Knollwood Nursing Center

Based on observations, interviews, and record review, the facility failed to follow professional standards of practice for food safety to prevent the potential spread of foodborne illness to facility residents on the steam table service area and on two (Bayberry Lane and [NAME] Lane) out of two facility kitchenettes. Specifically, the facility failed to ensure that:1. [NAME] Supervisor #1 changed gloves and performed appropriate hand hygiene while working on the resident food service line in the kitchenette located between the Bayberry Lane and [NAME] Lane units and handling food, clean dishes and touching equipment and surfaces in the steam table service area. 2. food items were appropriately stored in the Bayberry Lane and [NAME] Lane kitchenettes. Findings include:Review of the facility policy titled, Handwashing/Hand Hygiene, dated 2001, indicated: -all personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. -the use of gloves does not replace hand washing/hand hygiene. -perform hand…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview, the facility failed to ensure that one Resident (#59) out of a total sample of 18 residents received treatment and care in accordance with professional standards of practice related to wound care. Specifically, the facility failed to ensure that a verbal Provider order for a treatment change on wound care was transcribed and implemented when the Resident's wound was found to have increased in size and drainage, resulting in a delay of care and placing the Resident at risk for further wound deterioration and/or infection. Findings include: Review of the facility policy titled Medication and Treatment Orders, dated 2001, included but was not limited to the following: -Orders for medications and treatments will be consistent with principles of safe and effective order writing.-Verbal orders must be recorded immediately in the resident's chart by the person receiving the order .and include the time of the order. Resident #59 was admitted to the facility in July 2018 with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record review, the facility failed to maintain professional standards of practice relative to the care and treatment of a urinary catheter (a small, soft, flexible tube in the bladder that drains urine from the body) device for one Resident (#7) out of a total sample size of 18 residents. Specifically, the facility failed to ensure that Resident #7's urinary catheter drainage bag was not placed directly on the floor placing the Resident at risk for contamination and urinary infections. Findings include: Review of facility policy titled Catheter Maintenance of Urethral/Suprapubic, dated 7/1/11, included but was not limited to: >Purpose: To reduce the occurrence of catheter associated infections. >Procedure: Do not rest the (drainage) bag on the floor. Resident #7 was admitted to the facility in May 2024 with diagnoses including Dementia and Urine Retention. Review the most recent Minimum Data Set (MDS) assessment, dated 9/5/25, indicated Resident #7: -has severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and Facility Assessment Tool review, the facility failed to implement the Facility Assessment Tool's staff training/education and competencies plan, and update the Facility Assessment Tool to accurately reflect the resident population and care needs for day-to-day operations and medical emergencies for one Resident (#5) out of one applicable resident with a tunneled hemodialysis catheter (a type of central venous catheter that is inserted under the skin and tunneled into a large vein). Specifically, the facility failed to identify and ensure the need for Licensed Nurse education/training and competencies related to day-to-day care and emergency care for residents on dialysis when Resident #5 was admitted to the facility, and his/her dialysis care needs were not identified on the Facility Assessment Tool. Findings include:Review of the facility policy titled End Stage Renal Disease (ESRD), Care of a Resident with, last revised September 2010, indicated:-Residents…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and records reviewed, the facility failed to conduct an inspection of the mattress and bed rail to identify areas of possible entrapment for one Resident (#3) of two applicable residents, out of a total sample of 18 residents. Specifically, the facility failed to inspect Resident #3's mattress and bed rail for entrapment risk when the facility changed the Resident's mattress from a standard pressure reducing mattress to an air mattress and the Resident used a quarter length upper bed rail in the upward position when in bed with a gap observed between the air mattress and bed rails. Findings include:Review of the Food and Drug Administration (FDA) Hospital Bed System Dimensional and Assessment Guide to Reduce Entrapment, dated 3/10/06, indicated the following:- .air mattress replacements, and similar pressure reduction products that have therapeutic benefits such as reducing pressure on skin are easily compressed by the weight of a patient and may pose an additional risk of entrapment when used with conventional hospital bed systems.-When these…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, policy review, and test tray results, the facility failed to serve palatable food at an appetizing temperature for the residents on two units (Bayberry and Willow) out of two units. Findings include: During a Resident Council meeting held on 8/22/24 at 1:29 P.M., several residents said that there have been concerns that hot foods are arriving to the units at cool/cold temperatures. Test trays were ordered and test trays tasting were conducted by Surveyor #1 and #2 on 8/23/24. On 8/23/24, between 8:17 A.M. and 8:28 A.M., Surveyor #1 observed the following on the Bayberry Unit: -The Meal Tray caddy doors were left open between tray removal. -The last resident tray was served at 8:28 A.M. On 8/23/24 at 8:29 A.M., Surveyor #1 observed the Staff Development Coordinator (SDC) take temperatures of the Bayberry Unit test tray and beverages and the surveyor taste tested the food and beverage items on the tray with the following results: -Eggs: 95.3 degrees Fahrenheit (F), cold to taste -Sausage: 91 degrees F, cool to taste -Toast: 87 degrees F, cool to touch…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record and policy review, the facility failed to provide care in accordance with professional standards for one Resident (#275) out of a total sample of 18 residents. Specifically, the facility staff failed to apply medical devices as ordered by the Physician to assist in managing Resident #275's Orthostatic Hypotension (a sudden drop in blood pressure that occurs with position changes from a seated or lying position to standing). Findings include: Review of the Facility Policy titled Nursing