Above average — CMS composite of the measures below.
The next survey window likely opens around May 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 Pioneer Care Center during CMS and state inspections, most recent first.
Surveyors found that multiple medications, including eye drops, insulin pens, inhalers, and nitroglycerin, were not properly labeled or dated, and some were missing administration instructions or resident identifiers. Staff often relied on the EMAR for directions instead of ensuring medication containers were labeled, and medications brought in by families frequently lacked pharmacy labels. These deficiencies were confirmed through staff interviews and observations, revealing a failure to follow facility policy for medication labeling and storage.
Surveyors identified that food items in the kitchen refrigerators and freezers were not consistently labeled with opened dates or expiration dates, and some items were not discarded by their expiration dates. Both the cook and dietary manager confirmed that these practices did not meet facility policy, which requires all opened food to be dated and discarded appropriately.
The facility did not properly implement self-administration of medication assessments and procedures for two residents. One resident had lidocaine patches left unsecured in their room despite not being able to apply them independently, while another had topical antifungal medications left at the bedside without authorization for self-administration. Staff and pharmacy consultants confirmed that medications should have been secured and that proper assessments were not followed.
A resident with severe cognitive impairment and a history of falls was placed in a low bed to prevent further falls, but staff did not complete a restraint assessment or identify the low bed as a potential restraint. Interviews and observations showed that the low bed restricted the resident's ability to stand independently, and staff were uncertain about its classification as a restraint, despite facility policy requiring assessment.
A resident with complex medical needs and a history of falls was not accurately coded on the MDS for the use of bed and chair alarms, despite care plans, physician orders, and staff observations confirming their use. The MDS coordinator did not perform a visual assessment or fully review care documentation, resulting in the omission of this critical information from the assessment.
A resident did not receive appropriate care to maintain or improve ROM and mobility, and the facility did not ensure that necessary interventions were provided or documented, except when decline was medically unavoidable.
The facility did not consistently post up-to-date nurse staffing information as required, with outdated postings and incorrect resident census numbers observed. The DON and scheduler confirmed that postings were often prepared in advance and not always updated to reflect current census or staffing changes, leading to inaccurate information being displayed.
A resident with severe cognitive impairment was found with multiple bruises of unknown origin on her inner thighs and knee. Although the administrator and DON were notified, the physician was not informed until five days later, contrary to facility expectations for immediate notification. This delay prevented timely medical evaluation and intervention.
A resident with severe cognitive impairment and high care needs was found with multiple unexplained bruises on her inner thighs and knees, described as fingerprint-sized and in a straight line. The facility's investigation did not include comprehensive staff interviews about possible abuse or suspicious behavior, and staff who observed the bruising were not questioned about abuse. Leadership acknowledged that the investigation did not follow policy requirements for injuries of unknown origin.
A resident with severe cognitive impairment and multiple medical conditions developed several greenish, fingerprint-sized bruises on the inner thighs. Although there was an order to monitor the bruises, it lacked clear instructions and was not entered into the TAR, resulting in inconsistent monitoring and missing documentation over several days. Staff interviews confirmed a lack of awareness and follow-through regarding the monitoring order, and the medical provider was not notified at the time of the incident.
A resident with cognitive impairment and limited mobility was left unsupervised on a secured outdoor patio for several hours in hot weather, without access to water or sun protection. Staff failed to provide adequate supervision or communicate the resident's status during shift changes, resulting in the resident being found unresponsive and requiring emergency treatment for heat exhaustion and dehydration.
A resident with COPD was allowed to self-administer nebulizer medication without a proper assessment or order in place. The facility's staff, including a TMA and RN, failed to follow the process for evaluating and documenting the resident's ability to self-administer medication safely. The resident's care plan and electronic health record lacked necessary documentation, and the pharmacy consultant expected these assessments and orders to be completed to ensure safe medication administration.
A resident with severe cognitive impairment and a preference for no facial hair was not assisted with facial hair removal, despite requiring substantial assistance with hygiene. Observations showed the resident had facial hair, and interviews revealed staff failed to follow the facility's policy of offering daily assistance for facial hair removal to maintain dignity.
