Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Knute Nelson Care Center during CMS and state inspections, most recent first.
Resident rights were not reviewed verbally or in writing during resident council meetings, and the posted rights notice was outdated. Several residents stated the rights had not been reviewed, and the admin confirmed the meetings did not include this review and the poster was not current.
Incomplete Daily Staffing Posting: The facility failed to ensure the daily staffing posting included all required information. The posting showed the date and the total number of licensed staff with their designation, but it did not include the facility name, a clearly identified census, or the total actual hours worked by licensed staff. The senior manager of scheduling operations, RN-A, the DON, and the administrator gave differing accounts of who was responsible for updating weekend changes and acknowledged uncertainty about the exact posting requirements.
The facility failed to properly label, date, and discard food items in the kitchen, and did not maintain appropriate cold food temperatures during meal service on the Pines unit. Several food items were found without proper labeling or had expired, and potato salad was served at 51 degrees Fahrenheit, above the required 41 degrees Fahrenheit. This affected 59 residents receiving food from the refrigerators.
A resident with severe cognitive impairment and a stage 4 pressure ulcer on the left heel was not repositioned for over three hours, despite requiring repositioning every two hours as per the care plan. Staff interviews confirmed the resident's need for assistance and the failure to follow the care plan, increasing the risk of further skin breakdown.
The facility failed to serve food at the appropriate temperature, affecting four residents on the Pines unit. Observations showed that meals were served below the required 140 degrees Fahrenheit, with a test tray revealing significantly lower temperatures. The issue was linked to the warming cart not being plugged in during meal service, contrary to facility policy.
The facility failed to ensure that four residents received pneumococcal vaccinations according to CDC guidelines. The residents, aged 76 to 89, did not have documentation of being offered or receiving the PCV20 vaccine, despite CDC recommendations for adults 65 and older. The DON confirmed the oversight, which was contrary to the facility's policy to offer pneumococcal vaccines to all residents.
A resident with severe cognitive impairment and a history of pressure ulcers was not repositioned every two hours as required by their care plan. Observations showed the resident remained seated in a wheelchair for over three hours without repositioning. Staff interviews confirmed the resident's need for extensive assistance and the failure to follow the care plan, which increased the risk of skin breakdown.
A resident with severe cognitive impairment and a history of falls was observed with a Velcro belt fastened behind their wheelchair, which they could not remove independently. Despite staff believing the belt was not a restraint, a comprehensive assessment was not conducted, and the facility's policy on restraints was not followed. The deficiency was identified due to the lack of assessment and re-evaluation of the belt's use.
A facility failed to implement physician orders for a resident requiring daily weights to manage fluid retention. Despite having a process for recording weights, staff did not consistently obtain or document them, impacting the administration of Torsemide. Interviews revealed a lack of adherence to procedures, and the nurse practitioner was not informed of the missing weights, which were crucial for the resident's treatment plan.
A resident with cognitive impairment and a history of falls was not properly assessed for smoking safety, despite being a smoker. The resident managed cigarettes independently, disposing of butts in his room's garbage can, creating a fire risk. Staff interviews confirmed the lack of smoking assessments and interventions in the care plan, and the facility's policy required residents to smoke off-property without a designated area or supervision.
Resident Rights Not Reviewed or Posted Current
Penalty
Summary
The facility failed to ensure the resident bill of rights were provided verbally and in writing for all residents. During review of Resident Council Minutes Forms for 2/24/26, 3/26/26, and 4/16/26, the minutes did not document that the resident rights were reviewed. When seven residents attended a resident council meeting held by the surveyor, the residents stated the rights had not been reviewed. One resident said the rights were given at admission and posted in the facility, while another resident said they had been admitted years ago and were not coherent at that time. At 11:45 a.m., the poster near the nurses' station was reviewed and was dated 9/19, not the current 12/25 resident rights poster. During interview, the administrator stated the life enrichment supervisor was responsible for the resident council meetings and verified that the resident rights were not reviewed during those meetings and that the poster was not current. The facility policy for Resident and Family Council stated the facility would provide meeting space, inform residents of meeting opportunities, and respond to council concerns, but it did not include review of resident rights in the agenda.
Incomplete Daily Staffing Posting
Penalty
Summary
The facility failed to ensure that the daily staff posting included all required information. Review of the staff schedule and facility staff posting documentation dated 4/13/26 through 5/13/26 showed that the posting included the date and the total number of licensed staff with their designation, but it did not include the facility name, the census number clearly identified as such, or the total number of actual hours worked by licensed staff. On 5/13/26, the senior manager of scheduling operations stated they were responsible for updating and posting the daily facility staffing information Monday through Thursday evenings and posting the whole weekend on Friday night, with weekend nurses responsible for updating any changes. The senior manager stated they were unsure of the exact requirements for the posting. That same day, RN-A stated weekend staffing changes would be emailed to the DON and scheduling team and updated on internal unit sheets, but RN-A was unaware of responsibility to update the daily facility posting. The DON stated they were unsure whether weekend updates were always being done and confirmed the charge nurse was responsible for weekend changes. The administrator confirmed the scheduling team was responsible for updating and posting the daily staffing information and stated the posting needed to include the census and how many nurses and nursing assistants were in the building each day.