Clinical Procedures, Subject: Elastic Stockings, dated 3/1/07, indicated, the following: -Purpose: to facilitate venous blood return (the flow of blood from the body back to the heart) in patients/residents with impaired circulation. -Special Considerations >apply the stockings in the morning, if possible . Resident #275 was admitted to the facility in August 2024, with diagnoses including Orthostatic Hypotension, and Tachycardia (an increased heart rate over 100 beats per minute [bpm] that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview, the facility failed to coordinate vision care services for one Resident (#49) out of a total sample of 18 residents. Specifically, for Resident #49, the facility failed to ensure that the Resident with a diagnosis of Glaucoma (a group of eye diseases that can cause vision loss and blindness by damaging a nerve in the back of the eye called the optic nerve [which sends visual information from the eye to the brain]) received proper treatment to maintain vision abilities, after receiving consent from the Resident's Health Care Proxy (HCP- the person chosen as the healthcare decision maker when the individual is unable to do so for themself) for vision care services. Findings include: Resident #49 was admitted to the facility in December 2022, with diagnoses including Glaucoma and Type 2 Diabetes (DM II - condition in which the body does not produce enough insulin hormone and has trouble controlling blood sugar [glucose] levels). Review of the Minimum Data Set (MDS) assessment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record and policy review, the facility failed to maintain an environment that was free of accident and hazards for one Resident (#61), out of a total sample of 18 residents. Specifically, the facility staff failed to ensure the safe temperature of a hot beverage prior to serving Resident #61, placing resident at risk of being burned by the hot beverage. Findings include: Review of the facility's policy titled Nutrition Services -Food Temperature Recording Policy, revised 1/2014, indicated: -Beverages must be reheated at 15 second intervals and check temperature before serving to a resident. -No guidance for beverage temperature reheating was included in the facility policy. Review of Harvard Medical School research topics on scalding (to burn the skin with liquid), July 2023, at www.harvardhealth.edu indicated: -scalding of the skin from hot liquids could occur at temperatures as low as 120 Fahrenheit (F). Resident #61 was admitted to the facility in May 2024, with diagnoses…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, policy and record review, the facility failed to ensure that two Residents (#57 and #8) out of a total sample of 18 residents were free from significant medication errors. Specifically, the facility staff failed to: 1. For Resident #57, adhere to the Physician's order to administer a one-time dose of Trulicity (medication used to improve blood sugar control and reduce the risk of major adverse cardiovascular events in patients with multiple risks for, or existing cardiovascular disease) when staff administered two doses of Trulicity to the Resident over two consecutive days, which increased the Resident's risk for low blood sugar (hypoglycemia). 2. For Resident #8, adhere to the Physician's order relative to sliding scale Insulin (progressive increase in the pre-meal . insulin dose, based on pre-defined blood sugar ranges) administration when Humalog (type of Insulin medication) was administered to the Resident outside of the ordered parameters for Insulin administration, which increased the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and policy review, the facility failed to follow sanitation and food handling practices in accordance with professional standards for food service safety in the facility's main kitchen to prevent the risk of foodborne illnesses. Specifically, the facility failed to: 1. Ensure that Dietary Staff #3 performed hand hygiene (washing or sanitizing of hands) as indicated after touching her mask while handling resident food trays. 2. Ensure that Dietary Staff #1 changed gloves between food handling and used separate utensils for different types of food to prevent the potential for cross contamination. Findings include: 1. Review of the facility policy titled Handwashing/Hand Hygiene, revised August 2019, indicated but was not limited to the following: -Use an alcohol-based hand rub containing at least 62% alcohol; or alternative soap (antimicrobial or non-antimicrobial) and water for the following situations: >after handling . contaminated equipment, etc. During an observation of the kitchen tray line on 8/23/24 at 7:45 A.M., the surveyor observed Dietary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record and policy review, and interview, the facility failed to maintain infection control measures to prevent the development and transmission of communicable diseases and infections for two Residents (#25 and #225) out of a total sample of 18 residents. Specifically, the facility staff failed to: 1. For Resident #25, appropriately store the Resident's oxygen tubing and nasal cannula (a thin flexible tube that provides supplemental oxygen through the nose via nasal prongs) when not in use, and change the Resident's oxygen tubing weekly as ordered by the Physician placing the Resident at risk for equipment contamination and infection. 2. For Resident #225, failed to position the urinary catheter drainage bag (a bag used to collect urine) off the floor to prevent the risk of contamination and infection. Findings include: 1. Review of the facility policy for Departmental (Respiratory Therapy) - Prevention of Infection last revised November 2011, indicated: -change the oxygen cannula and tubing every seven days or as needed (PRN). -keep the oxygen cannula and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure its staff maintained complete clinical records related to an adverse interaction between two sampled Residents (#18 and #23), out of a total sample of 19 residents. Specifically, the facility staff failed to document: 1) the negative interaction for Resident #23, and 2) corresponding follow-up for both Resident #18 and Resident #23 after the adverse interaction occurred. Findings include: Resident #18 was admitted to the facility in June 2022 with diagnoses including Alzheimer's Dementia with Behavioral Disturbances, Mood Disorder, and Delusional Disorder, and had severe cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 5 out of 15 as indicated in a review of the Minimum Data Set (MDS) assessment dated [DATE]. Resident #23 was admitted to the facility in March 2021 with a diagnosis of Dementia with Mood Disorder and had severe cognitive impairment as evidenced by a BIMS score of 3 out of 15 as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.