A resident with severe cognitive impairment developed a stage two pressure ulcer behind the left ear due to nasal cannula tubing. The facility failed to assess, document, and implement interventions for the ulcer, despite the resident being at moderate risk. Nursing staff were unaware of the ulcer, and required procedures for pressure ulcer management were not followed, leading to inadequate care.
Medication Labeling and Storage Deficiencies
Penalty
Summary
Surveyors identified multiple deficiencies related to the labeling and storage of medications for nine residents. Medications, including eye drops, insulin pens, inhalers, and nitroglycerin, were found without proper labeling, such as missing resident names, administration directions, or dates of opening. In several cases, medications brought in by families lacked pharmacy labels, and staff relied on electronic medication administration records (EMAR) for instructions rather than ensuring the medication containers themselves were properly labeled. Some medications, such as eye drops and insulin pens, were not dated when opened, making it difficult to determine if they were still within the manufacturer’s recommended usage period. Observations revealed that staff did not consistently follow procedures for labeling medications upon opening or for maintaining medications in their original packaging with pharmacy labels. For example, eye drops and insulin pens were found undated, and some medications were stored outside of their labeled boxes, resulting in missing instructions and resident identifiers. Staff interviews confirmed that the expectation was to label medications with the date opened and to dispose of them after the recommended period, but this was not consistently practiced. In some instances, staff removed and destroyed improperly labeled or expired medications during the survey. The facility’s own policy required that all medications be labeled with the medication name, prescribed dose, strength, expiration date, resident’s name, route of administration, and instructions. However, the survey found that this policy was not followed for several medications, including those for dry eyes, glaucoma, diabetes, and chest pain. The lack of proper labeling and storage was confirmed by nursing staff, the clinical coordinator manager, the consultant pharmacist, and the director of nursing during interviews and observations.
Improper Food Labeling and Storage in Kitchen Refrigerators and Freezers
Penalty
Summary
Surveyors observed that the facility failed to ensure proper labeling, dating, and discarding of food items stored in the kitchen refrigerators and freezers. During a kitchen tour, it was found that a half container of sour cream in the walk-in cooler lacked an opened date and had an expiration date that had already passed. In the kitchen fridge, a quarter container of mustard was found with an expired date, and a half bottle of barbeque sauce was missing both an opened date and an expiration date. The cook confirmed these findings and stated that all opened food should be dated and discarded by the expiration date. The dietary manager also confirmed that food should be dated when opened and discarded after the shelf life or expiration date. Facility policy requires leftover foods to be stored in covered containers, clearly labeled, dated, and monitored to ensure consumption by safe use-by dates or frozen.
Failure to Implement and Secure Self-Administration of Medication Procedures
Penalty
Summary
The facility failed to properly implement self-administration of medication (SAM) assessments and procedures for two residents. One resident, who was cognitively intact and had diagnoses including diabetes, heart failure, and arthritis, had a physician's order for a lidocaine patch to be applied at bedtime and removed in the morning. Although the SAM assessment indicated the resident could self-administer medications after nurse setup, observations showed that nursing staff applied and removed the patch daily, and left an open box of lidocaine patches unsecured on the resident's dresser. Staff confirmed that the patches should have been secured in a locked medication drawer and that the resident was not able to apply the patch independently, only remove it. The pharmacy consultant and clinical coordinator both stated that only one patch should be left out at a time and that medications should be stored securely according to the SAM assessment. Another resident, with mild cognitive impairment and diagnoses including an indwelling urinary catheter, heart failure, and hypertension, had orders for topical antifungal medications. The care plan and SAM assessment indicated the resident was not able to self-administer medications. However, observations revealed that tubes of Clotrimazole cream and Nystatin powder were left on the nightstand in the resident's room. The resident reported that staff left the medications out for application, and if not left out, staff would not apply them as only one person could access the locked medications. Staff confirmed there was no order for self-administration and subsequently locked the medications away. Facility policy required that the interdisciplinary team assess each resident's cognitive and physical abilities to determine if self-administration is safe and appropriate, and that self-administered medications be stored securely. The policy also stated that any medications found at the bedside without authorization for self-administration should be turned over to the nurse in charge. The facility did not follow these procedures, resulting in unsecured medications at residents' bedsides and improper implementation of SAM assessments.
