Average — CMS composite of the measures below.
The next survey window likely opens around March 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 Knife River Care Center during CMS and state inspections, most recent first.
A resident with a known risk for elopement, documented wandering behaviors, and a functioning wander guard was able to exit the facility unsupervised. Although the door alarm was triggered and sent to staff walkie-talkies, staff did not respond promptly, allowing the resident to remain outside for several minutes before being returned by an employee who found them in the parking lot.
Surveyors found that two residents who used wheelchairs were affected by the facility's failure to maintain clean and safe equipment and living areas. One resident's wheelchair had damaged armrest pads, while another's Broda chair was observed with dried feces and food debris, and cleaning logs showed missed scheduled cleanings. Staff and family interviews confirmed these deficiencies.
A CNA transferred a resident with significant mobility limitations using a ceiling lift but failed to use the required cross-through method for the sling straps, as outlined in the manufacturer's instructions. This deviation from protocol during the transfer process resulted in inadequate assistance and supervision, increasing the risk of fall and injury for the resident.
A resident in a memory care unit was found on the floor being kicked by another resident in a wheelchair. Both residents had severely impaired cognition and histories of aggressive behavior related to dementia. The incident was discovered by two staff nurses who intervened to ensure the safety of the resident on the floor. The facility's policy prohibits abuse by anyone, including other residents, but this incident demonstrated a failure to maintain a safe environment.
A facility failed to update a resident's care plan to reflect their history of suicidal ideation, despite multiple documented instances of concerning behavior, including striking another resident and expressing suicidal thoughts. This oversight limited staff's ability to communicate the resident's needs and ensure continuity of care.
A resident with severely impaired cognition experienced physical abuse by a family member, who was observed gripping the resident's arm and slapping them. The facility failed to promptly investigate the incident or document the resident's injuries, including bruising and a dislocated finger, until two days later.
A resident with severely impaired cognition was physically abused by her daughter, who was reported to have slapped her. Although a nurse intervened and asked the daughter to leave, the facility failed to report the incident to the SSA within the required 2 to 24-hour timeframe, as confirmed by administrative staff.
A resident sustained burns from hot coffee after falling asleep at a table, highlighting the facility's failure to monitor beverage temperatures and provide mug lids as per the care plan. The resident had a history of spilling hot liquids, yet the care plan did not include necessary precautions. Temperature readings showed beverages were served at unsafe temperatures, and staff confirmed the lack of monitoring, leading to the incident.
Failure to Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
A deficiency occurred when a resident identified as being at risk for elopement was able to leave the facility unsupervised. The resident had a history of wandering, was disoriented to place, and had impaired safety awareness, as documented in quarterly elopement assessments and the care plan. The care plan included interventions such as the use of a wander guard, structured activities, and frequent checks, but these measures were not sufficient to prevent the resident from exiting the building. On the day of the incident, the resident was found outside in the facility's parking lot by an employee, fully dressed and sitting in a wheelchair, attempting to get into a parked car. The wander guard device was in place and appeared to be functioning, and the door alarm was triggered and sent to staff walkie-talkies. However, staff did not respond to the alarm in a timely manner, allowing the resident to remain outside for approximately five minutes before being returned to the building by a staff member who recognized the resident in the parking lot. Review of camera footage confirmed that the resident was able to hold the door to disarm the locking system and exit the facility. The incident lasted about ten minutes, with the resident outside for half of that time. Documentation and interviews confirmed that the alarm system was operational, but the lack of immediate staff response to the alarm resulted in the resident's unsupervised elopement.
Failure to Maintain Clean and Safe Wheelchairs and Resident Areas
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, and homelike environment for two residents who required wheelchairs. One resident's wheelchair was found in disrepair, with cracked, missing, and flaking vinyl on the armrest pads. A staff member confirmed that the armrest pads needed replacement. For another resident, a family member reported that staff did not clean the resident's Broda chair or room, pointing out tissues, a lollipop stick on the floor, and dried feces on the chair's frame. Observations confirmed the presence of dried feces and food debris in various parts of the chair, and a CNA acknowledged the need for cleaning. Review of the facility's cleaning logs revealed that the Broda chair was scheduled for weekly cleaning, but staff failed to sign off on this task for seven out of twelve scheduled weeks. An administrative nurse stated that she expected staff to clean the wheelchairs weekly as scheduled. These findings demonstrate that the facility did not ensure regular cleaning and maintenance of equipment and resident areas as required.
