Below average — CMS composite of the measures below.
The next survey window likely opens around March 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 Thief River Care Center during CMS and state inspections, most recent first.
Incorrect MDS Coding of Aspirin as an Anticoagulant: The facility failed to code MDS medication data accurately for four residents. In each case, aspirin was present on the MAR and medication review as an antiplatelet, but the MDS either omitted antiplatelet coding or incorrectly coded aspirin as an anticoagulant. RN-A stated he had always coded aspirin as an anticoagulant, and the DON stated MDS assessments should be coded accurately to reflect resident care needs.
Failure to follow a resident’s check-and-change care plan. A resident with severe cognitive impairment, cerebral palsy spastic quadriplegia, bowel incontinence, and an indwelling urinary catheter was to be checked and changed every 2 hours and as needed, with peri care and barrier cream after incontinent episodes. During observation, the resident remained in a wheelchair through breakfast and activities without incontinence care, and staff later stated they were unsure when toileting had last occurred and were not consistently using the care sheet.
Failure to reposition a resident at risk for skin breakdown occurred when staff did not follow the care plan directing turning and repositioning every 2 hours. The resident had severe cognitive impairment, cerebral palsy spastic quadriplegia, was dependent for all care, and had a moderate Braden risk score. During observation, the resident spent time in the dining room, at activities, and in the common area without being repositioned, and staff could not identify when the last repositioning had occurred. An LPN, RN, and DON confirmed the resident was supposed to be repositioned per the care plan.
A resident who was cognitively intact, non-ambulatory, and fully dependent on two staff for transfers and toileting fell to the floor during a hoyer lift transfer when a sling strap came off. The facility’s investigation did not determine whether the resident had been left unattended in the bathroom or whether the straps were double checked before the transfer. Surveyors later observed two NAs leaving the resident unattended on the toilet with the sling still attached to the hoyer, and staff interviews confirmed this was routine practice despite the RN and DON stating residents should not be left alone in that situation.
A resident with severe cognitive impairment, cerebral palsy spastic quadriplegia, and an enteral feeding tube was observed being transferred and repositioned while the tube feeding continued to run. The resident was laid flat, then only briefly raised to about 20 degrees before later being elevated higher, even though the care plan and posted sign directed staff to pause the feeding whenever the resident was below 30 degrees and to have nursing restart it after care was complete. Interviews confirmed staff knew the feeding should have been stopped before the transfer and restarted afterward, but it was not done.
A resident with Alzheimer's disease and a history of exit-seeking behavior eloped from the facility during severe winter weather after staff failed to recognize and communicate recent exit-seeking behaviors, did not update the care plan or elopement risk assessment, and discontinued the use of a wander guard. The resident was found outside in a wheelchair, inadequately dressed, after being last seen in a common area. Documentation and communication lapses among staff contributed to the lack of supervision and failure to prevent the incident.
A resident with severe cognitive impairment and a history of falls was not assisted with toileting as per their care plan, leading to a fall and hip fracture. Despite expressing the need to use the bathroom, staff did not assist the resident, who attempted to self-transfer and fell. The facility's documentation lacked evidence of regular checks and assistance, and there were no audits to ensure compliance with care plan interventions.
The facility failed to maintain the required 180-degree rinse temperature in the dishwasher, compromising dish sanitization. Staff were inadequately trained on temperature monitoring, relying only on front gauges. Maintenance was not informed of the issue, and corrective actions were not consistently followed, leading to repeated instances of insufficient sanitization.
The facility failed to expand COVID-19 testing and contact tracing after positive cases were identified, contrary to CDC guidelines. Despite staff and residents potentially intermingling across units, broad-based testing was not conducted. Additionally, a resident with severe cognitive impairment and medical devices did not receive proper enhanced barrier precautions during care, as staff failed to wear appropriate PPE.
The facility failed to serve meals at safe and palatable temperatures, affecting five residents. Meals were served from an open cart, resulting in food temperatures significantly below the required 135 degrees. The issue was attributed to inadequate warming of the steam table and improper use of the plate warmer function.
A facility failed to assess a resident's electric scooter for mobility, despite the resident being cognitively intact and having discussed the scooter with staff. The care plan did not include the scooter, and no assessment or referral was documented. Social services staff believed an assessment was done, but physical therapy confirmed no referral was received. An undated note about a scooter evaluation was not communicated to nursing staff, and no policy on following up resident requests was provided.
