Knute Nelson Care Center

In the surveyor’s words

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

• Actual harm, isolatedF689Sep 8, 2021

  Based on interview and document review, the facility failed to provide safe transport for residents who require the use of a wheelchair on the facility bus. This resulted in 1 of 3 residents (R1) who were not strapped in securely and slid out of wheelchair during transport, causing multiple fractures. Findings include: R1's quarterly Minimal Data Set (MDS) dated [DATE], indicated R1's diagnoses included dementia, [CONDITION(S)] and showed moderate cognitive impairments. R1 required extensive assist by two staff members for bed mobility, dressing, toileting and extensive assist of one staff member for locomotion on and off the unit. […]

• No harm, potential for more than minimal, widespreadF812Mar 5, 2025

  Based on observation, interview, and document review, the facility failed to ensure food and beverages stored in the refrigerators, were labeled, dated and discarded properly. Further, the facility failed to maintain proper holding food temperatures during the noon meal on the Pines unit. This deficient practice had the potential to affect 59 residents who received food and beverages from the refrigerators. Findings include: On 3/3/25 at 11:05 p.m., during the kitchen tour with the dietary manager(DM), the following concerns were identified: Kitchen refrigerator: -half of a large container of orange sauce with a black crusty substance around the lid with an open date of 1/6/25. […]

• No harm, potential for more than minimal, patternF804May 22, 2024

  Based on observation, interview and document review, the facility failed to ensure food was served at a palatable and appetizing temperature for 4 of 4 residents (R 21, R29, R48 and R52) who resided on the Pines unit reviewed for food. This deficient practice had the potential to affect all 42 residents residing on this unit. Findings include: R21's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had intact cognition ad was able to feed herself after staff set up her tray. R29's quarterly MDS dated [DATE], indicated R29 had intact cognition and could feed himself after staff set up his tray. […]

• No harm, potential for more than minimal, patternF883May 22, 2024

  Based on interview and document review, the facility failed to ensure 4 of 5 residents (R6, R36, R41 and R44) received pneumococcal vaccinations based on shared clinical decision-making in accordance with the Center for Disease Control (CDC) recommendations reviewed for immunizations. Findings include: Review of the current CDC recommendations 3/15/2023, revealed The CDC identified Adults [AGE] years of age or older received the (PPSV23) or (PCV13) at any age and who have not received the Pneumo 20-valent conjugate Vaccine (PCV20) should receive a dose of the PCV20 at least one year after the most recent PPSV23 or PCV13 vaccine. […]

• No harm, potential for more than minimal, patternF730Apr 19, 2023

  Based on interview and document review, the facility failed to complete a performance review of every nurse aide at least once every 12 months for three of five nurse aides (NA-C, NA-D, and NA-E) reviewed for performance reviews. Findings include: On 4/19/23 at 11:57 AM, performance reviews for five nurse aides were reviewed with the administrator. Review of the performance reviews revealed the following: 1. NA-C was hired on 10/05/20, and did not have a performance review in the past 12 months. 2. NA-D was hired on 11/30/20, and did not have a performance review in the past 12 months. 3. NA-E was hired on 12/18/19, and did not have a performance review in the past 12 months. […]