Failure to Assess Low Bed as Potential Physical Restraint
Penalty
Summary
The facility failed to comprehensively assess the use of a low bed as a potential physical restraint for a resident with severe cognitive impairment, Parkinson's disease, hypertension, arthritis, and a history of falls. The resident required extensive assistance with activities of daily living, including bed mobility, transfers, and toileting, and used a wheelchair for mobility. Despite the resident's ability to stand independently, staff placed the bed in the lowest position as an intervention following a fall, with the intention of preventing further falls. However, there was no documentation of a restraint assessment being completed prior to implementing this intervention, and the resident's care plan and assessments did not identify the low bed as a restraint. Observations and staff interviews revealed that the low bed made it difficult for the resident to stand up independently, and staff were unsure whether the low bed constituted a restraint. The facility's policy defined a physical restraint as any device that restricts freedom of movement and cannot be easily removed by the resident. Despite this, the low bed was not evaluated as a potential restraint, and the required assessment was not performed before its use. The director of nursing confirmed that a restraint assessment should have been completed but was not done in this case.
Failure to Accurately Code MDS for Resident Safety Alarms
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment was accurately coded to reflect the use of safety alarms for a resident with medically complex conditions, including hypertension, anxiety, and depression, who required extensive assistance with activities of daily living. Despite the resident's care plan and physician orders indicating the use of bed, recliner, and wheelchair alarms as fall interventions, the MDS assessment did not document the presence of these alarms. Multiple observations confirmed the resident was consistently using bed and chair alarms, and staff interviews verified that these alarms had been in place for an extended period. The MDS coordinator acknowledged that the alarms were not coded on the MDS and stated that the standard process involved reviewing assessments, care plans, and care conference notes, but a visual assessment was not performed for this resident at the time of the MDS completion. Both the MDS coordinator and nursing staff confirmed that the alarms should have been included in the MDS coding. The facility's policy required that MDS assessments consistently reflect information from progress notes, care plans, and resident observations, which was not followed in this instance.
Failure to Maintain or Improve Resident Range of Motion
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide appropriate care to maintain and/or improve a resident's range of motion (ROM), limited ROM, and/or mobility. The facility did not ensure that care and services were provided to prevent avoidable decline in ROM or mobility, except in cases where a decline was medically unavoidable. The report notes that the necessary interventions to maintain or improve the resident's physical abilities were not implemented or documented as required.
Failure to Consistently Post Accurate Daily Nurse Staffing Information
Penalty
Summary
The facility failed to consistently post required nurse staffing information on a daily basis as mandated. On the day of observation, the staff posting displayed was outdated, showing information from two days prior and an incorrect resident census. The current day's posting was found behind previous days' postings and also contained an incorrect census. The DON confirmed these discrepancies and explained that the process was to update the nurse staff posting daily, with the scheduler responsible for creating the postings and the charge nurse responsible for updating them with census or staffing changes. Interviews revealed that the scheduler typically prepares postings for upcoming days in advance, especially before weekends, and places them behind the current posting. Updates to the census or staffing changes occurring on weekends are expected to be made by the charge nurse. However, the process did not ensure that the most current and accurate information was consistently displayed, as required by facility policy. The policy specifies that daily postings must include the facility name, current date, resident census at the beginning of the shift, shift schedule, type and category of nursing staff, actual time worked, and totals for licensed and non-licensed staff.
Failure to Timely Notify Physician of Resident Injury
Penalty
Summary
The facility failed to notify a physician in a timely manner regarding a change in condition for a resident who was found with multiple bruises of unknown origin on her inner thighs and knee. The resident had severely impaired cognition, inattention, and disorganized thinking, making her unable to communicate how the bruises occurred or whether she felt safe. Documentation showed that the incident was discovered by staff in the morning, and while the administrator and DON were notified, the section of the incident report regarding physician notification was left blank. Progress notes indicated that the resident's family was informed, but there was no documentation of immediate provider notification. The physician was not notified until five days after the bruises were discovered, via fax, and was unaware of the incident during a routine visit that occurred in the interim. Interviews with staff confirmed that the expectation was for immediate provider notification, especially given the potential for abuse or injury. The lack of timely communication prevented the physician from evaluating the resident promptly and determining if further medical assessment or interventions were necessary.