Improper Use of Ceiling Lift Sling During Resident Transfer
Penalty
Summary
A certified nurse aide (CNA) transferred a resident with limited physical mobility, contractures, and muscle weakness from a wheelchair to a bed using a ceiling lift. During the transfer, the CNA attached the leg strap loops of the sling to the spreader bar but did not use the cross-through method as specified in the manufacturer's instructions for the Maxi Sky 2 ceiling lift. The resident's care plan required the use of a ceiling track for transfers due to their physical limitations. A nursing supervisor confirmed that the cross-through method should have been used, particularly for this resident given their muscle weakness. This failure to follow the proper sling strap method during the ceiling lift transfer resulted in inadequate assistance and supervision, placing the resident at risk for a fall and injury.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse, as evidenced by an incident involving two residents in the memory care unit. On the specified date, two staff nurses heard moaning and discovered one resident lying on the floor while another resident, seated in a wheelchair, was kicking the resident on the floor. The resident in the wheelchair was known to have severely impaired cognition and a history of aggressive behavior related to dementia and childhood trauma. The resident on the floor also had severely impaired cognition and was identified as a wanderer with potential for verbal and physical aggression due to dementia. The incident was documented in the progress notes, indicating that the resident on the floor was assessed and found to have no injuries, and both family and providers were updated. The facility's policy on abuse prohibition clearly states that residents must not be subjected to abuse by anyone, including other residents. Despite this policy, the incident occurred, demonstrating a failure to ensure an environment free from abuse, which placed the involved resident and potentially others at risk for harm.
Failure to Update Care Plan for Resident with Suicidal Ideation
Penalty
Summary
The facility failed to review and revise the care plan for one of the sampled residents, which resulted in a deficiency. The medical record review for the resident revealed multiple instances of concerning behavior, including striking another resident, expressing suicidal ideation, and verbal agitation. Despite these documented behaviors, the resident's care plan did not include a history of suicidal ideation, which limited the staff's ability to communicate the resident's needs and ensure continuity of care.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse, as evidenced by an incident involving the resident's daughter. The daughter was observed by an activity aide to have a firm grip on the resident's arm, causing discoloration, and subsequently slapped the resident across the face. The activity aide intervened by involving the charge nurse and removing the daughter from the situation. Despite the immediate intervention, the facility did not promptly investigate the incident or document the resident's condition, including bruising and a dislocated finger, until two days later. The resident involved had severely impaired cognition, as identified in their medical records. The lack of immediate investigation and documentation of the resident's injuries, such as bruising and a dislocated finger, highlights the facility's failure to ensure the resident's safety and protection from abuse. The medical record lacked documentation of the resident's skin condition, pain, or discomfort following the incident until after the resident returned from the emergency room two days later.
Failure to Timely Report Resident Abuse Incident
Penalty
Summary
The facility failed to report an incident of physical abuse involving a resident to the State Survey Agency (SSA) within the required time frame. The incident involved a resident with severely impaired cognition, whose daughter was reported by the activities director to have been slapping the resident in the face. A nurse intervened by asking the daughter to leave the facility and informed her that abuse is not tolerated. Despite this immediate action, the facility did not report the incident to the SSA within the mandated 2 to 24-hour period. An administrative staff member confirmed that the charge nurse had informed them of the incident on the day it occurred, but the investigation and notification to the SSA were not initiated until two days later. This delay in reporting constitutes a failure to comply with regulations designed to protect residents from abuse. The facility's policy clearly outlines the requirement for immediate reporting of any alleged abuse to the appropriate authorities, which was not adhered to in this case.
Resident Burned by Hot Coffee Due to Lack of Temperature Monitoring
Penalty
Summary
The facility failed to ensure an environment free of accident hazards, resulting in a resident sustaining burns from hot coffee. The incident involved a resident who fell asleep at a table and spilled hot coffee on her lap, causing large areas of redness and blistering on her thighs. The resident's medical record indicated a history of risk for injury related to hot liquids, with previous incidents of spilling tea on herself. Despite this, the resident's care plan did not include a requirement for mug lids on the meal ticket or dietary care plan, and staff interviews confirmed that the tray provided to the resident lacked a lid on the hot beverage. Temperature readings taken during the investigation revealed that the coffee and hot water temperatures in various kitchenettes and machines were significantly above the safe serving temperature of 140 degrees Fahrenheit. The facility did not monitor the temperature of hot beverages before or on the day of the incident, which contributed to the resident's injury. Interviews with administrative and dietary staff confirmed the lack of temperature monitoring and the absence of mug lids, highlighting the facility's failure to prevent the accident hazard.
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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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Nursing homes near Beulah
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Garrison Mem Hosp Nsg Fac | 30.5 mi | ★★★★★ | 9 | 0 |
| Benedictine Living Center Of Garrison | 30.9 mi | ★★★★★ | 0 | 0 |
| Marian Manor Healthcare Center | 32.6 mi | ★★★★★ | 4 | 1 |
| Elm Crest Manor | 33.8 mi | ★★★★★ | 3 | 0 |
| Richardton Health Center Inc | 37.6 mi | ★★★★★ | 3 | 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.