Improper Food Storage and Temperature Maintenance
Penalty
Summary
The facility failed to ensure proper labeling, dating, and discarding of food and beverages stored in the refrigerators, as well as maintaining appropriate food temperatures during meal service. During a kitchen tour, it was observed that several food items, including orange sauce, barbeque sauce, a chicken salad sandwich, pureed bread, and pork sausages, were either not labeled with an opening date or had expired. Additionally, a bottle of staff pop was found without a date. These practices were not in accordance with the facility's policy, which requires all foods to be labeled with contents, preparation date, and specific instructions. Furthermore, during meal service on the Pines unit, the facility failed to maintain proper cold food temperatures. Potato salad was observed being served at 51 degrees Fahrenheit, which is above the required 41 degrees Fahrenheit or lower, as per the facility's policy. The dietary aide acknowledged the error and stated that the potato salad should have been kept on ice to maintain a safe temperature. The dietary manager confirmed these findings and reiterated the expectation that all cold food should be held at 41 degrees Fahrenheit or lower to prevent foodborne illness. This deficiency had the potential to affect 59 residents who received food and beverages from the refrigerators.
Failure to Reposition Resident with Pressure Ulcer
Penalty
Summary
The facility failed to provide timely assistance with repositioning for a resident (R2) who had a current pressure ulcer and was at risk for further development of pressure ulcers. R2 had severe cognitive impairment and required extensive assistance with activities of daily living, including bed mobility and transfers. The resident had a stage 4 pressure ulcer on the left heel and was on a repositioning program that required repositioning every two hours while awake. However, during a continuous observation on March 4, 2025, R2 was not repositioned for over three hours while seated in a wheelchair, contrary to the care plan directives. Interviews with staff, including a nursing assistant (NA-A), a clinical manager (CM-A), and the director of nursing (DON), confirmed that R2 required staff assistance to reposition and that the care plan for repositioning every two hours was not followed. The facility's policy on repositioning, revised in January 2025, required staff to check the care plan or assignment sheet for resident-specific positioning needs. Despite this, R2 remained seated without repositioning for an extended period, increasing the risk of further skin breakdown.
Failure to Serve Food at Appropriate Temperature
Penalty
Summary
The facility failed to ensure that food was served at a palatable and appetizing temperature for four residents on the Pines unit. Observations and interviews revealed that residents frequently received meals that were not at the appropriate temperature. Specifically, residents reported that their food was often cold, and during a meal service, a test tray showed that the food items were below the required temperature of 140 degrees Fahrenheit. The cheese pizza was 88 degrees, mashed potatoes were 125 degrees, pureed pizza was 116 degrees, and pureed carrots were 114 degrees, all of which were below the facility's policy requirements. The deficiency was attributed to the improper use of the warming cart, which was not plugged in during meal service, as confirmed by a dietary aide. This resulted in the food being served at inadequate temperatures. The dietary manager stated that the expectation was for the warming cart to be plugged in to maintain food temperatures at or above 140 degrees Fahrenheit. The facility's policy on food temperature, revised in March 2020, indicated that all hot food items must be served at a minimum of 140 degrees Fahrenheit, which was not adhered to during the observed meal service.
Failure to Administer Pneumococcal Vaccinations per CDC Guidelines
Penalty
Summary
The facility failed to ensure that four out of five residents received pneumococcal vaccinations in accordance with the CDC recommendations. The CDC guidelines specify that adults aged 65 and older who have previously received the PPSV23 or PCV13 vaccines should receive a dose of the PCV20 vaccine at least one year after the most recent PPSV23 or PCV13 vaccine. Additionally, adults 65 and older who have received both PCV13 and PPSV23 should receive a dose of PCV20 at least five years after the last pneumococcal vaccine dose, based on shared clinical decision-making. However, the medical records for residents aged 76 to 89 lacked documentation that they had been offered or received the PCV20 vaccine as recommended. The Director of Nursing, who also serves as the infection preventionist, confirmed that the residents had not received the pneumococcal vaccinations as per CDC guidelines. The facility's policy, dated 2001, stated that all residents should be offered the pneumococcal vaccine to prevent pneumonia and pneumococcal infections, with eligibility assessed within five working days of admission. Despite this policy, the facility did not adhere to the updated CDC recommendations, resulting in a deficiency in the vaccination process for the residents involved.