The facility failed to update care plans for two residents, one requiring a new transfer status after a hip fracture and another needing a revised repositioning schedule due to a new skin issue. Despite changes in care needs, the care plans were not updated, leading to inconsistencies in care delivery.
A resident with severe cognitive impairment and incontinence was not provided timely toileting assistance as per her care plan, which required check and change every two hours due to impaired skin integrity. Observations showed the resident was not offered toileting from morning until late morning, resulting in soiled briefs and a scabbed area on her buttocks. Staff interviews revealed a lack of awareness and adherence to the updated care plan.
A resident experienced a significant weight gain and dependent edema, which the facility failed to assess or address. Despite a 13.79% weight increase and visible swelling in the resident's lower extremities, the care plan did not include interventions for these issues. Family concerns about the lack of leg elevation were noted, and although the facility notified the provider, no response or new interventions were documented. The facility's weight monitoring policy was not followed, leading to this deficiency.
A resident with severe cognitive impairment and at risk for pressure ulcers was not repositioned as required by their care plan, leading to the development of a new skin issue. Despite an updated care plan mandating repositioning every two hours, the resident remained in the same position for nearly four hours. Staff interviews revealed a lack of adherence to the repositioning schedule, and the facility's policy to establish individualized repositioning schedules was not effectively implemented.
A resident with a history of epilepsy experienced a seizure after receiving partial doses of Lamotrigine due to a medication administration error at the facility. The resident, who had been seizure-free since 2017, was prescribed Lamotrigine, Keppra, and Zonisamide. However, staff failed to administer the full dose of Lamotrigine on three occasions, leading to a breakthrough seizure and emergency department intervention. The error was attributed to confusion in the medication administration process and was not promptly identified or reported.
A facility failed to honor a resident's rights by removing his shoes to slow his movement, despite his severe cognitive impairment and need for assistance. The resident, diagnosed with Alzheimer's and dementia, was upset by the removal, and his family member confirmed he had to attend an appointment in the rain without shoes. Staff interviews revealed the shoes were taken to limit his mobility due to wandering, but there was no evidence of behaviors justifying this action. Facility policy allows residents to retain personal possessions unless it infringes on others' rights or safety.
A resident with Alzheimer's, dementia, anxiety, and depression, known for inappropriate behavior, was left unsupervised in the dining room and engaged in sexual contact with another female resident diagnosed with Hemiplegia, schizoaffective disorder, depression, anxiety, and aphasia. The incident, witnessed by a nursing assistant, highlighted a lapse in supervision protocols. Despite non-pharmacological interventions and antipsychotic medications, the resident's inappropriate behavior persisted, leading to the incident. Staff acknowledged the need for increased supervision, but the initial plan to have the resident be the first and last in the dining room was ineffective.
The facility failed to report an incident of resident-to-resident sexual abuse to law enforcement. A resident with Alzheimer's and dementia was observed rubbing the genital area of another resident with hemiplegia and schizoaffective disorder. The Director of Nursing admitted the incident was not reported and was unaware of the requirement to do so, violating the facility's policy on reporting suspected crimes.
The facility failed to report an allegation of sexual assault to the state agency for a cognitively impaired resident who accused a male nursing assistant of rape. Despite the resident's history of delusional behavior and false accusations, the facility's staff did not follow the required protocol to report the allegations immediately.
The facility failed to investigate a sexual assault allegation made by a cognitively impaired resident with a history of hallucinations and delusions. Despite the facility's policy requiring thorough investigations, no evidence of an investigation was found, and key staff were either not involved or unaware of the process.
