Thief River Care Center
Thief River Falls, Minnesota · CCN 245252
37 surveys since 2011. The first finding at harm level was recorded in 2017.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 156
- Surveys
- 37
- Harm or worse
- 18
- Immediate jeopardy
- 7
Findings at the most serious level CMS records. 2 of these were recorded as past non-compliance — corrected before the survey.
Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.
The facility
- Certified beds
- 70
- Ownership
- Non profit - Corporation
- Chain
- ST. FRANCIS HEALTH SERVICES
- County
- Pennington · rural
- Medicare-certified since
- 1982
CMS ratings
- Overall
- 2
- Health inspection
- 1
- Staffing
- 5
- Quality measures
- 2
CMS’s own Five-Star ratings.
Compared with similar facilities
Since 2021, this facility recorded more weighted findings than most of its peer group.
Weighted by harm level, against 52 not-for-profit facilities of 66–99 beds in Minnesota.
Last survey on record
Apr 1, 2026
222 days ago.
Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.
Staffing
| Measure | This facility | Peer median |
|---|---|---|
| Nurse hours per resident day | 3.71 | 4.39 |
| Registered-nurse hours per resident day | 0.90 | — |
| Annual nurse turnover | 40.9% | 37.0% |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
- Fines
- $245,902 across 5 penalties
- Payment denials
- 2
Federal civil money penalties and remedies as CMS currently publishes them. Amounts may still be under appeal.
Severity of recent findings
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J413.8% | K— | L— |
| Actual harm | G13.4% | H— | I— |
| No harm, potential for more than minimal | D1965.5% | E26.9% | F310.3% |
| No harm, potential for minimal | A— | B— | C— |
Most frequently cited here
In CMS’s current monthly file.
- F6895×
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F6093×
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- F6773×
Provide care and assistance to perform activities of daily living for any resident who is unable.
- F6842×
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- F6862×
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
In the surveyor’s words
From the most serious findings on record at Thief River Care Center, in the surveyor’s own words.
- Immediate jeopardy, widespreadF880Jan 12, 2023
Based on observation, interview and document review the facility failed to ensure 5 of 5 employees, (licensed practical nurse (LPN)-A, dietary aide (DA)-D, activity aide (AA)-C, nursing assistant (NA)-D and LPN-B) were appropriately cleared to return to work following reports of potential symptoms of COVID-19; failed to initate contact tracing or facility wide testing for COVID-19 following potential exposure from a staff who tested positive for COVID-19; failed to ensure 3 of 53 residents (R108, R29, R41) were isolated while presenting with symptoms of COVID-19; and failed to utilize appropriate protective equipment for 2 of 3 residents (R41, R50) when they were placed in isolation. […]
- Immediate jeopardy, widespreadF886Jan 12, 2023
Based on observation, interview and record review, the facility failed to ensure all staff were tested for COVID-19 during outbreak testing; and failed to test and/or implement confirmatory testing for symptomatic residents and staff, licensed practical nurse (LPN)-A, LPN-B, dietary aide (DA)-D, activity aide (AA)-C, nursing assistant (NA)-D, R108, R29 and R41, who were not tested or had an initial negative rapid antigen testing for COVID-19, per the Centers for Disease Control (CDC) guidance on testing protocols. This system wide breakdown resulted in an immediate jeopardy (IJ) situation which had the high likelihood to cause serious illness and/or death to all 54 residents residing in the facility, along with staff and visitors. […]
- Immediate jeopardy, isolatedF689Dec 30, 2025
