Knollwood Healthcare

In the surveyor’s words

From the most serious findings on record at Knollwood Healthcare, in the surveyor’s own words.

• Immediate jeopardy, widespreadF580Mar 27, 2025

  Based on interviews and record review the facility failed to ensure the physician was notified when residents on the second and third floors did not receive their medications and treatments as ordered when the facility experienced an internet outage preventing access to the Electronic Health Record (EHR) system on 01/21/2025 and 01/22/2025. Nurses did not have access to pre-printed paper documentation forms such as physician orders and MARs (Medication Administration Record) to administer medications on 01/21/2025 and 01/22/2025. […]

• Immediate jeopardy, widespreadF600Mar 27, 2025

  Based on interviews, record review and review of facility policies titled, Abuse Policy and Policy on Computer or Internet Downtime and EHR (Electronic Health Record) Access, the facility failed to protect the resident's right to be free from neglect when systems were not in place to ensure continuity of care and operations when the facility experienced a forecasted winter storm which caused internet outage preventing access to the EHR system on 01/21/2025 and 01/22/2025. The facility failed to ensure pre-printed paper documentation forms such as physician orders and MARs were available and accessible for the licensed nursing staff to utilize for resident care, treatment, and medication administration prior to the internet outage. […]

• Immediate jeopardy, widespreadF658Mar 27, 2025

  Based on interviews, record review, review of facility policies titled Administering Medications, and Policy on Computer or Internet Downtime and EHR (Electronic Health Record) Access, the facility failed to ensure Licensed Practical Nurse (LPN) #14, Registered Nurse (RN) #15, RN #16, RN #20, and LPN #18 followed standards of practice and facility's policies. Specifically, LPN #14 and RN #15 failed to follow standards of practice to administer medications and perform Capillary Blood Glucose (CBG) monitoring as ordered by the physician on 01/21/2025 during the 2 PM to 10 PM shift on the Second Floor. […]

• Immediate jeopardy, widespreadF760Mar 27, 2025

  Based on interviews, record review, and review of a facility policy titled Administering Medications the facility failed to ensure residents were free of significant medication errors when licensed nursing staff failed to administer medications including insulin and other significant medications. Specifically, on 01/21/2025 during a forecasted snowstorm the facility lost internet connection sometime after lunch which resulted in inability to access residents Electronic Health Record (EHR)/Electronic Medication Administration Record (eMAR) until the evening of 01/22/2025. Resident Identifier (RI) #12, RI #15, RI #30, and RI #308 were not administered significant medications from 01/21/2025 at 5:00 PM until 01/22/2025 at 9:00 PM. […]

• Immediate jeopardy, widespreadF835Apr 25, 2024

  Based on interviews and review of the Administrator job description, the facility's Administrator, responsible for the day-to-day operation of the facility failed to ensure the QAPI (Quality Assurance and Performance Improvement) committee met to identify all concerns using root cause analysis to ensure corrective actions needed with plans to prevent further occurrence including ongoing monitoring after Resident Identifier (RI) #1 eloped from the facility on 02/05/2023. This failure placed all 53 residents residing in the facility at risk for immediate jeopardy, as it was likely to result in serious injury, serious harm, serious impairment, or death, due to the ongoing risk of elopement. […]