Failure to Thoroughly Investigate Injury of Unknown Source
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown source for a resident with severe cognitive impairment and multiple physical dependencies. The resident, who had diagnoses including Parkinson's disease, dementia, and anxiety, was non-ambulatory, required substantial to maximal assistance with all activities of daily living, and was unable to communicate about her safety or the cause of her injuries. On assessment, staff identified multiple bruises of varying sizes and colors on the resident's inner thighs and knees, which were described as fingerprint-sized and arranged in a straight line. The resident's care plan directed staff to use caution during transfers and to monitor and report any suspected abuse or neglect, but the source of the bruising was not observed, and the resident could not explain the injuries. The facility's documentation and investigation into the incident were incomplete. Progress notes indicated that the resource manager was notified and the resident's family was informed, but did not specify what actions were taken. The state agency report and facility records showed that previous skin assessments did not note any discoloration or bruising, and that the bruising could have been related to the process of changing the resident's brief. However, there was no evidence that staff interviews included questions about possible abuse, aggressive care, or suspicious behavior by staff or other residents. Staff who discovered or observed the bruising confirmed they were not interviewed about abuse or the incident itself. Interviews with facility leadership and the medical director confirmed that the investigation did not follow policy requirements for injuries of unknown origin, which called for comprehensive interviews with all staff who had contact with the resident during the relevant period, including questions about abuse. The director of nursing acknowledged that staff were only asked about skin changes, difficulties with repositioning, and care challenges, and not about abuse. The medical director stated that he was not notified of the incident and would have expected a more thorough investigation, including an examination to determine if the injuries were suspicious.
Failure to Monitor and Document Bruising for Cognitively Impaired Resident
Penalty
Summary
The facility failed to properly assess and monitor bruises for a resident with severely impaired cognition, Parkinson's disease, dementia, and significant physical limitations. The resident was dependent on staff for all activities of daily living and had an order for weekly skin monitoring, as well as a specific order to monitor bruising to the inner thighs after staff observed multiple greenish, fingerprint-sized bruises. Documentation showed that the order to monitor the bruises lacked clear directions and frequency, and was not entered into the Treatment Administration Record (TAR), resulting in inconsistent monitoring and documentation. Progress notes were missing for several days following the discovery of the bruises, and staff interviews confirmed a lack of awareness and follow-through regarding the monitoring order. The incident report and progress notes indicated that the medical provider was not notified at the time of the incident, and the order to monitor the bruises was not effectively communicated or implemented among nursing staff. The DON and other staff acknowledged that the order should have been placed in the TAR with a specified frequency to ensure consistent monitoring, but this was not done. As a result, there was no documented evidence that the resident's bruises were assessed every shift or daily as would have been expected, leading to a failure in providing appropriate treatment and care according to orders and the resident's needs.
Resident Left Unsupervised Outdoors Resulting in Heat Exhaustion
Penalty
Summary
A deficiency occurred when a resident with mild neurocognitive disorder, impaired mobility, and a history of delusions and agitation was left unsupervised on an outdoor patio. The resident was dependent on staff for transfers, had impaired balance, and required supervision with all decision-making. According to the care plan, the resident was at risk for falls and required prompt response to requests for assistance, as well as supervision when outside. Despite these needs, the resident was brought outside by staff and left alone for an extended period in hot weather, without access to water or sun protection. Staff interviews and documentation revealed that the resident was placed on the patio around early afternoon and checked on intermittently. Multiple staff members noted that the resident refused to return inside when offered, but she was not provided with water or adequate sun protection, and there was no way for her to independently alert staff if she needed help. The patio door required a code to re-enter the building, which the resident could not operate due to her physical limitations. Staff were unclear about the frequency of required checks and did not consistently communicate the resident's location or status during shift changes. The resident was found unresponsive after being left outside for several hours in temperatures reaching 90 degrees Fahrenheit. She exhibited signs of heat exhaustion and dehydration, including confusion, elevated vital signs, and sunburn. Emergency services were called, and the resident was treated in the emergency department for heat exposure, dehydration, and hyperkalemia before being returned to the facility. The facility's policy required supervision based on individual assessment and environmental hazards, but staff failed to provide adequate supervision and did not follow established procedures for monitoring residents outside.
