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Nursing HomeMedicaid Investigative

Pioneer Care and Rehabilitation

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

200 N Oregon St, Dillon, MT 5972587 bedsLicensed & Active
1/5
Medicare
Inspection
Quality
Staffing
Google rating
3.2/5

based on 15 Google reviews

5
4
3
2
1

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5/ 10
high Risk

Quality Concerns Identified

Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.

  • Low overall rating (1/5 stars)
  • Low staffing rating (2/5 stars)
  • Above-median deficiencies (20 vs median 9.0)
  • High staff turnover (88%)

Bottom 25% in MT · Below recommended RN staffing · Very high staff turnover · Worst in SWEETWATER CARE chain · $158,103 in fines

Source: Medicare data

What this means for your family

This facility has shown a concerning downward trend in quality over the last several years, with multiple recent reports of medical neglect and severe understaffing. While the therapy department has historically been a strength, families should exercise extreme caution and conduct an in-person tour to verify current hygiene and staffing levels before considering this facility.

Google Reviews

Google Reviews

15 reviews on Google
Pioneer Care and Rehabilitation receives highly polarized feedback, with recent reviews highlighting significant concerns regarding neglect, poor communication, and unprofessional management. While some older reviews praise the therapy team and staff dedication, recent experiences describe a facility struggling with chronic understaffing, poor hygiene, and inadequate medical care.

Quality Themes

Tap a score for details
Food1.0Staff3.0Clean1.0ActivitiesN/AMeds1.0MemoryN/AComms2.0ValueN/A

Strengths

  • Effective rehabilitation therapy programs
  • Some friendly and dedicated nursing staff
  • Welcoming environment for visitors

Concerns

  • Chronic understaffing and reliance on travel staff (mentioned by 3 reviewers)
  • Unprofessional or rude management/administrative staff (mentioned by 3 reviewers)
  • Poor hygiene, cleanliness, and facility maintenance (mentioned by 2 reviewers)
  • Inadequate response to call lights and resident needs (mentioned by 2 reviewers)

Rating Trends

Tap a year to see what changed

234'13(1)'15(1)'20(1)'22(2)'24(1)'26(1)

Distribution · 15 analyzed

5
6
4
1
3
2
2
2
1
4

How They Respond to Reviews

0%response rate

Questions for Your Tour

  • 1Given the facility's current reliance on travel staff, how do you ensure consistent, personalized care and familiarity for my loved one throughout the week?
  • 2I noticed some concerns regarding facility maintenance; what is your current plan or schedule for deep cleaning and addressing repairs in resident living areas?
  • 3How does your leadership team handle communication with families when concerns about administrative responsiveness or staff interactions arise?
  • 4With the current staffing levels, what is your protocol for ensuring that call lights are answered promptly and resident needs are met in a timely manner?
  • 5Could you walk me through your process for medication management and how you ensure accuracy, especially during staff shift changes?
  • 6What specific steps are you taking to improve the dining experience and nutritional variety for residents, given the feedback on food quality?

Personalized based on this facility's data


Key Review Excerpts

The neglect was beyond horrible. My son was 100% tube fed. They had to feed him and provide water through his feeding tube. The oral care, more than once the hospital removed huge chunks of yuk from his mouth.

Long-term resident's family · 2026☆☆☆☆

This facility is roughly 95% travel nurses and aides and chronically understaffed. Ask anybody in town, they'll warn you about this place and that horrible woman.

Community member · 2025★★☆☆☆

The therapy seems to be great there, as my dad has made progress. The director of nursing, Jocelyn is rude, unprofessional, very impatient and quick to hand off any phone calls or questions to other staff.

