Knife River Care Center

F-F600 is considered past non-compliance. The facility implemented corrective actions as follows:

* The interdepartmental team met to problem solve, implement changes and interventions for resident care and safety.

* Providers were notified, follow up care and treatment provided.

* The local police department and Women's Action Resource Center (WARC) were notified and involved.

* A No Trespassing order to be served to the family member.

* The Resident Representative(s) and State Ombudsman was notified of the incident and actions implemented.

* Education to all managers regarding the facility abuse policy, reporting time period, response to allegations of abuse, and action plan implemented.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 5 355053 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 355053 B. Wing 08/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Knife River Care Center 118 22nd St NE Beulah, ND 58523

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 * All staff education regarding the facility abuse policy, notification to management staff, assuring resident safety/protection and the facility action plan implemented. Level of Harm - Actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 5 355053 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 355053 B. Wing 08/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Knife River Care Center 118 22nd St NE Beulah, ND 58523

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 39211

Residents Affected - Few Based 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.

Findings include:

This surveyor determined a deficient practice existed on 08/10/24. The facility implemented corrective action and completed on 08/13/24.

Review of the facility policy titled Abuse Prohibition Policy occurred on 08/14/24. This policy, revised November 2023, stated, . Residents must not be subject to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the individual, family members or legal guardians, friends, or other individuals. Abuse shall be defined as follows: . 'Physical abuse' shall include hitting, slapping, pinching, and kicking. Any alleged violation(s) should be recorded and reported immediately to the facility Administrator and/or designee. The Administrator or his/her designee will report to other officials through established procedures and in accordance with State law (including to the State survey and certification agency) as warranted. The Administrator or his designee shall report the allegation to the State survey and certification agency within a 24-hour time period unless the event resulted

in serious bodily injury then it needs to be within 2 hours.

Review of Resident #1's medical record occurred on 08/14/24. An admission Minimum Data Set (MDS), dated [DATE REDACTED], identified severely impaired cognition. A nurse's note, dated 08/10/24 at 2:06 p.m., stated, Activities director, [name of staff member], reported res [resident] daughter was in res room slapping her in

the face. This nurse, [name of staff member], LPN [licensed practical nurse] went to the room and asked daughter to leave facility and tell daughter abuse is not tolerated at this facility.

During an interview the afternoon of 08/14/24, an administrative staff member (#1) reported he/she received

a phone call from the charge nurse on 08/10/24, regarding the incident, and that the charge nurse had instructed the daughter to leave the facility. The administrative staff member (#1) reported on 08/12/24, he/she began an investigation and notified the SSA.

During an interview the afternoon of 08/14/24, an administrative staff member (#2) confirmed the facility did not report the incident to the SSA within the required 2 to 24-hour time period.

Based on the following information, non-compliance at

F-F609 is considered past non-compliance. The facility implemented corrective actions as follows:

* The interdepartmental team met to problem solve and implement changes.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 5 355053 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 355053 B. Wing 08/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Knife River Care Center 118 22nd St NE Beulah, ND 58523

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 * Education to all managers regarding the facility abuse policy and reporting time period to state survey agency. Level of Harm - Minimal harm or potential for actual harm * All staff education regarding the facility abuse policy, assuring resident safety and protection and notification to management staff. Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 5 355053