Failure to Ensure Safe Self-Administration of Nebulizer Medication
Penalty
Summary
The facility failed to ensure the safe administration of nebulizer medication for a resident who was observed to self-administer without being assessed as safe to do so. The resident, who was cognitively intact and had diagnoses including COPD, heart failure, and anxiety disorder, required assistance with activities of daily living. Despite this, the resident's care plan did not include interventions for self-administration of medication, and there was no documented self-administration medication (SAM) assessment or order for the resident to self-administer the nebulizer medication. During observations, a trained medication aide set up the nebulizer for the resident and left the room, allowing the resident to self-administer the medication unsupervised. The aide assumed the resident had been assessed for self-administration, but upon review, it was confirmed that no such assessment or order existed. Interviews with the unit manager RN and the DON revealed that the facility's process for SAM assessments and obtaining orders was not followed, and the resident's care plan and electronic health record lacked the necessary documentation. The pharmacy consultant also expected a SAM assessment and order to be in place to ensure safe medication administration.
Failure to Assist Resident with Facial Hair Removal
Penalty
Summary
The facility failed to ensure that a resident, who required assistance with hygiene, had her facial hair removed, despite her preference for no facial hair. The resident, who was severely cognitively impaired with diagnoses including dementia, coronary artery disease, and hypertension, required substantial assistance with bathing and dressing but was noted to be independent with personal hygiene. However, observations revealed that the resident had multiple white facial hairs on her cheeks, chin, and around her mouth, which she was unable to remove herself. Interviews with nursing assistants and the clinical manager revealed that the usual practice was to assist residents with facial hair removal to maintain their dignity. However, the staff failed to check and assist the resident with facial hair removal as per her care plan and facility policy. The director of nursing confirmed that staff were expected to offer facial hair removal daily and document any refusals. A family member also confirmed the resident's preference for no facial hair. The facility's policy emphasized promoting cleanliness and skin care, yet the staff did not adhere to these guidelines, leading to the deficiency.
Failure to Assess and Manage Pressure Ulcer
Penalty
Summary
The facility failed to comprehensively assess, monitor, and implement interventions for a resident with a stage two pressure ulcer. The resident, who had severe cognitive impairment and required extensive assistance with activities of daily living, developed a pressure ulcer behind the left ear due to nasal cannula tubing. Despite being at moderate risk for pressure ulcer development, the resident's care plan and assessments lacked documentation of the pressure ulcer, and no interventions were implemented to prevent further skin breakdown. Observations and interviews revealed that nursing staff were unaware of the pressure ulcer and had not completed necessary assessments or documentation. A registered nurse discovered the ulcer during an observation and noted that it had not been assessed or measured previously. The facility's policy required a wound checklist to be completed when a new pressure ulcer was identified, but this was not done, leading to a lack of monitoring and intervention. Interviews with nursing staff and the director of nursing confirmed that the facility's procedures for pressure ulcer management were not followed. The resident's care plan was not updated to reflect the presence of the ulcer, and the necessary steps to promote healing and prevent further deterioration were not taken. The facility's policies on skin assessment and wound treatment documentation were not adhered to, resulting in inadequate care for the resident's pressure ulcer.
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Illustrative
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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Illustrative
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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 | 0.3 mi | ★★★★★ | 5 | 0 |
| Mn Veterans Home Fergus Falls | 2.1 mi | ★★★★★ | 8 | 1 |
| Good Samaritan Society - Battle Lake | 16.4 mi | ★★★★★ | 1 | 0 |
| Pelican Valley Health Center | 20.5 mi | ★★★★★ | 2 | 0 |
| St Francis Home | 25.2 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.