Incorrect MDS Coding of Aspirin as an Anticoagulant
Penalty
Summary
The facility failed to ensure medications were coded correctly on the Minimum Data Set (MDS) for 4 of 7 residents reviewed for MDS discrepancies. For R22, the significant change MDS identified hyperlipidemia and coded an anticoagulant, antibiotic, diuretic, and hypoglycemic medication, but did not identify aspirin as an antiplatelet medication. R22’s March 2026 MAR showed aspirin 81 mg daily for hyperlipidemia, and R22 was not receiving an anticoagulant during that time. For R62, the quarterly MDS identified hyperlipidemia and coded an antipsychotic, antidepressant, anticoagulant, and diuretic, but did not identify aspirin as an antiplatelet medication. R62’s December 2025 MAR showed aspirin 81 mg daily for hyperlipidemia, and R62 was not receiving an anticoagulant during that time. For R29, the quarterly MDS identified diagnoses including lower extremity artery aneurysm, diabetes type II, depression, hypertension, and anxiety, and coded antipsychotic, antianxiety, antidepressant, anticoagulant, opioid, hypoglycemic, and anticonvulsant medications. However, the March 2026 MAR did not identify an anticoagulant during the observation period, and the Medication Review Report showed aspirin 81 mg daily for prophylactic use; R29 did not have a history of taking an anticoagulant. For R46, the quarterly MDS identified Alzheimer’s disease and diabetes type II and coded antipsychotic, antidepressant, anticoagulant, diuretic, and hypoglycemic medications, but the March 2026 MAR did not identify an anticoagulant during the observation period. The Medication Review Report showed aspirin EC 325 mg daily for ischemic cardiomyopathy, and R46 did not have a history of taking an anticoagulant. RN-A stated he had always coded aspirin as an anticoagulant medication, and the DON stated resident MDS assessments should be coded accurately to reflect care needs.
Failure to Follow Check-and-Change Care Plan
Penalty
Summary
The facility failed to follow the care plan for check and change for a resident with severe cognitive impairment and cerebral palsy spastic quadriplegia who was dependent on staff for all care. The resident’s MDS identified total dependence, and the urinary incontinence and indwelling catheter assessment noted an indwelling urinary catheter for chronic urinary retention secondary to cerebral palsy, with bowel incontinence and a need to be checked every 2 hours and as needed. The revised care plan directed staff to check and change the resident’s brief when repositioned, apply barrier cream, and provide peri care after each incontinent episode, with toileting/check-and-change every 2 hours and as needed. During continuous observation, the resident remained in a wheelchair in the common area through breakfast, group activities, and time in the common area without incontinence care being provided. When the resident was later transferred to bed, the brief was clean and dry. Staff interviews showed uncertainty about when the resident had last been toileted or checked, and one NA stated she did not have the care sheet and was not sure how often the resident needed toileting until she retrieved the sheet from the nurse’s desk. Another NA stated she was only helping with repositioning and did not know the last time the resident had been toileted. An LPN and RN stated the resident should have been toileted every 2 hours as care planned, and the DON stated staff were expected to follow the resident care plan.
Failure to Reposition a Resident at Risk for Skin Breakdown
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was cited after staff failed to turn and reposition a resident who was at risk for skin breakdown. The resident had severe cognitive impairment, cerebral palsy spastic quadriplegia, was dependent on staff for all care, and had a Braden score indicating moderate risk for skin breakdown. The resident’s care plan directed staff to turn and reposition every two hours, and the resident also had a history of recurrent redness under the bilateral breasts and lateral trunk folds, with pressure-reducing devices and a turning/repositioning program in place. During continuous observation, the resident attended breakfast in the dining room, participated in large group activities, and later returned to the common area to watch television, but staff did not reposition the resident during that period. At 9:58 a.m., two nursing assistants assisted the resident to lie down in bed using a full body mechanical lift. One NA stated she did not know the last time the resident had been repositioned, and another NA stated she was not sure how often the resident needed repositioning until she found the care sheet, which indicated every two hours. Staff also stated the resident had a bath earlier that morning, but no one could identify when the last repositioning had occurred. An LPN and RN confirmed the resident should have been repositioned every two hours per the care plan, and the DON stated staff were expected to follow the care plan.
Failure to Safely Supervise Hoyer Lift Transfers
Penalty
Summary
The facility failed to ensure staff comprehensively assessed falls and implemented appropriate interventions for a resident who was cognitively intact, dependent on two staff for ADLs including toileting and transfers, non-ambulatory, and had contractures of both lower extremities. The resident’s diagnoses included cerebral palsy, epilepsy, schizophrenia, and mild intellectual disability. The care plan identified the resident as totally dependent on two staff and requiring a total mechanical lift for transfers to and from the bed, wheelchair, and toilet, and also identified fall risk related to impaired mobility and psychoactive medication use. During a transfer from the toilet to the wheelchair using the hoyer lift, the top strap on the right side came off and the resident was lowered to the floor with the lift. The incident investigation stated staff were following the care plan, but it did not identify whether the resident could be left unattended in the bathroom with the hoyer or whether the straps had been double checked before the transfer. Survey observation later showed two NAs transferring the resident onto the toilet with the hoyer, leaving the sling attached to the lift, locking the brakes, and leaving the resident unattended in the bathroom. Staff interviews confirmed this was routine practice, while the RN and DON stated residents should not be left unattended on the toilet with the lift sheet under them and attached to the hoyer.