Based on observation, interview and document review the facility failed to provide adequate supervision for 1 of 1 resident (R1) had a history of exit seeking behavior, communicated a desire to leave the facility and was able to elope. This resulted in an immediate jeopardy (IJ) for R1 when R1 was found outside in a wheelchair during hazardous weather conditions. The IJ began on 12/18/25 at 10:25 a.m., a visitor reported to the director of social services a resident in a wheelchair was stuck in the snow outside by the sidewalk. R1 was last seen by staff at 9:30 a.m. The weather was blizzard-like conditions, temperature approximately 0 to 5 degrees with wind from 38 to 44 miles per hour. […]
- Immediate jeopardy, isolatedF600Apr 19, 2024
Based on observation, interview and document review, the facility failed to ensure adequate supervision to prevent resident to resident sexual abuse when 1 of 2 resident (R1) who had a recent incident of resident-to-resident sexual abuse was found in the dining room rubbing a second female resident's (R2) genitals. This was an immediate jeopardy for R2 because this type of inappropriate and unwanted sexual contact would reasonably cause anyone to have psychosocial harm. It can be determined that the reasonable person in the resident's position would have experienced severe psychosocial harm including dehumanization and humiliation as a result of the sexual abuse. The immediate jeopardy (IJ) began on 4/13/24, at approximately 1:15 p.m. […]
- Immediate jeopardy, isolatedF689Jan 3, 2024
Based on observation, interview and document review the facility failed to ensure safe transfer using a mechanical lift during provision of care for 3 of 3 residents (R1, R2, R3) and failed to ensure staff competency following two separate falls from a mechanical lift (R1, R2). This resulted in an Immediate Jeopardy (IJ) for R1, R2, R3. The IJ began on 12/22/23, when R1 fell from the Hoyer lift during provision of care and the facility failed to thoroughly investigate and identify if staff were correctly using the lift per manufacturer's guidelines when the incident occurred. Then, a second fall from a lift occurred on 12/25/23, involving R2 with the same failed response from the facility. The IJ was identified on 1/2/24. […]
Read 34 findings in full →The most serious and the most recent: 34 of 156 on record.
Every survey on record
FindingsAt actual harm or above
- Apr 1, 2026Standard and complaint5 findings
- Dec 30, 2025Complaint1 finding · 1 harm
- Jan 16, 2025Standard and complaint9 findings · 1 harm
- Aug 1, 2024Complaint1 finding · 1 harm
- May 2, 2024Complaint1 finding
- Apr 19, 2024Complaint2 findings · 1 harm
- Apr 12, 2024Complaint2 findings
- Jan 3, 2024Complaint2 findings · 1 harm
Show the 29 earlier surveys
- Nov 1, 2023Standard4 findings · 1 harm
- Aug 30, 2023Complaint3 findings
- Jan 12, 2023Standard13 findings · 3 harm
- Dec 28, 2022Complaint2 findings
- May 4, 2022Complaint2 findings
- Dec 16, 2021Complaint1 finding · 1 harm
- Nov 17, 2021Complaint1 finding
- Aug 19, 2021Standard7 findings
- Jul 29, 2021Complaint2 findings
- Feb 18, 2021Complaint2 findings
- Jan 19, 2021Complaint5 findings
- Dec 31, 2020Complaint2 findings
- Oct 30, 2020Complaint4 findings
- Jun 4, 2020Complaint2 findings · 1 harm
- Aug 20, 2019Complaint1 finding
- Jun 14, 2019Standard7 findings
- Aug 31, 2018Standard20 findings · 6 harm
- Dec 15, 2017Complaint2 findings · 1 harm
- Sep 14, 2017Standard3 findings
- Jul 10, 2017Complaint3 findings
- Aug 25, 2016Standard5 findings
- Apr 5, 2016Complaint3 findings
- Jan 27, 2016Complaint1 finding
- Sep 17, 2015Standard5 findings
- Jul 31, 2014Standard7 findings
- Sep 12, 2013—8 findings
- Jun 28, 2012—8 findings
- Oct 31, 2011—2 findings
- Apr 22, 2011—8 findings
Surveys that found no deficiencies are not in CMS’s files and do not appear here.
Comparable facilities
The nearest facilities to this one in the same peer group, by weighted findings.
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