10 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
8 fire-safety deficiencies
Top issue: Miscellaneous (3 deficiencies)
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
2001 Eastwood Drive, Thief River Falls, MN
(218) 683-8100
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Beds
70
Certified beds
Average residents
67
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
St. Francis Health Services
Operator or chain grouping
Approved since
1982-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
14 facilities
Chain averages 3 overall / 2 health / 4 staffing / 3 quality stars
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
RN hours / resident day
0.88
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.62
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
1.98
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
3.47
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
1.49
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.02
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
0.32
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
1.04
CMS adjusted RN staffing hours
Adjusted total hours
4.12
CMS adjusted total nurse staffing hours
Case-mix index
1.15
Higher values indicate more complex resident acuity
RN turnover
44%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
53%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Program rank
4,318
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
40.43
Composite VBP score used to determine payment impact.
Payment multiplier
0.9934
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
2.04
Performance 20.49% · Measure score 2.04 · Achievement 2.04 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
4.66
Performance 6.44% · Measure score 4.66 · Achievement 4.66 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
3.52
Baseline 48.28% · Performance 49.30% · Measure score 3.52 · Achievement 3.52 · Improvement 0
Adjusted total nurse staffing
5.96
Baseline 4.56 hours · Performance 4.77 hours · Measure score 5.96 · Achievement 5.96 · Improvement 1.25
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.98% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 50 · Observed rate 8% · Lower 95% interval 6.79% |
| Discharge to community | 41.44% |
50.57%
9.1 pts worse
|
No Different than the National Rate · Eligible stays 42 · Observed rate 30.95% · Lower 95% interval 29.18% |
| Medicare spending per beneficiary | 0.96 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 81.82% |
95.27%
13.5 pts worse
|
Numerator 27 · Denominator 33 |
| Falls with major injury | 3.03% |
0.77%
2.3 pts worse
|
Numerator 1 · Denominator 33 |
| Discharge self-care score | 36% |
53.69%
17.7 pts worse
|
Numerator 9 · Denominator 25 |
| Discharge mobility score | 48% |
50.94%
2.9 pts worse
|
Numerator 12 · Denominator 25 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 33 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.44% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 32 · Observed rate 3.13% · Lower 95% interval 3.81% |
| Staff COVID-19 vaccination coverage | 2.11% |
8.2%
6.1 pts worse
|
Numerator 2 · Denominator 95 |
| Staff flu vaccination coverage | 6.14% |
42%
35.9 pts worse
|
Numerator 7 · Denominator 114 |
| Discharge function score | 36% |
56.45%
20.5 pts worse
|
Numerator 9 · Denominator 25 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
Quality measures
| 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 | 93.7% |
96.1%
2.4 pts worse
|
95.5%
1.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.2% |
3.9%
0.3 pts worse
|
3.3%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 4.8% · Q3 5.2% · Q4 4.5% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.3%
4.3 pts better
|
11.4%
11.4 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 who lose too much weight | 3.6% |
4.1%
0.5 pts better
|
5.4%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 3.6% · Q3 1.8% · Q4 6.5% · 4Q avg 3.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.4% |
12.4%
4 pts worse
|
19.6%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 19.0% · Q3 16.4% · Q4 11.3% · 4Q avg 16.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.2% |
17.5%
0.7 pts worse
|
16.7%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.9% · Q2 18.6% · Q3 19.1% · Q4 14.8% · 4Q avg 18.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 1.2% |
0.1%
1.1 pts worse
|
0.1%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.6% · Q3 1.7% · Q4 1.5% · 4Q avg 1.2% |
| Percentage of long-stay residents whose ability to walk independently worsened | 35.2% |
22.5%
12.7 pts worse
|
16.3%
18.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 40.7% · Q4 37.2% · 4Q avg 35.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.9% |
18.6%
4.3 pts worse
|
14.9%
8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.8% · Q2 25.0% · Q3 23.1% · Q4 15.3% · 4Q avg 22.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.4% |
2.3%
2.1 pts worse
|
1.0%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 6.1% · Q3 3.9% · Q4 3.1% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.6% |
2.6%
2 pts worse
|
1.7%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 5.0% · Q3 3.4% · Q4 3.0% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.8% |
24.8%
2 pts better
|
19.8%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.2% · Q2 27.2% · Q3 27.5% · Q4 19.1% · 4Q avg 22.8% |
| Percentage of long-stay residents with pressure ulcers | 1.3% |
5.4%
4.1 pts better
|
5.1%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 1.8% · Q3 0.0% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.2% |
88.6%
8.6 pts better
|
81.7%
15.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · 4Q avg 97.2% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.9%
1.9 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (5 deficiencies)
8 fire-safety deficiencies
Top issue: Miscellaneous (3 deficiencies)
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Quality of Life and Care (7 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-02-19
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-02-19
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-02-19
Fire Safety
Install noncombustible or limited-combustible interior walls.
Corrected 2025-02-19
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-02-19
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-02-19
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2025-02-19
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-02-19
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-02-16
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-02-16
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2023-02-16
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-02-16
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-02-16
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-02-16
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-02-16
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-02-16
Inspection history
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-12-18
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-02-19
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-02-19
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-14
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-02-19
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-02-19
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 2025-03-14
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-02-19
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-19
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-02-19
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-05-31
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-04-15
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-05-17
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-05-06
Health
Respond appropriately to all alleged violations.
Corrected 2024-05-06
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-01-20
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-01-20
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-12-01
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-12-01
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-12-01
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-12-01
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-23
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-10-23
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-10-23
Health
Provide and implement an infection prevention and control program.
Corrected 2023-02-16
Health
Perform COVID19 testing on residents and staff.
Corrected 2023-02-16
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-02-16
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2023-02-16
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-02-16
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-02-16
Health
Implement a program that monitors antibiotic use.
Corrected 2023-02-16
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2023-02-16
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-02-16
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2023-02-16
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-02-16
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 2023-02-16
Health
Ensure staff are vaccinated for COVID-19
Corrected 2023-02-16
Penalties and ownership
Fine · fine $19,800
Fine
Fine · fine $65,302
Fine
Fine · fine $9,315
Fine
Payment Denial · denial start 2023-11-29 · 2 days
2 day denial
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Individual
Corporate Officer · Individual
W-2 Managing Employee · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
W-2 Managing Employee · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
W-2 Managing Employee · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Operational/Managerial Control · Organization
Corporate Director · Individual
W-2 Managing Employee · Individual
Corporate Director · Individual
Nearby options
Thief River Falls, MN
1-star overall rating with 2-star inspections with 6 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
Warren, MN
3-star overall rating with 4-star inspections with 1 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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
Jump out