Improper Tube Feeding Management During Repositioning
Penalty
Summary
The facility failed to ensure proper positioning during gastrostomy tube care for a resident with severe cognitive impairment and cerebral palsy spastic quadriplegia who was dependent on staff for all care and had an enteral feeding tube. The resident’s care plan directed staff to keep the head of bed elevated above 30 degrees when the feeding was connected, and the care sheet instructed staff to stop the tube feeding before transfers and restart it afterward, with nursing staff to manage the feeding if nursing assistants were assisting with the transfer. During an observation, two nursing assistants used a full-body mechanical lift to place the resident in bed and performed turning and repositioning while the tube feeding continued to run. When the resident was initially laid down, the head of bed was flat, then raised only to about 20 degrees before later being raised to 45 degrees. A posted sign at the head of the bed reminded staff to have nurses pause the feeding when the resident was lying lower than 30 degrees during repositioning, transfers, or cares, but the nursing assistants did not ask a nurse to pause the feeding. Interviews with the nursing assistants, an LPN, an RN, and the DON confirmed staff were expected to stop the feeding before transfers and restart it afterward every time, but this did not occur during the observed care.
Failure to Prevent Elopement of Cognitively Impaired Resident During Hazardous Weather
Penalty
Summary
A deficiency occurred when a resident with a history of Alzheimer's disease, dementia, and paranoid personality disorder was not provided adequate supervision and was able to elope from the facility during hazardous winter weather. The resident had a documented history of exit-seeking behavior, impaired cognition, and poor safety awareness, and had previously required a wander guard device. However, the wander guard was discontinued after staff determined there were no recent exit-seeking behaviors, and the elopement risk was removed from the care plan. Despite this, the resident continued to display confusion, impulsivity, and had triggers related to the holiday season that were not adequately considered in risk assessments or care planning. On the day of the incident, the resident was last seen by staff in the facility's common area and was later found outside in a wheelchair, inadequately dressed for the severe weather conditions. The resident had expressed a desire to leave and was looking for his truck the evening prior, but this information was not effectively communicated between shifts. Staff interviews revealed that the resident required supervision due to his cognitive deficits and that staff were expected to check on him every two to three hours, but closer monitoring was not implemented despite recent exit-seeking behaviors. Documentation and communication failures contributed to the deficiency. The resident's care plan and elopement risk assessments did not reflect his ongoing risk factors, including his history of elopement, cognitive impairment, and seasonal behavioral triggers. Staff were unaware of the resident's increased risk and did not implement appropriate interventions or monitoring. The lack of timely reassessment and failure to update the care plan after the resident expressed exit-seeking behavior directly led to the resident's unsupervised exit during dangerous weather conditions.
Removal Plan
- A complete head to toe health assessment was completed for R1 upon return to facility
- R1's provider was updated
- An elopement assessment with past and recent risk for elopement was included
- A wander guard was placed on R1's wheelchair
- Reviewed and revised R1's care plan to ensure it included details related to holiday challenges, staff communication, behavioral tracking, and interventions for exit seeking
- Elopement assessment practices were reviewed and revised to best determine resident elopement risk, including consideration of history, mental health, seasonal challenges, and medication changes
- Nursing staff completing elopement assessments were retrained on recognizing and responding to exit seeking behavior
- All staff were trained on R1's care plan changes and facility policy changes
- Facility education document 'Critical Safety Alert: Elopement Prevention & Emergency Protocol' with mandatory interventions and communication requirements was issued
Failure to Assist Resident with Toileting Leads to Fall and Injury
Penalty
Summary
The facility failed to ensure a dependent resident was toileted per request, resulting in actual harm when the resident fell while attempting to self-transfer to the toilet, leading to a hip fracture. The resident, who had severe cognitive impairment and was dependent on staff for toileting, had a history of falls since admission. Despite being care planned for frequent toileting assistance, the resident was not adequately supervised or assisted when expressing the need to use the bathroom. On the day of the incident, the resident expressed a need to use the bathroom after being toileted thirty minutes prior. An activities aide informed nursing assistants of the resident's request, but they did not assist the resident as they were busy with meal service. The resident, unable to wait, attempted to go to the bathroom independently and was later found on the floor with a hip fracture. The care plan directed staff to anticipate and meet the resident's needs, including toileting every two hours and before and after meals, but documentation showed these interventions were not consistently followed. Interviews with staff and family members revealed that the resident was anxious about having accidents and would often attempt to toilet herself. The facility's documentation lacked evidence of regular checks and assistance as per the care plan, and there were no audits to ensure compliance with the care plan interventions. The facility's fall prevention policy required a comprehensive assessment and intervention plan for residents with multiple falls, but it appears this was not effectively implemented for the resident in question.
