Knolls West Post Acute LLC

In the surveyor’s words

From the most serious findings on record at Knolls West Post Acute LLC, in the surveyor’s own words.

• Actual harm, isolatedF689Jun 21, 2023

  Based on observation, interview, and record review, the facility failed to ensure the prevention of avoidable accidents for one of three sampled residents (Resident 1), when a Certified Nursing Assistant 1 (CNA 1) failed to perform a two-person transfer while using a Hoyer Lift (a mechanical lift used to transfer residents from their bed to a chair, or wheelchair, etc.) with Resident 1, and failed to use the appropriate Hoyer Lift sling with Resident 1 during a transfer from a bed to a wheelchair. These failures resulted in Resident 1 falling to the floor and sustaining a laceration (a break in the skin caused by blunt force trauma) to the back of the head, requiring evaluation and treatment at a hospital. […]

• Actual harm, isolatedF686Dec 15, 2022

  Based on observation, interview, and record review, the facility failed to ensure the facility's policy and procedure titled Policy and Procedure on Pressure Ulcers (wounds caused by prolonged pressure on a bony prominence that may be superficial (Stage 1) to involving damage which includes all layers of skin down to the bone (Stage IV), dated August 22, 2017, for two of two sampled residents (Residents 3 and 44) was followed when: 1. The facility did not provide documented evidence for Resident 3 who had a Stage 4 pressure (involves all layers of skin down to the bone) ulcer on the sacrum (located above the tailbone) and a Stage 3 pressure (Involves all layers of skin down to the muscle) ulcer on the left hip to show the resident had been repositioned at least every two hours to prevent… […]

• No harm, potential for more than minimal, widespreadF812May 22, 2025

  Based on observation, interview, and record review, the facility failed to maintain food safety practices in the kitchen as required by facility's policy and procedure (P&P). The facility did not ensure food preparation areas, equipment, and storage were kept clean, labeled, and safe and failed to prevent cross-contamination, improper thawing and unsanitary conditions when: 1. One kitchen staff was not wearing a hairnet in the food prep area. 2. The juice machine nuzzle, and black rubber ring had dark grime, old stains, and residue. 3. Six red colored drink pitchers were left on a counter without date labels. 4. A large blue plastic container labeled ICE ONLY was found uncovered and filled with ice on a metal prep table. 5. […]

• No harm, potential for more than minimal, widespreadF908May 22, 2025

  Based on observation, interview, and record review, the facility failed to maintain essential kitchen equipment in safety operating condition when: 1. Two ovens located in the kitchen were observed to be non-functional not in use, yet they remained accessible and unmarked as out of order. This failure has the potential to result in limited cooking capacity, delays, and disruption in the kitchen's ability to deliver timely meals and maintain appropriate sanitation. Findings: During a concurrent observation and interview on May 19, 2025, at 9:06 AM with the Dietary Services Supervisor Assistant 1 (DSSA 1) inside the kitchen, during and inspection two of five ovens were to be visible nonfunctional. […]

• No harm, potential for more than minimal, widespreadF563Dec 15, 2022

  Based on observation, interview, and record review, the facility failed to uphold residents' rights for visitation for all 105 residents residing within the facility when the facility was restricting visitors by requiring visitors to be tested for COVID-19 (an illness caused by a virus) prior to entering the facility, charging visitors five dollars for COVID-19 tests, limiting visitation time to 1 hour, and by posting limiting visitation hours as was all specified by the Visiting Policy posted at the reception desk (main entrance) of the facility. These failures resulted in the infringement of the rights for visitation of all 105 residents by potentially deterring visitors as a result of the posted requirements. […]