Rehab patient's family · 2021★★☆☆☆
Source: 15 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.53hrs
71%
Registered nurses for medical care
Total Nursing
3.64hrs
89%
All nurses + aides combined
Staff Turnover
88%
Lower is better (< 30% = good)
RN Turnover
71%
Lower is better (< 30% = good)

Both RN and total nursing hours are below national benchmarks. This can mean less clinical attention per resident, so ask about their staffing plan.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 17 measures

Medicare Rating
3/ 5
Better Than Avg

9

measures

Worse Than Avg

5

measures

Mixed Results

3

measures

Long-Stay Residents
🚶

Residents whose walking got worse

↓ Lower is better
This Facility2.3%
Better than Avg
Here
2.3%
US
15.3%
MT
19.1%
🛏️

Residents needing more daily help over time

↓ Lower is better
This Facility6.1%
Better than Avg
Here
6.1%
US
14.4%
MT
19.4%
🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility15.1%
Better than Avg
Here
15.1%
US
19.4%
MT
25.2%
💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility11.9%
Better than Avg
Here
11.9%
US
19.5%
MT
16.4%
💉

Residents vaccinated for pneumonia

↑ Higher is better
This Facility88.8%
Worse than Avg
Here
88.8%
US
93.4%
MT
95.6%
😔

Residents with depression symptoms

↓ Lower is better
This Facility9.8%
Mixed vs Avgs
Here
9.8%
US
12.1%
MT
5.0%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility41.2%
Worse than Avg
Here
41.2%
US
79.8%
MT
73.8%
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility51.2%
Worse than Avg
Here
51.2%
US
81.8%
MT
79.2%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility8.5%
Worse than Avg
Here
8.5%
US
1.6%
MT
1.4%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

20deficiencies
6penalties
Well above state avg (11.3)
14 complaint-triggered
$158,103 in fines

This facility shows concerning patterns with families filing multiple complaints about safety hazards, medication management, and infection control issues. Safety hazard deficiencies occurred three times including one complaint-triggered case, while medication errors appeared in both regular and complaint inspections. Additional complaint areas included care planning problems, resident discharge issues, and protection of belongings, indicating families have raised serious concerns about multiple aspects of care quality and resident safety.

Dec 31, 2025Complaint
1
0744Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

May 8, 2025Routine
25
0689Actual harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0841Potential for harm · WidespreadCorrected

Nursing and Physician Services Deficiencies

Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.

0882Potential for harm · WidespreadCorrected

Infection Control Deficiencies

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

0022Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Establish policies and procedures for sheltering.

0024Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Establish policies and procedures for volunteers.

0026Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Establish roles under a Waiver declared by secretary.

0039Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Conduct testing and exercise requirements.

0578Potential for harm · PatternCorrected

Resident Rights Deficiencies

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

0756Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

0881Potential for harm · PatternCorrected

Infection Control Deficiencies

Implement a program that monitors antibiotic use.

0609Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

0627Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.

0628Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

0655Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

0676Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

0692Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

0695Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

0697Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

0760Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

0761Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

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.

0880Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0943Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

0211Potential for harm · IsolatedCorrected

Egress Deficiencies

Keep aisles, corridors, and exits free of obstruction in case of emergency.

0271Potential for harm · IsolatedCorrected

Egress Deficiencies

Have exits that are accessible at all times.

0355Potential for harm · IsolatedCorrected

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

May 8, 2025Complaint
1
0865Potential for harm · WidespreadCorrected

Administration Deficiencies

Have a plan that describes the process for conducting QAPI and QAA activities.

Feb 27, 2025Complaint
2
0835Potential for harm · PatternCorrected

Administration Deficiencies

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

0755Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Dec 5, 2024Complaint
2
0760Actual harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

0880Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Aug 27, 2024Complaint
1
0689Actual harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Federal Penalties

Fine

Feb 19, 2026

$7,360

Fine

May 8, 2025

$48,464

Fine

Dec 5, 2024

$12,529

Fine

Aug 27, 2024

$18,850

Fine

May 21, 2024

$40,641

Fine

Jan 4, 2024

$12,786

Ownership & Operations

Who Operates This Facility

Owner / Operator

Pioneer Care and Rehabilitation

Organization Type

for profit

Chain Affiliation

Chain Name

Sweetwater Care

Chain Size

10 facilities nationwide

Chain avg rating: 2.8/5 · Rank 9 of 9 (Worst)

Ownership & Management

Owners

Sweetwater Care Opco LLC

Owner (parent company) · Organization

Chesley, Aaron

Owner (parent company)

Key personnel

Boesch, MadisonW-2 Managing EmployeeCrickmore, ReidW-2 Managing EmployeeChesley, AaronOfficer / Director
Source: Medicare provider data

Contact

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References & Resources

EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.

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