Dishwasher Temperature Deficiency
Penalty
Summary
The facility failed to ensure that the final rinse temperature of the dishwasher reached the required 180 degrees Fahrenheit to properly sanitize dishes. This deficiency was observed during a kitchen tour where a dietary aide ran plate covers through the dishwasher multiple times, with the rinse temperature only reaching 180 degrees on the third attempt. The temperature logs for January and December showed multiple instances where the rinse temperature was recorded below the required 180 degrees, indicating a recurring issue. Interviews with staff revealed a lack of proper communication and training regarding the dishwasher's operation and temperature monitoring. The dietary aide and cook were unaware of alternative methods to check the dishwasher's temperature, relying solely on the front gauges. Maintenance staff were not informed of the dishwasher's issues, and the repair technician did not provide training on accurate temperature measurement methods. This lack of communication and training contributed to the failure to maintain proper sanitization standards. The facility's policy required a minimum rinse temperature of 180 degrees for sanitization, and staff were expected to take corrective actions if this was not achieved. However, the staff did not consistently follow these procedures, as evidenced by the dietary aide's admission of not knowing what else to do when the rinse temperature was insufficient. The director of dietary services acknowledged the need for staff training in this area, highlighting the deficiency in ensuring proper dish sanitization.
Failure to Expand COVID-19 Testing and Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to expand COVID-19 testing and contact tracing of staff and residents on other units after residents tested positive for COVID-19, as per CDC guidelines. Initially, a nursing assistant (NA-E) developed symptoms and tested positive for COVID-19 after working on the Evergreen unit. Following this, four residents on the same unit also tested positive. Despite these cases, the facility did not extend testing to other units or conduct broad-based testing of all staff and residents, even though staff and residents from different units could potentially intermingle during shifts and activities. The facility's COVID-19 outbreak document indicated that high-risk staff and residents on the Evergreen unit were tested, but other staff and residents who might have been exposed were not included in the testing protocol. The Director of Nursing acknowledged that the facility should have tested the entire facility once additional cases were identified, as staff worked across different units, increasing the risk of spreading the virus. The facility's policy required broad testing if close exposure could not be determined, but this was not implemented. Additionally, the facility failed to implement enhanced barrier precautions (EBP) for a resident with severely impaired cognition and multiple medical devices. During an observation, a nursing assistant did not wear a gown while providing high-contact care, which included peri care and transferring the resident, despite the presence of a PPE cart and signage indicating the need for EBP. The infection preventionist confirmed that staff were educated on EBP and should have worn the appropriate PPE during such care activities.
Failure to Serve Meals at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to ensure that food was served at warm, palatable temperatures for five residents who received meal trays that were out of the acceptable temperature range. On a specific date, a resident with intact cognition and independent eating abilities reported that meals served in their room were almost always cold, regardless of the meal time. Observations during the supper meal service on the Blueberry unit revealed that residents were served meals from an open metal cart, and the food temperatures were significantly below the required 135 degrees, with a hot dog measuring 99.5 degrees and tater tots at 94 degrees. The cook acknowledged that the food was cold and attributed the issue to the dietary aide not allowing the steam table to warm up adequately before meal service and not using the plate warmer function. The Director of Nursing confirmed that the food temperatures were unacceptable and unappetizing. The Director of Dietary Services noted that the use of an open tray cart could contribute to the food cooling off quickly, and reiterated that food is not safe if the temperature drops below 135 degrees. The facility's policy on General Food Preparation and Handling requires all meats to be heated to a safe minimum internal temperature, with hot holding temperatures maintained at 135 degrees.
