Knollwood Manor

In the surveyor’s words

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

• Immediate jeopardy, isolatedF657Jul 14, 2022

  Based on facility documentation, facility policy review, medical record review, and interview, the facility failed to revise a wandering/elopement care plan for 1 of 2 sampled residents (Resident #39) reviewed for wandering and elopement risk (Residents who have a history of leaving or trying to leave the facility, or have wandered or have potential to wander into unsafe areas), placing the resident in an Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment or death to a resident). […]

• Immediate jeopardy, isolatedF689Jul 14, 2022

  Based on facility documentation review, facility policy review, medical record review, and interview, the facility failed to provide adequate supervision to prevent elopement for 1 of 2 sampled residents (Resident #39) reviewed for wandering and elopement risk (Residents who have a history of leaving or trying to leave the facility, or have wandered or have potential to wander into unsafe areas), placing the resident in an Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment or death to a resident). […]

• Immediate jeopardy, isolatedF835Jul 14, 2022

  Based on medical record review and interview, the Administrator failed to administer the facility in a manner to ensure resident care plans were revised and to provide adequate supervision to prevent unsafe wandering and elopement from the facility for 1 of 1 resident (Resident #39) who was an elopement risk. The administrator's failure to ensure resident care plans were revised and to provide supervision and keep residents safe placed the residents in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). […]

• Actual harm, isolatedF656Jul 14, 2022

  Based on facility policy review, medical record review, observation, and interview the facility failed to implement a fall care plan for 1 of 7 sampled residents (Resident #16) which resulted in a left Femoral Neck fracture (hip fracture) which caused harm, and the facility also failed to implement a behavioral care plan for [CONDITION(S)] for 1 of 25 sampled residents (Resident #8) which did not rise to the level of G. The findings include: Review of the facility's undated policy titled, Policy for Care Plan Implementation, revealed, The resident assessment process shall be completed by the following steps: 1. […]

• No harm, potential for more than minimal, patternF609Nov 21, 2025

  Based on policy review, medical record review, and interview, the facility failed to report an injury of unknown origin for 6 of 6 (Resident #8, #16, #20, #23, #25, and #35) sampled residents reviewed. The findings include: 1. Review of the undated facility policy titled, ABUSE, revealed .Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents shall not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals.if an incident is determined to have unknown origin or is suspicious in nature.then that incident shall be reported to the State of Tennessee within 2 hours… […]