Knife River Care Center

In the surveyor’s words

From the most serious findings on record at Knife River Care Center, in the surveyor’s own words.

• Immediate jeopardy, patternF689Jul 10, 2024

  Based on observation, record review, and staff interview, the facility failed to ensure an environment free of accident hazards for 1 of 1 sampled resident (Resident #5) who experienced a burn related to hot coffee. Failure to ensure appropriate coffee/water temperatures resulted in Resident #5 sustaining burns and placed all residents at risk for serious burns/injuries. During the on-site facility reported incident (FRI) investigation, the team consulted with the State Survey Agency (SSA) and determined an Immediate Jeopardy (IJ) situation existed on 07/03/24. A nursing progress note, dated 07/03/24 at 1:03 p.m., stated, . Resident fell asleep at the table and spill [sic] hot coffee on her lap. Taken back to her room, pants removed. […]

• Immediate jeopardy, patternF880Dec 1, 2022

  1. Based on observation, review of facility policy, and staff interview, the facility failed to ensure staff followed infection control practices for 1 of 3 sampled residents (Resident #71) on transmission based precautions related to positive COVID-19 status. Failure to provide and properly utilize personal protective equipment (PPE) for residents on transmission based precautions has the potential to spread the COVID-19 virus to other residents, personnel, and visitors. During the on-site survey, the team determined a potential Immediate Jeopardy (IJ) situation existed on 11/28/22 at 4:30 p.m. The IJ potential resulted from observations of improper use of PPE and lack of staff knowledge/education regarding infection control practices and procedures. […]

• Actual harm, isolatedF600Aug 14, 2024

  Based on review of the facility reported incident and investigation documents, record review, review of facility policy, and staff interview, the facility failed to ensure residents remain free from abuse for 1 of 1 sampled resident (Resident #1) who experienced physical abuse. Failure to immediately investigate an incident of physical abuse and provide necessary services to protect residents from harm resulted in an unsafe environment and the potential for further harm. This citation is considered past non-compliance based on review of the corrective action the facility implemented immediately following the incident. Findings include: This surveyor determined a deficient practice existed on 08/10/24. […]

• No harm, potential for more than minimal, patternF550Dec 21, 2023

  Based on review of facility policy, review of resident council meeting minutes, and resident interviews, the facility failed to respect each resident's dignity and individuality and care for residents in a manner and an environment that promotes, maintains, or enhances the quality of life for 2 of 21 sampled residents (Residents C and E) and 2 supplemental residents (Residents A and D). Failure to provide cares in a respectful manner and respect personal property does not preserve the residents' personal dignity or enhance their quality of life. Findings include: Review of the policy titled, Promoting/Maintaining Resident Dignity occurred on 12/21/23. This policy, dated December 2022, stated, . […]

• No harm, potential for more than minimal, patternF692Dec 21, 2023

  Based on observation, record review, and resident and staff interviews, facility staff failed to offer fluids to 1 of 21 sampled residents (Resident #63) and 1 supplemental resident (Resident #43) during cares who required staff assistance for fluid intake and failed to provide water consistently for 4 of 21 sampled residents (Resident #6, #23, #27 and #67) and 2 supplemental residents (Resident #13, and #66). Failure to provide water to all residents consistently and provide assistance with fluid intake may result in dehydration, constipation, and urinary tract infections (UTIs). Findings include: - Review of Resident #63's medical record occurred on all days of survey. […]