Thief River Care Center
THIEF RIVER CARE CENTER in THIEF RIVER FALLS, MN — inspection on December 30, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
holiday challenges, how staff will communicate, behavioral tracking and interventions that will be
jeopardy to resident health or revised as needed to best determine resident elopement risk. (i.e. ensure other factors such as safety history, mental health, seasonal challenges, med changes are considered) -Nursing staff completing elopement assessments were retrained on recognizing and responding to exit seeking behavior.
document Critical Safety Alert: Elopement Prevention & Emergency Protocol dated 12/18/25, identified: this training is issued following a critical safety event where a resident with Alzheimer's successfully eloped from the facility during dangerous blizzard conditions.
This lapse in clinical judgement and protocol adherence placed a vulnerable life at immediate risk:1.
Zero Tolerance for Reasoning: Attempting to reason with a cognitively impaired resident regarding their safety is clinically insufficient and an unacceptable intervention. If a resident vocalizes a desire to leave and/or displays wandering behavior, you must take immediate physical action.2. MANDATORY Immediate Interventions: When exit-seeking behavior is identified, the following actions must be taken immediately: Elopement Assessment, interventions must be documented immediately, wander guard placement, increased Surveillance, environmental Safety. 3.
Failed Communication - Endangerment: Communication breakdowns are the primary cause of elopement: Mandatory Handover- you are required to provide a detailed verbal or written report to the oncoming shift and the nurse in charge regarding any wandering or behavioral changes.
Point Click Care (PCC) Entry - Documentation of elopement prevention protocols must be entered into PCC immediately and not at the end of the shift.4.
Professional & Legal Consequences: State reporting and Disciplinary Action.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.