Knollwood HSC

In the surveyor’s words

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

• Actual harm, isolatedF689May 30, 2025

  Based on record review and staff interviews for one (1) of eight (8) sampled residents, facility staff failed to adequately monitor and supervise a resident with a high fall risk. Subsequently, the Resident had three unwitnessed falls in the same month (02/07/25, 02/22/25, and 02/28/25). The unwitnessed fall on 02/28/25 resulted in a sustained injury. Resident #8The findings included:A review of the facility's policies and procedures approved on 09/06/24, entitled, Fall Prevention Policy documented: Policy Goals: ' .To reduce the risk of falls and related injuries by addressing modifiable factors . Procedure: A fall risk assessment should be completed on admission and quarterly at a minimum. If the total score is 10 or greater, the resident should be considered at risk for falling. […]

• Actual harm, isolatedF686Jun 2, 2021

  Based on observation, record review, and staff interview, the facility's staff failed to ensure that Resident #5, who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure resulted in actual harm to Resident #5. The findings include: Resident #5 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Significant Change Minimum Data Set (Assessment Reference Date of 11/25/2020), documented the following: In Section C0500 (Brief Interview for Mental Status), the resident had a summary score of 14, indicating the resident was cognitively intact. In Section I, -(Additional Active Diagnoses) coded the resident for Pressure Ulcer of Sacral Region, Stage 3. […]

• Actual harm, isolatedF689Jun 2, 2021

  Based on record review and staff interview, for two (2) of 18 sampled residents, the facility's staff failed to provide adequate supervision and monitoring to prevent falls with major injuries (fractures) for Residents' #5 and #31. This failure resulted in actual harm to Residents' #5 and #31. The findings include: 1. The facility's staff failed to provide adequate supervision to prevent a fall with major injuries (fractures) for Resident #5. Resident #5 was admitted to the facility on [DATE], with multiple diagnoses including, [CONDITION(S)], Coronary Artery Disease, [CONDITION(S)], [CONDITION(S)], and Spinal Stenosis. […]

• No harm, potential for more than minimal, widespreadF868Apr 26, 2023

  Based on record reviews and staff interviews, facility staff failed to show documented evidence that the facility conducted quarterly QAPI (Quality Assurance & Performance Improvement) meetings to identify and evaluate quality activities for the year 2022. The resident census during the survey was 44. The findings included: A review of an email correspondence provided to the surveyor dated 06/09/22, showed in the subject line QAPI-1st Quarter 2022 Microsoft Teams Meeting. The facility staff was unable to show documented evidence that the QAPI committee met more than once in the year 2022. […]

• No harm, potential for more than minimal, patternF658Apr 26, 2023

  Based on record review and staff interview, facility staff failed to provide care and services that met the professional standards of quality and practice as evidenced by one facility staff administering expired Influenza vaccines to ten (10) of 22 sampled residents. Residents' #11, #14, #22, #25, #27, #29, #31, #33, #35, and #44. The findings included: Review of a document provided by the facility titled, Medication Expiration and Beyond Use Dating dated 04/06/17 documented, Medications will be discarded according to .expiration date or according to the manufacturer's expiration date . Review of the facility policy Medication Administration - Guidelines for All Medications with a revised date of 06/01/22 directed, . Check expiration date on package/container . […]