Pioneer Care Center
1131 South Mabelle Avenue, Fergus Falls, MN 56537 · Otter Tail County · 105 certified beds · avg 91 residents/day · certified since Apr 11, 1987
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★★☆4/5 · CMS overall rating: 5/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
All citations in the current public record (16)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Aug 6, 2025 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Aug 6, 2025 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Aug 6, 2025 | D · Potential for harm, one-off | The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. |
| Aug 6, 2025 | D · Potential for harm, one-off | The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment. |
| Aug 6, 2025 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Aug 6, 2025 | D · Potential for harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Aug 6, 2025 | C · Minimal risk, facility-wide | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. |
| May 27, 2025 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| May 27, 2025 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| May 27, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| May 16, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jul 24, 2024 | D · Potential for harm, one-off | The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. |
| Jul 24, 2024 | D · Potential for harm, one-off | The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have. |
| Jul 24, 2024 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Jan 9, 2024 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Sep 13, 2023 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
Inspection trend by year
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 1 | 0 | D |
| 2024 | 4 | 0 | D |
| 2025 | 11 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
No fines or payment denials in the published 3-year window.
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Minnesota avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 4.61 | 4.83 | 3.95 | bottom 43% in Minnesota; top 20% in the U.S. |
| Registered Nurse hours | 1.06 | 1.22 | 0.69 | bottom 41% in Minnesota; top 13% in the U.S. |
| Weekend total nurse staffing | 4.18 | 4.27 | 3.50 | top 50% in Minnesota; top 18% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.60 | 0.69 | 0.48 | top 49% in Minnesota; top 23% in the U.S. |
| Total nursing staff turnover (%) | 32.7 | 42.2 | 45.8 | top 29% in Minnesota; top 19% in the U.S. |
| RN turnover (%) | 21.1 | 38.6 | 42.9 | top 20% in Minnesota; top 16% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.55, RN 1.04, weekend 4.13. Staffing rating: 5/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 4/5 · short-stay residents: 4/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Ackerson, Jeff | Individual | Managing Control - Governing Body | NOT APPLICABLE | 04/01/2018 |
| Ackerson, Jeff | Individual | Corporate Director | NOT APPLICABLE | 04/01/2018 |
| Aegis Therapies, INC. | Organization | ADP of the SNF | NOT APPLICABLE | 06/01/2021 |
| Brenna, Lowell | Individual | Managing Control - Governing Body | NOT APPLICABLE | 04/01/2021 |
| Brenna, Lowell | Individual | Corporate Officer | NOT APPLICABLE | 04/01/2021 |
| Bushinger, Brad | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/02/1996 |
| Demuth, Suzanne | Individual | Managing Control - Governing Body | NOT APPLICABLE | 04/01/2020 |
| Demuth, Suzanne | Individual | Corporate Officer | NOT APPLICABLE | 04/01/2020 |
| Ellig, Joe | Individual | Managing Control - Governing Body | NOT APPLICABLE | 04/01/2020 |
| Ellig, Joe | Individual | Corporate Officer | NOT APPLICABLE | 04/01/2020 |
| Freeman, Janet | Individual | Managing Control - Governing Body | NOT APPLICABLE | 04/01/2019 |
| Freeman, Janet | Individual | Corporate Officer | NOT APPLICABLE | 04/01/2019 |
| Hocum, April | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/01/2025 |
| Hunter, Katie | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/24/2012 |
| Johnson, Kari | Individual | Managing Control - Governing Body | NOT APPLICABLE | 04/01/2025 |
| Johnson, Kari | Individual | Corporate Officer | NOT APPLICABLE | 04/01/2025 |
| Johnson, Nathan | Individual | Managing Control - Governing Body | NOT APPLICABLE | 11/03/2009 |
| Johnson, Nathan | Individual | Corporate Director | NOT APPLICABLE | 11/03/2009 |
| Johnson, Nathan | Individual | Operational/Managerial Control | NOT APPLICABLE | 11/03/2009 |
| Johnson, Nathan | Individual | ADP of the SNF | NOT APPLICABLE | 11/03/2009 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "If my family member is able to manage their own medications, would you allow it, and how is that decided?"
- "What is your policy on physical restraints, and what alternatives do you try first?"
- "Who completes resident assessments here, and how do you check them for accuracy?"
- "What do you do daily to keep residents moving, and how do you help residents at risk of losing mobility?"
- "Where do you post your daily staffing numbers, and can I see today's?"
- "If my family member falls or their condition changes, exactly when and how will I be notified?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| LB Broen Home | 0.3 mi | Fergus Falls, MN | ★★☆☆☆ | 2/5 | |
| MN Veterans Home-Fergus Falls | 2.1 mi | Fergus Falls, MN | ★★★★☆ | 2/5 | abuse |
| Good Samaritan Society - Battle Lake | 16.4 mi | Battle Lake, MN | ★★★★★ | 5/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 245463.