did not double-check the sling loops before lifting, and the competency checklist did not require a double-check of the sling loops prior to lifting the resident. The failure to immediately remove the lift and sling from service and to restrict staff involved in the incident from performing further transfers before retraining resulted in insufficient protection for other residents who required staff assistance with total body lift transfers. The deficiency was substantiated through interviews, document review, and reenactments, which confirmed that the incident occurred as described and that facility policies and procedures were not followed at the time of the event.
Failure to Implement Safe Smoking Interventions
Penalty
Summary
The facility failed to accurately assess and implement safe smoking interventions for a resident with severe cognitive impairment and a history of chronic obstructive pulmonary disease, hypertension, and stroke. The resident was identified as a modified independent smoker, with the facility storing their cigarettes and allowing them to smoke independently. However, observations revealed that the resident was not safely disposing of cigarette ashes, which were falling onto their lap and clothing, resulting in burn-holes in their pants. Despite the resident's smoking assessment indicating they were safe to smoke independently without supervision or a smoking apron, multiple observations showed the resident leaving burning cigarettes unattended and failing to extinguish them properly. Staff interviews revealed that the resident's smoking assessments were conducted by observing through a window rather than directly in the smoking room, and staff were aware of the burn-holes in the resident's clothing but unsure of their duration. The facility's policy required quarterly smoking assessments and interventions based on individualized assessments, yet the assessments inaccurately reported no visible holes in the resident's clothing. The Director of Nursing acknowledged the presence of burn-holes and the need for a new smoking assessment to ensure the resident's safety while smoking, highlighting a deficiency in the facility's implementation of safety interventions for smoking residents.
Failure to Prime Insulin Pen Before Administration
Penalty
Summary
The facility failed to ensure professional standards of practice were followed during the administration of insulin to a resident with type two diabetes. The resident, who had intact cognition, was prescribed Semglee insulin to be administered subcutaneously twice daily. During a medication pass, a registered nurse (RN) prepared and administered the insulin without priming the pen as per the manufacturer's instructions. The RN attached a needle to the insulin pen, dialed the dose to 12 units, and administered it to the resident without performing the necessary airshot to remove air bubbles, which is crucial for ensuring the correct dosage. The RN acknowledged the oversight during an interview, confirming awareness of the requirement to prime the insulin pen before administration. The consultant pharmacist and the director of nursing both emphasized the importance of priming the pen to ensure accurate dosing. The facility's policy on medication administration, revised in May 2023, mandates adherence to appropriate standards and protocols, which were not followed in this instance. The manufacturer's package insert for Semglee insulin also specifies the need for an airshot before each injection to remove air bubbles, a step that was omitted in this case.
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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.
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Nursing homes near Fergus Falls
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lb Broen Home | 1.9 mi | ★★★★★ | 5 | 0 |
| Pioneer Care Center | 2.1 mi | ★★★★★ | 7 | 0 |
| Good Samaritan Society - Battle Lake | 17.1 mi | ★★★★★ | 1 | 0 |
| Pelican Valley Health Center | 18.5 mi | ★★★★★ | 2 | 0 |
| St Francis Home | 24.6 mi | ★★★★★ | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.