Failure to Assess Resident's Electric Scooter for Mobility
Penalty
Summary
The facility failed to complete an assessment for a resident's electric scooter, which was intended to increase the resident's mobility. The resident, who was cognitively intact and independent with bed mobility, had a care plan that did not include the use of an electric scooter, despite the resident having one at home and discussing it with the staff. The resident's care plan only mentioned the use of a walker and wheelchair for mobility and required assistance for transfers and walking. The resident's care conference notes and medical records lacked any mention or assessment of the electric scooter. The resident's electric scooter was brought to the facility by the resident's son, but no follow-up was conducted by the staff. Social services staff believed the resident was assessed by occupational therapy and deemed not strong enough to use the scooter, but there was no documentation to support this. The physical therapy assistant confirmed that no referral for scooter assessment was received. An undated note by social services staff mentioned a scooter evaluation but was not communicated to the nursing staff. The facility did not provide a policy regarding follow-up on resident requests.
Failure to Update Care Plans for Transfer and Repositioning Needs
Penalty
Summary
The facility failed to update the care plan for a resident with a new transfer status following a fall that resulted in a hip fracture. The resident, who had severe cognitive impairment, was initially dependent on staff for toileting transfer and was weight-bearing as tolerated. However, after the fall, the resident became non-weight bearing and required a Hoyer lift for transfers. Despite this change, the care plan was not updated to reflect the new transfer needs, leading to inconsistencies in the care provided. Nursing assistants reported using the Hoyer lift, but the care plan did not accurately reflect this requirement, which was acknowledged by the Director of Nursing. Additionally, the facility failed to update the care plan for another resident who developed a new skin issue. This resident, also with severe cognitive impairment, required substantial assistance with turning and repositioning and was at risk for pressure ulcers. Although the resident's care plan initially indicated repositioning every three hours, a new skin issue necessitated repositioning every two hours. While this change was communicated to the nursing staff and assistants, it was not updated in the care plan, leading to potential inconsistencies in care delivery. The facility's policy required that care plans be updated to reflect immediate health and safety concerns, which was not adhered to in these cases.
Failure to Provide Timely Toileting Assistance
Penalty
Summary
The facility failed to provide timely assistance with toileting and incontinence care for a resident with severe cognitive impairment and dependency on staff for activities of daily living. The resident, who was incontinent of bowel and bladder, was observed from 7:18 a.m. to 11:13 a.m. without being offered toileting assistance, despite being involved in various activities and remaining in her wheelchair. The resident's care plan required toileting and incontinence care every three hours and as needed, but this was not adhered to during the observation period. Interviews with nursing assistants revealed a lack of awareness and adherence to the updated care plan, which required check and change every two hours due to a new area of impaired skin integrity. The nursing assistant assigned to the resident was unsure of the last time the resident was checked or offered toileting assistance, and it was noted that the resident had a small amount of feces and urine in her brief, along with a scabbed area on her buttocks. The facility's policy on urinary incontinence care was not followed, as confirmed by the director of nursing, who stated that staff were expected to adhere to the care plan to prevent incontinence-related complications.
Failure to Address Significant Weight Gain and Edema in Resident
Penalty
Summary
The facility failed to identify and address a significant weight gain and dependent edema in a resident, R55, who was admitted with intact cognition and required assistance with activities of daily living. R55's medical record showed a weight increase from 203 lbs at admission to 231 lbs over a period of approximately two months, indicating a 13.79% gain. Despite this significant weight gain, the facility did not conduct a comprehensive assessment or implement interventions to address the edema or weight gain. The care plan for R55 did not include issues related to intact skin, weight, or edema, and there was no evidence in the medical record that the weight gains were assessed or that interventions were implemented. Observations and interviews revealed that R55 had significant swelling in both lower extremities, which was not adequately addressed by the facility. Family members expressed concerns about the lack of attempts to have R55 lie down or elevate his legs to reduce swelling. Although the facility notified R55's provider about the edema and requested compression wraps, there was no response, and no new interventions were attempted. The facility's weight monitoring program policy required that medically significant weight gains be assessed and tracked, but this was not done for R55. Staff interviews indicated a lack of documentation and follow-up on the resident's weight gain and edema, contributing to the deficiency.
