Thief River Care Center

Inspectors wroteBased on interview and document review, the facility failed to ensure medications were coded correctly on the Minimum Data Set (MDS) for 4 of 7 residents (R22, R62, R29, R46) reviewed for MDS discrepancies.

Inspectors wroteBased on observation, interview, and document review, the facility failed to follow the care plan for check and change for 1 of 2 residents (R10) observed for activities of daily living (ADLs).

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure turning and repositioning was timely for 1 of 1 resident (R10) reviewed who was at risk for the development of pressure ulcers.

Inspectors wroteBased on interview and document review, the facility failed to ensure staff were comprehensively assessing falls and implementing appropriate interventions for 1 of 3 (R50) residents reviewed for falls.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure staff maintained the proper positioning for gastrostomy tube care for 1 of 1 resident (R10) reviewed for tube feedings.

Inspectors wroteBased 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. R1 wore light weight material sweatpants, long sleeved t-shirt (waffle like material), tan colored gripper socks on his feet, with no coat/gloves/hat. [...]

Inspectors wroteBased on interview and document review the facility failed to ensure a dependent resident was toileted per request for 1 of 2 residents (R32) reviewed for accidents. This resulted in actual harm for R32 who fell when self transferring to the toilet and fractured their hip.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure the final rinse on the dishwasher reached 180 degrees Fahrenheit (F) to sanitize dishes. This had the potential to affect 61 of 62 residents who consumed food from the main production kitchen.

Inspectors wroteBased on observation, interview and document review, the facility failed to expand COVID-19 testing/ and or contact tracing of staff and residents on other units after residents tested positive for COVID19 per Centers for Disease Control (CDC) guidelines. In addition, the facility failed to implement enhanced barrier precautions (EBP) for 1 of 3 residents (R53) reviewed for activities of daily living (ADLs). This had the potential to affect all 60 residents residing in the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure food was served at warm, palatable temperatures for 5 of 5 residents (R30, R4, R32, R11,R18) who received meal trays out of temperature range.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure an assessment was completed for an electric scooter to increase mobility for 1 of 1 residents (R57) reviewed for accomadation of needs.

Inspectors wroteBased on interview and document review, the facility failed to update the care plan with a new transfer status for 1 of 2 residents (R32) reviewed for falls; and the facility failed to update the care plan with a new turning and repositioning schedule for 1 of 2 residents (R8) reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide timely assistance with toileting/incontinence care for 1 of 3 residents (R8) reviewed for activities of daily living (ADLs) and who were dependent on staff for their care.

Inspectors wroteBased on observation, interview, and document review, the facility failed to identify a significant increase in weight with dependent edema in the lower extremeties and conducted a comprehensive assessment and implement interventions for 1 of 1 residents (R55) reviewed for edema.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide timely repositioning for 1 of 2 residents (R8) reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure resident rights for 1 of 3 residents (R1) when the facility took shoes away from R1 to slow his movement in the facility.

Inspectors wroteBased 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. when R1 was left in the dining room unsupervised and found rubbing the genitals of a female resident (R2) who was unable to leave the area on her own. [...]

Inspectors wroteBased on interview and document review the facility failed to ensure resident to resident abuse was reported to law enforcement for 2 of 2 residents (R1, R2) reviewed for sexual assault.

Inspectors wroteBased on interview and document review the facility failed to report an allegation of sexual assault to the state agency (SA) for 1 of 3 residents reviewed who alleged she had been raped at the facility.

Inspectors wroteBased on interview and document review the facility failed to thoroughly investigation an allegation of sexual assault for 1 of 3 residents (R4) who alleged she was raped at the facility.

Inspectors wroteBased 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. The director of nursing (DON) was notified of the immediate jeopardy at 5:55 p.m. on 1/2/24. [...]

Inspectors wroteBased on interview and document review the facility failed to report a fall from a mechanical lift to the state agency (SA) for 1 of 2 residents (R2) who fell while being transferred in a mechanical lift.

Inspectors wroteBased on interview, and document review, the facility failed to ensure resident advance directives were accurately documented in the clinical record to reflect the residents' current wishes which affected 3 of 28 residents (R57, R32, R25) reviewed for advanced directives. This deficient practice resulted in an immediate jeopardy (IJ) for R57, R32, and R25 who would have received cardiopulmonary resuscitation (CPR), contrary to their wishes, in the absence of a pulse or respirations. The IJ began on [DATE], when R57's, R32's, and R25's electronic health record (EHR) main screen banner identified they were Full Code (administer CPR) however, their updated Physician Orders For Life Sustaining Treatment (POLST) all identified wishes of do not resuscitate (DNR). The administrator, director of nursing (DON), and nurse consultant (NC)-A were notified of the IJ on [DATE], at 4:54 p.m. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure refrigerated food items were properly labeled, dated, and closed after the packaging was opened to prevent cross contamination which had the potential to affect all 59 residents currently residing in the facility. In addition, the facility failed to ensure refrigerated food items were disposed of after the expiration date.

Inspectors wroteBased on interview and document review, the facility failed to notify the Long Term Care (LTC) ombudsman of a facility initiated transfer for 1 of 1 residents (R60) who was transferred to an acute care facility on an emergency basis reviewed for hospitalization.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide shaving assistance and personal care for 1 of 1 residents (R19) who was dependent on staff to provide personal hygiene reviewed for activities of daily living (ADL's).