Knife River Care Center

Inspectors wroteBased on record review, review of the facility reported incident (FRI) investigation, and staff interview, the facility failed to ensure residents received adequate supervision and/or monitoring to prevent elopements from the facility for 1 of 1 sampled resident (Resident #1) Failure to provide adequate supervision and monitoring and respond to door alarms immediately resulted in Resident #1's elopement from the facility and may result in injury from prolonged exposure to cold temperatures. This citation is considered past non-compliance based on review of the corrective actions the facility implemented immediately following the elopement.

Inspectors wroteBased on observation, review of facility cleaning logs, and family and staff interview, the facility failed to ensure a safe, clean, comfortable, and homelike environment for 2 of 11 sampled residents (Resident #32 and #65) who required a wheelchair. Failure to maintain a safe, clean, and sanitary environment may lead to injury from unsafe equipment, does not provide a homelike living area for residents, and fails to promote quality of life.

Inspectors wroteBased on observation, record review, review of manufacturer's instructions, and staff interview, the facility failed to provide adequate assistance for 1 of 4 sampled residents (Resident #40) observed during a ceiling lift transfer. Failure to ensure proper use of the ceiling lift, including use of the sling/straps, placed the resident at risk for a fall and injury.

Inspectors wroteBased on review of the facility reported incident and investigation documents, record review, and review of facility policy, the facility failed to ensure residents remained free from abuse for 1 of 1 sampled resident (Resident #2) who experienced physical abuse. Failure to ensure an environment free from abuse placed Resident #2 and all other residents residing in the memory care unit at risk for abuse, fear, anxiety, and/or psychosocial harm. This citation is considered past non-compliance based on review of the corrective action the facility implemented following the incident.

Inspectors wroteBased on record review, the facility failed to review and revise care plans to reflect residents' current status for 1 of 2 sampled residents (Resident #1). Failure to update Resident #1's care plan limited staffs ability to communicate needs and ensure continuity of care.

Inspectors wroteBased 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.

Inspectors wroteBased on review of the facility reported incident (FRI), record review, review of facility policy, and staff interview, the facility failed to report an incident of abuse for 1 of 1 sampled resident (Resident #1) who experienced physical abuse to the State Survey Agency (SSA) . Failure to report an event of physical abuse in the prescribed time frame does not comply with regulations established to protect residents. This citation is considered past non-compliance based on review of the corrective action the facility implemented immediately following the incident.

Inspectors wroteBased 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. Large area of redness to bilateral thighs (top and inner) with blistering noted. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased on observation, review of menus, and staff and resident interviews, the facility failed to serve food according to prepared menus for 3 of 3 units observed ([NAME] Lane, Harvest Lane, and Whispering Winds) during meals. Failure to serve food according to the portion sizes listed on the menu may result in inadequate nutrition and either weight loss or gain.

Inspectors wroteBased on observation, review of facility policy, and staff interview, the facility failed to serve food in a sanitary manner for 2 of 3 kitchenettes ([NAME] Lane and Harvest Lane). Failure to change gloves when the type of food being handled has changed or after touching the face and prior to handling ready-to-eat food has the potential to result in cross-contamination and/or food borne illness.

Inspectors wroteBased on observation and review of the facility policy, the facility failed to provide reasonable accommodation of needs regarding call lights for 3 supplemental residents (Residents #26, #45 and #50). Failure to ensure the resident can reach/access the call light may result in unmet needs and the inability to call for help.

Inspectors wroteBased on observation, record review, review of professional reference, and resident interview, the facility failed to honor resident choices for 1 of 19 sampled residents (Resident #10) who use incontinence products. Failure to honor Resident #10's choice to choose an incontinence product does not respect their autonomy or right to determine what is significant to their care and well-being.

Inspectors wroteBased on observation, review of facility policy, and staff interview, the facility failed to ensure a safe, clean, comfortable, and homelike environment for 2 of 6 units (Golden Grain and Fruit Blossom) in the facility and one resident room on Golden Grain observed during the survey. Failure to maintain a clean, comfortable, and sanitary environment does not provide a homelike living area for residents and fails to promote quality of life.

Inspectors wroteBased on observation, record review, review of facility policy, and resident and staff interview, the facility failed to review and revise comprehensive care plans to reflect the residents' current status for 2 of 21 sampled residents (Resident #15 and #27). Failure to review and revise the care plan limited staff's ability to communicate needs and ensure continuity of care.

Inspectors wroteBased on observation and record review, the facility failed to provide care and services to aid the healing or to prevent the development of pressure ulcers for 1 of 1 supplemental resident (Resident #26) with pressure ulcers. Failure to apply the blue pressure relief boot may result in worsening and/or the development of pressure ulcers.

Inspectors wroteBased on observation, review of facility policy, record review, and staff interview, the facility failed to provide appropriate services and assistance to maintain bowel/bladder continence for 1 of 12 sampled residents (Resident #23) who required toileting assistance/incontinence care. Failure to provide toileting assistance may result in unnecessary incontinence and a loss of dignity.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to provide the necessary care and services for 1 of 3 sampled residents (Resident #130) receiving oxygen. Failure of maintain respiratory supplies by routinely changing and documenting the replacement of the cannula/tubing may compromise the integrity of the cannula/tubing and could result in adverse effects for the resident.

Inspectors wroteBased on observation, record review, and review of facility policy, the facility failed to ensure safe and secure storage of medicated shampoo in 1 of 5 medication carts (memory unit). Failure to store the medicated shampoo properly may result in unauthorized access and has the potential to cause resident harm.

Inspectors wroteBased on observation, review of facility policy, record review, and resident and staff interviews, the facility failed to assist with obtaining dental services to meet the needs of 1 of 1 sampled resident (Resident #27) with lost dentures. Failure to assist the resident in making an appointment may have resulted in chewing and/or eating difficulties, weight loss, delayed dental care and/or dental complications.

Inspectors wroteBased on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control for 1 of 10 sampled residents (Resident #64) observed during personal cares. Failure to practice infection control standards related to hand hygiene during personal cares has the potential to spread infection throughout the facility.