Knute Nelson Care Center

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. -half of a large container of barbeque sauce with a crusty black substance around the lid without a notation of an open date and an expiration date of 1/6/25. - one chicken salad sandwich without notation of a date. - three bowls of pureed bread without notation of a date. -bottle of staff pop without notation of a date. Freezer: -six pork sausages in a bag without notation of an opening date. Food temps:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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 (R64) who was transferred to an acute care facility on an emergency basis reviewed for hospitalization. Findings include: R64's admission Minimum Data Set (MDS) dated [DATE], indicated R64 had severe cognitive impairment and had diagnoses which included right femur (long bone in the leg) fracture, cancer, and hypertension (elevated blood pressure). Identified R64 required staff assistance with activities of daily living (ADL's) which included bed mobility, transfers, and toileting. Review of R64's progress notes dated 12/3/24, revealed the following: -on 12/3/24 at 5:35 p.m., R64 was seated in the dining room in his wheelchair eating supper. R64 stood up from the wheelchair and as R64 went to sit back down the wheelchair rolled away and R64 landed on the floor and a loud crack was heard. R64 was unable to move his right leg and had shortening of the right…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure timely assistance with repositioning occurred for 1 of 5 residents (R2) with a current pressure ulcer and at risk for further development of pressure ulcers. Findings include: R2's quarterly Minimum Data Set (MDS) dated [DATE], identified R2 had severe cognitive impairment and diagnoses which included diabetes mellitus (DM), hypertension (elevated blood pressure) and dementia. Identified R2 required extensive assistance with activities of daily living (ADL's) which included bed mobility, transfers, and toileting. Identified R2 had two pressure ulcers and was on a repositioning program. R2's annual Care Area Assessment (CAA) dated 10/22/24, identified R2 was a at risk for skin breakdown and had a pressure ulcer to her left heel. Identified R2 required extensive assistance to reposition in bed and in the wheelchair. R2's care plan dated 4/25/24, identified R2 had a pressure ulcer on her left heel. Care plan directed staff to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. R48's admission MDS dated [DATE], indicated R48 had impaired cognition and required staff supervision to eat. R52's significant change MDS dated [DATE], indicated R52 had intact cognition ad could feed herself after staff set up her tray. During an interview on 5/20/24 at 1:05 p.m., R52 stated the food was often cold. During an interview on 5/20/24 at 1:25 p.m., R29 stated the food did not taste very good and the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. In addition, the CDC identified adults 65 and older who had previously received both PCV13 and PPSV23 at age [AGE] and older, based on shared clinical decision-making with the patient and the provider one dose of PCV20 at least five years after the last pneumococcal vaccine dose. Review of R6's facesheet identified R6, age [AGE] was admitted to the facility on [DATE]. Review of R6's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to comprehensively assess the use of a restrictive device as a potential restraint for 1 of 1 resident (R6) reviewed for restraints. Findings include: Review of R6's annual Minimum Data Set, dated [DATE], identified R6 had severe cognitive impairment and had diagnoses which included Parkinson's, Diabetes Mellitus, and anxiety disorder. Indicated R6 required extensive assistance for activities of daily living (ADL's) which included bed mobility, transfers, and toileting. Identified R6 had one fall with no injury since the last assessment, three months prior and required a wheelchair for mobility. Indicated R6 did not use any restraints. Review of R6's annual Care Area Assessment (CAA) dated 3/6/24, identified R6 had severe cognitive impairment, was a high fall risk and had one fall with no injury since last assessment. CAA identified R6 did not use any restraints. Review of R6's quarterly fall assessment dated [DATE], identified R6 was at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure physician orders were implemented to prevent potential fluid retention for 1 of 1 resident reviewed for quality of care. Findings include: R33's quarterly Minimum Data Set (MDS) dated [DATE], identified R33 was cognitively intact. Diagnoses included atrial fibrillation and hypertension. Review of Nurse practitioner (NP) signed orders from 4/1/24, revealed an active order for Torsemide (loop diuretic to treat fluid retention and high blood pressure) oral tablet 20 milligrams (mg). Order to give 20 mg one tablet by mouth PRN (as needed) for weight gain > three pounds (lbs) overnight or > five lbs in seven days every day as needed. Order date 3/6/24, start date 3/6/24. Review of the electronic medication administration record (EMAR) dated 3/6/24, the Torsemide order was added to the EMAR. Order read: Torsemide oral tablet 20 mg give one tablet by mouth as needed for weight gain >three lbs overnight or > five lbs in seven days every…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure timely assistance with repositioning occurred for 1 of 5 residents (R6) with a history of pressure ulcers and at risk for further development of pressure ulcers. Findings include: Review of R6's annual Minimum Data Set (MDS) dated [DATE], identified R6 had severe cognitive impairment and diagnoses which included Parkinson's, Diabetes Mellitus, and anxiety disorder. Indicated R6 required extensive assistance with activities of daily living (ADL's) which included bed mobility, transfers, and toileting. Identified R6 had a turning and repositioning program, was at risk for pressure ulcers and had a scar over a bony prominence from a previous pressure ulcer. R6's annual Care Area Assessment (CAA) dated 3/6/24, identified R6 was at risk for skin breakdown related to diagnosis of Parkinson's, anxiety, and diabetes mellitus (DM). Identified R6 required extensive assistance with ADL's. R6's care plan dated 8/6/2019, identified R6 was at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to comprehensively assess smoking safety for 1 of 1 residents (R38) who currently smoked. Findings include: R38's quarterly Minimum Data Set (MDS) dated [DATE], indicated R38 was moderately cognitively impaired and had diagnoses which included tracheostomy (also known as a tracheotomy, was a small surgical opening that was made through the front of the neck into the windpipe, or trachea. A curved plastic tube, known as a tracheostomy tube, was placed through the hole allowing air to flow in and out of the windpipe) anxiety, depression, history of falling, weakness, hypertension (high blood pressure) and history of alcohol dependence. Identified R38 was independent with transfers, toileting, bed mobility, locomotion with use of cane, dressing and personal hygiene. The MDS did not identify R38 as a smoker. R38's care plan prior to 5/21/24, lacked documentation R38 was a cigarette smoker. On 5/21/24, R38's care plan was then updated and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to maintain personal privacy for 4 of 4 residents (R1, R4, R5, R6) who had video monitoring devices in their bedrooms as an intervention to prevent falls and elopement. Findings include: R1's admission Minimum Data Set, dated [DATE], identified intact cognition, diagnosis of a stroke with wandering tendencies that placed R1 at significant risk of getting to a potentially dangerous place (e.g. outside facility, stairs). R1 used a walker and a wheelchair for mobility, impairment of lower extremity on one side, and required supervision with transfers, locomotion on and off unit, dressing, personal hygiene, toileting, and always continent of bowel and bladder. R1's care plan dated 9/18/23, identified R1 elopement risk and video monitor used along with wander guard applied. R1 resided in alarmed unit and staff were directed to check wander guard every shift. R4's significant change MDS dated [DATE], identified severely impaired cognition and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.