Failure to Reposition Resident Leads to Pressure Ulcer Development
Penalty
Summary
The facility failed to provide timely repositioning for a resident (R8) who was at risk for pressure ulcers. R8 had severe cognitive impairment and required substantial assistance with turning and repositioning. Despite being identified as at moderate risk for developing pressure ulcers, R8's care plan initially required repositioning every three hours, which was later updated to every two hours after a new skin issue was identified. Observations on a specific day revealed that R8 was not repositioned for nearly four hours while seated in a wheelchair, contrary to the updated care plan. Interviews with staff indicated a lack of adherence to the updated repositioning schedule. A nursing assistant assigned to R8 was unaware of when the last repositioning occurred and admitted to not repositioning R8 after breakfast. The director of nursing confirmed that staff were expected to follow the care plan, which included timely repositioning. The facility's policy aimed to establish individualized repositioning schedules based on skin assessments, but this was not effectively implemented for R8, leading to the development of a new skin issue.
Medication Administration Error Leads to Resident Seizure
Penalty
Summary
The facility failed to ensure that physician orders for an anticonvulsant medication were administered correctly for a resident with a seizure disorder. The resident, who had a history of epilepsy and had been seizure-free since 2017, was prescribed Lamotrigine, Keppra, and Zonisamide to manage his condition. However, due to a medication administration error, the resident received partial doses of Lamotrigine on three separate days, which led to a breakthrough seizure. The resident was subsequently transported to the emergency department for medical intervention. The medication error occurred because the nursing staff did not follow the correct procedure for administering the resident's Lamotrigine. The medication was provided in three separate punch cards, and staff failed to administer the full dose as ordered. Specifically, 200 mg of Lamotrigine was omitted on three occasions, resulting in the resident receiving only 250 mg instead of the prescribed 450 mg. This error was not immediately identified, and the resident experienced a seizure, which was likely due to the inadequate dosing. Interviews with facility staff revealed that the medication administration process was confusing, leading to the error. The staff did not consistently start at the correct position on the medication punch cards, and the sequence of administration was disrupted. This oversight was compounded by the fact that the error was not promptly reported or addressed, resulting in harm to the resident. The facility's failure to adhere to the prescribed medication regimen and ensure accurate administration of anticonvulsant drugs directly contributed to the resident's seizure.
Facility Failed to Honor Resident's Rights by Removing Shoes
Penalty
Summary
The facility failed to honor a resident's rights by removing his shoes to slow his movement within the facility. The resident, who had diagnoses including Alzheimer's, dementia, anxiety, and depression, was identified as having severe cognitive impairment and required assistance with transfers but could self-propel short distances in his wheelchair. The facility's action to take away his shoes was documented in a report log, and during an observation, the resident's family member confirmed that the shoes were taken to limit his mobility, which upset the resident. The family member also reported that the resident had to attend a dental appointment in the rain without shoes, as the facility refused to provide them. Interviews with facility staff, including a registered nurse and a nursing assistant, revealed that the shoes were removed to slow the resident down due to his wandering behavior. The director of nursing mentioned that the shoes were taken because the resident had behaviors such as kicking staff when agitated, although there was no evidence in the medical record to support this claim. The facility's policy on resident rights indicated that residents should be allowed to retain personal possessions, including clothing, unless it infringes on the rights or safety of others. However, the facility did not provide evidence that the resident's behavior posed such a risk.
Inadequate Supervision Leads to Resident-to-Resident Sexual Abuse Incident
Penalty
Summary
The facility failed to ensure adequate supervision to prevent resident-to-resident sexual abuse when a resident (R1) with a history of inappropriate behavior was found engaging in sexual contact with another female resident (R2) in the dining room. R1, diagnosed with Alzheimer's, dementia, anxiety, and depression, had a documented history of inappropriate actions and touching female residents. Despite being identified as needing assistance with transfer and self-propelled in his wheelchair, R1 was left unsupervised in the dining room, where he engaged in inappropriate behavior with R2, who had a diagnosis of Hemiplegia, schizoaffective disorder, depression, anxiety, and aphasia. The incident of sexual abuse was witnessed by a nursing assistant, highlighting the lack of supervision at the time. The facility's failure to adequately supervise R1 to prevent resident-to-resident sexual abuse resulted in an immediate jeopardy situation for R2, who expressed feeling uncomfortable and scared during the incident. The investigation revealed that R1 had a pattern of inappropriate behavior towards female residents, leading to the implementation of non-pharmacological interventions and eventually the addition of antipsychotic medications. Despite these interventions, R1 was still able to engage in sexual abuse towards R2 in the dining room, indicating a lapse in supervision protocols. The facility's response to the incident included changes in R1's seating arrangements, increased supervision during meals and activities, and ongoing monitoring to prevent further incidents. Multiple staff members acknowledged the need for increased supervision of R1 following the incident, with interventions such as hourly checks, changing R1's seating arrangements, and ensuring staff members were present during R1's time in common areas. The facility's initial plan to have R1 be the first and last resident in the dining room for supervision was deemed ineffective as staff left him unsupervised, leading to the resident-to-resident sexual abuse incident. The lack of a 24-hour supervision plan for R1 raised concerns about the facility's ability to prevent future incidents of abuse.
