Cycle 1
Health 2025-12-31 · Fire 2025-12-31
6 health deficiencies
Top issue: Infection Control (2 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Thief River Falls, MN
Oakland Park Nursing Home
1-star overall rating with 2-star inspections with 6 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
123 Baken Street, Thief River Falls, MN
(218) 681-1675
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
35
Certified beds
Average residents
34
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1991-12-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.90
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.37
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
2.52
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
3.79
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
1.27
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.14
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
0.42
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.99
CMS adjusted RN staffing hours
Adjusted total hours
4.15
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
80%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
56%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,127
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
24.68
Composite VBP score used to determine payment impact.
Payment multiplier
0.9835
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
0
Baseline 48.94% · Performance 64.58% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
4.94
Baseline 4.42 hours · Performance 4.48 hours · Measure score 4.94 · Achievement 4.94 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 14 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 11 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 11 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 14 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 1.77% |
8.2%
6.4 pts worse
|
Numerator 2 · Denominator 113 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.3%
2.7 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.1% |
96.1%
1 pts better
|
95.5%
1.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.6% |
3.9%
2.3 pts better
|
3.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.2% · Q4 3.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.6% |
4.3%
1.7 pts better
|
11.4%
8.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 7.1% · Q4 3.4% · 4Q avg 2.6% |
| Percentage of long-stay residents who lose too much weight | 5.0% |
4.1%
0.9 pts worse
|
5.4%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 3.7% · Q3 8.7% · Q4 4.2% · 4Q avg 5.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.8% |
12.4%
4.6 pts better
|
19.6%
11.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 7.4% · Q3 8.3% · Q4 8.0% · 4Q avg 7.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.6% |
17.5%
3.1 pts worse
|
16.7%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 17.9% · Q3 25.0% · Q4 17.9% · 4Q avg 20.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 25.5% |
22.5%
3 pts worse
|
16.3%
9.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 25.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.9% |
18.6%
8.3 pts worse
|
14.9%
12 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.2% · Q2 16.0% · Q3 22.7% · Q4 40.9% · 4Q avg 26.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.8% |
2.3%
0.5 pts worse
|
1.0%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.2% · Q3 2.5% · Q4 5.7% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 7.9% |
2.6%
5.3 pts worse
|
1.7%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 6.1% · Q3 6.7% · Q4 15.6% · 4Q avg 7.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.0% |
24.8%
6.2 pts worse
|
19.8%
11.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 44.6% · Q2 24.8% · Q3 32.9% · Q4 21.9% · 4Q avg 31.0% |
| Percentage of long-stay residents with pressure ulcers | 1.0% |
5.4%
4.4 pts better
|
5.1%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.2% · Q4 2.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.5% |
88.6%
1.9 pts better
|
81.7%
8.8 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 90.5% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2025-01-30 · Fire 2025-01-30
13 health deficiencies
Top issue: Administration (3 deficiencies)
12 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Cycle 3
Health 2024-03-21 · Fire 2024-03-21
7 health deficiencies
Top issue: Infection Control (2 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-12-31
K226 · Egress Deficiencies
Fire Safety
Have horizontal exits used in accordance with safety requirements.
Corrected 2026-01-13
F · Potential for more than minimal harm
2025-12-31
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-01-14
F · Potential for more than minimal harm
2025-12-31
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2026-01-13
F · Potential for more than minimal harm
2025-12-31
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2026-01-22
F · Potential for more than minimal harm
2025-12-31
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2026-04-30
D · Potential for more than minimal harm
2025-12-31
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2026-01-22
D · Potential for more than minimal harm
2025-12-31
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2026-01-21
D · Potential for more than minimal harm
2025-12-31
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2026-01-21
D · Potential for more than minimal harm
2025-12-31
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2026-01-14
D · Potential for more than minimal harm
2025-12-31
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2026-01-22
D · Potential for more than minimal harm
2025-12-31
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2026-01-30
F · Potential for more than minimal harm
2025-01-30
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2025-02-28
F · Potential for more than minimal harm
2025-01-30
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2025-02-28
F · Potential for more than minimal harm
2025-01-30
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-02-28
F · Potential for more than minimal harm
2025-01-30
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-02-28
F · Potential for more than minimal harm
2025-01-30
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-03-26
F · Potential for more than minimal harm
2025-01-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-28
F · Potential for more than minimal harm
2025-01-30
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Not marked corrected
F · Potential for more than minimal harm
2025-01-30
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-02-28
F · Potential for more than minimal harm
2025-01-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-02-28
F · Potential for more than minimal harm
2025-01-30
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-01-30
K226 · Egress Deficiencies
Fire Safety
Have horizontal exits used in accordance with safety requirements.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-01-30
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-02-28
F · Potential for more than minimal harm
2024-03-21
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-03-19
F · Potential for more than minimal harm
2024-03-21
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-04-04
F · Potential for more than minimal harm
2024-03-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-08
F · Potential for more than minimal harm
2024-03-21
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-04-01
F · Potential for more than minimal harm
2024-03-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-04-11
F · Potential for more than minimal harm
2024-03-21
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-04-12
D · Potential for more than minimal harm
2024-03-21
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2024-04-01
D · Potential for more than minimal harm
2024-03-21
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-04-02
D · Potential for more than minimal harm
2024-03-21
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-04-02
D · Potential for more than minimal harm
2024-03-21
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-04-03
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-31
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2026-01-31
D · Potential for more than minimal harm
2025-12-31
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2026-01-31
D · Potential for more than minimal harm
2025-12-31
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2026-01-31
D · Potential for more than minimal harm
2025-12-31
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2026-01-31
D · Potential for more than minimal harm
2025-12-31
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2026-01-31
J · Immediate jeopardy
2025-07-17
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-07-02
G · Actual harm
2025-01-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-28
F · Potential for more than minimal harm
2025-01-30
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2025-02-28
F · Potential for more than minimal harm
2025-01-30
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-02-28
F · Potential for more than minimal harm
2025-01-30
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2025-02-28
F · Potential for more than minimal harm
2025-01-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-01-30
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-01-30
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-01-30
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-01-30
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-01-30
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-01-30
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-01-30
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-01-30
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-02-28
F · Potential for more than minimal harm
2024-03-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-08
E · Potential for more than minimal harm
2024-03-21
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-04-10
E · Potential for more than minimal harm
2024-03-21
F920 · Environmental Deficiencies
Health
Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture.
Corrected 2024-04-01
D · Potential for more than minimal harm
2024-03-21
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2024-04-17
D · Potential for more than minimal harm
2024-03-21
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-04-15
D · Potential for more than minimal harm
2024-03-21
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-04-15
C · Minimal harm
2024-03-21
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-04-08
Penalties and ownership
What sits behind the stars
Ownership
Birchem, James
5% Or Greater Direct Ownership Interest · Individual
Birchem, Kathleen
5% Or Greater Direct Ownership Interest · Individual
Birchem, James
Corporate Director · Individual
Birchem, Kathleen
Corporate Director · Individual
Castillon, Adina
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Thief River Care Center
Thief River Falls, MN
1-star overall rating with 1-star inspections with $94,417 in total fines with 10 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
North Star Manor
Warren, MN
3-star overall rating with 4-star inspections with 1 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Villa St Vincent
Crookston, MN
1-star overall rating with 2-star inspections with abuse icon flag with $29,234 in total fines with 7 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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