Failure to Reposition Resident at Risk for Pressure Ulcers
Penalty
Summary
The facility failed to provide timely assistance with repositioning for a resident with a history of pressure ulcers and at risk for further development of pressure ulcers. The resident, who had severe cognitive impairment and diagnoses including Parkinson's, Diabetes Mellitus, and anxiety disorder, required extensive assistance with activities of daily living, including bed mobility, transfers, and toileting. The care plan directed staff to reposition the resident every two hours to prevent skin breakdown. However, observations revealed that the resident remained seated in a wheelchair for at least three hours without being repositioned, contrary to the care plan instructions. Interviews with staff, including a nursing assistant, LPN, RN, and the Director of Nursing, confirmed that the resident required extensive assistance to reposition and was at risk for skin breakdown. The staff acknowledged that the resident had not been repositioned as required, with the last repositioning occurring at 7:30 a.m., despite the care plan's directive for repositioning every two hours. The facility's policy on repositioning also emphasized the importance of following the care plan for each resident's specific needs, which was not adhered to in this case.
Failure to Assess Restrictive Device as Potential Restraint
Penalty
Summary
The facility failed to comprehensively assess the use of a restrictive device as a potential restraint for a resident with severe cognitive impairment and a history of falls. The resident, who had diagnoses including Parkinson's, Diabetes Mellitus, and anxiety disorder, required extensive assistance for activities of daily living and used a wheelchair for mobility. Despite the resident's care plan indicating the use of a non-restraint belt, observations revealed the resident was consistently seated in a wheelchair with a Velcro belt fastened behind the chair, which the resident was unable to remove independently. Interviews with staff, including a nursing assistant, LPN, RN, and the director of nursing, revealed a lack of clarity and assessment regarding the use of the Velcro belt. The staff believed the belt was not a restraint because the resident had previously been able to remove it, although current observations and attempts showed the resident could not do so. The director of nursing confirmed that a restraint assessment had not been completed prior to the belt's use, and the need for the belt had not been reassessed. The facility's policy on identifying involuntary seclusion and unauthorized restraint defined a physical restraint as any device that a resident could not easily remove and that restricted their freedom of movement. The policy emphasized that restraints should not be used unless required to treat a medical condition and should be the least restrictive option. The use of the Velcro belt, which the resident could not remove, was not accompanied by ongoing re-evaluation, leading to the deficiency identified in the report.
Failure to Implement Physician Orders for Daily Weights
Penalty
Summary
The facility failed to implement physician orders for a resident, identified as R33, who was at risk for fluid retention due to conditions such as atrial fibrillation and hypertension. The resident had an active order for Torsemide, a diuretic, to be administered as needed based on specific weight gain parameters. However, the facility did not consistently record daily weights as required, which were crucial for determining the administration of the medication. The absence of recorded weights was noted on multiple days across March, April, and May 2024, and there was no documentation indicating that the resident refused to be weighed or that the nurse practitioner was informed of the missing weights. Interviews with various staff members, including nursing assistants, LPNs, RNs, and the director of nursing, revealed a lack of adherence to the process for obtaining and documenting daily weights. Staff members acknowledged the importance of daily weights for the administration of Torsemide but admitted that weights were not consistently obtained or recorded in the electronic medical administration record (EMAR). The nurse practitioner and pharmacist were not informed about the missing weights, which could have impacted the resident's health management. The nurse practitioner confirmed that the facility did not communicate the lack of daily weights, which was essential for the resident's treatment plan. The director of nursing also confirmed the expectation for staff to follow physician orders, including obtaining daily weights. Despite the facility's process for recording weights, there was a significant lapse in execution, leading to the deficiency in care for the resident. A policy regarding vitals and weights was requested but not provided, indicating a possible gap in procedural documentation.
Failure to Assess and Supervise Resident Smoking Safety
Penalty
Summary
The facility failed to comprehensively assess smoking safety for a resident who was moderately cognitively impaired and had a history of falls and weakness. The resident, who had a tracheostomy and other medical conditions, was not identified as a smoker in the initial assessments and care plans. Despite being a cigarette smoker prior to admission and resuming smoking shortly after, the resident's electronic health record lacked any smoking assessments or interventions until a care plan update. The resident managed his cigarettes and lighter independently, kept them in his room, and disposed of cigarette butts in his room's garbage can, posing a fire risk. Interviews with staff, including an LPN, clinical manager, and DON, confirmed the lack of smoking assessments and interventions in the resident's care plan. The facility's policy prohibited tobacco use on the premises, requiring residents to go off-property to smoke. However, the resident was observed propping open facility doors with a cane to exit and smoke off-property, without a designated smoking area or proper supervision. Staff were unaware of the resident's smoking habits and disposal methods, highlighting a significant oversight in ensuring the resident's safety and compliance with facility policies.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bethany On The Lake Llc | 0.8 mi | ★★★★★ | 14 | 0 |
| Galeon | 10.2 mi | ★★★★★ | 7 | 0 |
| Glenwood Village Care Center | 16.3 mi | ★★★★★ | 2 | 1 |
| Evansville Care Center | 18 mi | ★★★★★ | 5 | 0 |
| St Williams Living Center | 19.1 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.