Failure to Report Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to report an incident of resident-to-resident sexual abuse to law enforcement. Resident 1, who has Alzheimer's, dementia, anxiety, and depression, was observed by a nursing assistant rubbing the genital area of Resident 2 in the dining room. Resident 2, who has hemiplegia, schizoaffective disorder, depression, anxiety, and aphasia, expressed discomfort and fear during the incident. The Director of Nursing admitted that the incident was not reported to law enforcement and was unaware of the requirement to do so. Resident 1's service plan had previously noted inappropriate actions and touching of female residents, indicating a history of such behavior. Despite this, no immediate action was taken to report the incident to the appropriate authorities. The facility's policy on reporting reasonable suspicion of a crime was not followed, as it mandates reporting to the Minnesota Adult Abuse Reporting Center and the state agency. This oversight led to a failure in ensuring the safety and well-being of the residents involved.
Failure to Report Allegation of Sexual Assault
Penalty
Summary
The facility failed to report an allegation of sexual assault to the state agency for a resident who alleged she had been raped at the facility. The resident, who had diagnoses including Parkinsonism, Alzheimer's disease, and dementia, exhibited severe cognitive impairment and displayed physical and verbal behaviors, hallucinations, and delusions. Despite these behaviors, the facility's care plan noted that the resident had a history of making false accusations about staff. On multiple occasions, the resident accused a male nursing assistant of raping her, but these allegations were not substantiated. The facility's progress notes documented these accusations, but the allegations were not reported to the state agency as required by the facility's maltreatment reporting guidelines. Interviews with facility staff, including the social services designee, director of nursing, and registered nurses, revealed that they were aware of the resident's accusations but did not report them to the state agency. The director of nursing and registered nurses acknowledged the resident's cognitive impairments and history of delusional behavior but did not take the necessary steps to report the allegations. The facility's administrator also confirmed that the allegations had not been reported and stated that she was unaware of the rape allegations. The facility's policy required immediate reporting of any suspected maltreatment, including abuse, neglect, exploitation, or misappropriation of resident property, but this protocol was not followed in this case.
Failure to Investigate Allegation of Sexual Assault
Penalty
Summary
The facility failed to thoroughly investigate an allegation of sexual assault made by a resident (R4) who had severe cognitive impairment and a history of hallucinations and delusions. R4's care plan indicated that she exhibited auditory hallucinations and had a history of making false accusations about staff. Despite R4's severe cognitive impairment and history of delusional behavior, the facility did not conduct a thorough investigation into her allegations of rape. The Director of Nursing (DON) admitted that no evidence of an investigation was available because they did not believe the rape had occurred. Additionally, the social services designee (SSD) and the administrator were not involved in or aware of the investigation process, respectively. The facility's policy on maltreatment reporting required staff to begin an investigation of alleged maltreatment, including resident and staff interviews, observations, and medical record reviews. However, this protocol was not followed in R4's case. The DON stated that a registered nurse (RN) had spoken with R4 and determined that the rape had not occurred, but there was no documentation or evidence to support that an investigation had been completed. This lack of a thorough investigation is a clear violation of the facility's maltreatment reporting guidelines and demonstrates a failure to respond appropriately to serious allegations made by a resident with severe cognitive impairments.
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 19 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Thief River Falls
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oakland Park Communities, Inc. | 0.2 mi | ★★★★★ | 19 | 0 |
| North Star Manor | 28.1 mi | ★★★★★ | 0 | 0 |
| Villa St Vincent | 29.6 mi | ★★★★★ | 16 | 1 |
| Mcintosh Senior Living | 34.8 mi | ★★★★★ | 6 | 0 |
| Karlstad Healthcare Center Inc | 36 mi | ★★★★★ | 7 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.