Thief River Care Center
THIEF RIVER CARE CENTER in THIEF RIVER FALLS, MN — inspection on April 1, 2026.
Found 5 citations. 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
During an interview on 4/1/26 at 2:53 p.m., registered nurse (RN)-A stated he was the facility's MDS coordinator. RN-A had always coded aspirin as an anticoagulant medication and had never been told differently.
During an interview on 4/1/26 at 3:57 p.m., the director of nursing (DON) stated the resident MDS assessments should be coded accurately to ensure the MDS reflected the resident's care needs.
The facility policy MDS 3.0 Assessment reviewed/amended 8/20/24, identified the facility would conduct comprehensive, accurate and standardized assessments known as Minimum Data Set (MDS) for each resident, as specified in the Centers for Medicare and Medicaid and the State of Minnesota Resident Assessment Instrument (RAI) Manual.
The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated October 2025, instructed to code all high-risk drug class medication according to their pharmacological classification, not how they were being used: N0415I1.
Antiplatelet: Check if an antiplatelet medication (e.g., aspirin/extended release) was taken by the resident at any time during the 7-day observation period (or since admission/entry or reentry if less than 7 days).
245252 04/01/2026
Thief River Care Center 2001 Eastwood Drive Thief River Falls, MN 56701
During this time, R10 attended breakfast in the dining room, attended large group activities and returned to the common area to watch television.
Staff did not provide incontinence care for R10. At 4/1/26 9:58 a.m., nursing assistant (NA)-A pushed R10's wheelchair to R10's room and stated she was just waiting for NA-D to come with the full body mechanical lift to reposition R10.
NA-A and NA-D transferred R10 into bed, however, R10's incontinence brief was clean and dry.During an interview on 4/1/26 at 10:15 a.m., NA-D stated she was only helping NA-A to reposition R10 and did not know the last time R10 had been toileted.
During an interview on 4/1/26 at 10:48 a.m., NA-A stated she didn't have a care sheet and was not sure how often R10 needed to be toileted. NA-A went to the nurses' desk and picked up a resident care sheet and stated R10 required toileting every two hours. NA-A stated staff were expected to write down toileting times on the care sheets, but NA-A could not find her care sheet. NA-A replaced the care sheet on the stack at the nurse's desk. NA-A stated she did not know the last time R10 had been toileted that morning because R10 had a bath and the bath aide assisted R10.
During an interview on 4/1/26 at 11:14 a.m., NA-F stated R10 was the first resident to have a bath that morning and was done at approximately 6:30 a.m.
During an interview on 4/1/26 at 2:29 p.m., licensed practical nurse (LPN)-A stated R10 should be provided toileting every 2 hours to prevent skin breakdown as care planned.
During an interview on 4/1/26 at 2:36 p.m., registered nurse (RN)-B stated staff were expected to follow the resident care plans. R10 should be toileted every two hours as care planned to prevent skin breakdown. R10 had no ability to move on her own at all and R10 was at risk for skin breakdown due to moisture and pressure.
That's a huge concern.
During an interview on 4/1/26 at 3:58 p.m., the director of nursing (DON) stated staff were expected to follow the resident care plan because the care plan reflected the resident's needs as well as the assessed needs to prevent complications.
The facility policy Urinary Incontinence Program revised 4/16/15, identified each resident who is incontinent will be identified, assessed, and provided appropriate care and services to achieve or maintain their greatest level of continence.
Each resident will receive the appropriate care and services to prevent incontinence related complications to the extent possible. An indwelling catheter will not be used unless there is valid medical justification for use, and if there is no indication for use, it will be discontinued as soon as clinically warranted.
245252 04/01/2026
Thief River Care Center 2001 Eastwood Drive Thief River Falls, MN 56701
During an interview on 4/1/26 at 10:48 a.m., NA-A stated she didn't have a care sheet and was not sure how often R10 needed to be repositioned. NA-A went to the nurses' desk and picked up a resident care sheet and stated R10 required repositioning every two hours. NA-A stated staff were expected to write down repositioning times on the care sheets, but NA-A could not find her care sheet. NA-A placed the care sheet on the stack at the nurse's desk. NA-A stated she did not know the last time R10 had been repositioned that morning because R10 had a bath and the bath aide assisted R10.
During an interview on 4/1/26 at 11:14 a.m., NA-F stated R10 was the first resident to have a bath that morning and was done at approximately 6:30 a.m.
During an interview on 4/1/26 at 2:29 p.m., licensed practical nurse (LPN)-A stated R10 should be provided repositioning every two hours to prevent skin breakdown as care planned.
During an interview on 4/1/26 at 2:36 p.m., registered nurse (RN)-B stated staff were expected to follow the resident care plans. R10 should be repositioned every two hours to prevent skin breakdown as care planned. R10 had no ability to move on her own at all and R10 was at risk for skin breakdown due to moisture and pressure.
That's a huge concern.
During an interview on 4/1/26 at 3:58 p.m., the director of nursing (DON) stated staff were expected to follow the resident care plan because the care plan reflected the resident's needs as well as the assessed needs to prevent complications such as pressure ulcer/injury. A turning and repositioning policy was requested but not received.
245252 04/01/2026
Thief River Care Center 2001 Eastwood Drive Thief River Falls, MN 56701
well-being of staff and residents, to promote quality care, and to follow applicable laws regarding use
before lifting or transferring a patient or resident, as well as ensuring all four retainer springs were
245252 04/01/2026
Thief River Care Center 2001 Eastwood Drive Thief River Falls, MN 56701
During an interview on 4/1/26 at 10:15 a.m., NA-D stated she was only helping NA-A to lay R10 down and didn't think of the feeding at all. NA-D stated they should have asked the nurse to pause R10's feeding because R10 could have vomited.
During an interview on 4/1/26 at 2:29 p.m., licensed practical nurse (LPN)-A stated whenever the aides were going to lie R10 down they were supposed to ask a nurse to come and pause the feeding, then when they're done, they're supposed to call the nurse to turn it back on.
That is supposed to happen every time.
During an interview on 4/1/26 at 2:36 p.m., registered nurse (RN)-B stated the nursing assistants were expected to ask nursing to pause R10's feeding before transfers and to restart once the transfers/cares were done.
This was required every time to prevent complications such as vomiting and aspiration.
During an interview on 4/1/26 at 3:58 p.m., the director of nursing (DON) stated R10 had been assessed for possible aspiration but lung sounds were clear and R10 had no signs or symptoms of distress.
The DON stated staff were expected to follow R10's care plan and request to have R10's feeding paused prior to transfers because the care plan reflected the R10's needs as well as the assessed needs to prevent complications.
The DON stated R10 had been assessed for possible aspiration but lung sounds were clear and R10 had no signs or symptoms of distress.
The facility policy Enteral Feeding Tube Usage revised 4/1/19, identified the facility provided enteral feeding tube care and services.
However, the policy failed to direct staff how to care for the feeding during turning and repositioning.Nursing Skills textbook ISBN-13: 9781734914122 (ebook) dated 2021, identified the head of the bed (HOB) should be elevated to a 30 to 45-degree angle (semi-Fowler's position) during enteral feeding and for at least 30-60 minutes afterward to prevent aspiration.
This positioning is crucial for all patients receiving tube feeds to reduce the risk of formula entering the lungs.