Complete Care at Green Knoll

Inspectors wroteBased on observation, interviews, and review of other facility documentation, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to keep the dumpster and surrounding area free of garbage and debris. On 02/04/2026 9:21 AM, in the presence of the Food Service Director (FSD), the surveyor toured the kitchen and the designated garbage area and observed the following: There were multiple carboard boxes outside of the dumpster on the ground and surrounding area. The FSD stated that the area should have been cleaned by the maintenance and dietary departments. On 2/5/26 at 9:00 AM, the FSD provided the surveyor with a facility policy titled, Garbage and dumpster area policy with a revised date of 5/8/21. The policy revealed, 3. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to keep the call bell within residents' reach. This deficient practice was identified for 8 of 30 residents (Resident #6,15, 37, 44, 55, 139, 152 and 155) reviewed for accommodations of needs and was evidenced by the following:1. On [DATE] at 11:56 AM, the surveyor observed Resident #139 in bed wearing glasses with floor mats on both sides of the bed and the call bell on the floor not within the resident's reach. On [DATE] at 7:40 AM, the surveyor observed Resident #139 in bed with floor mats on both sides of the bed and the call bell on the floor not within the resident's reach. The surveyor reviewed the medical record for Resident #139. [...]

Inspectors wroteBased on observation, interview, record review and review of facility provided documents, it was determined the facility failed to a.) ensure the timeliness of each resident's person-centered comprehensive care plan (PCCP), that is reviewed and revised by an interdisciplinary care team, (IDCP) during the IDCP meeting with the resident and a resident representative (if applicable) every quarter, and b) updating the care plan to reflect new physician orders. The deficient practice was identified for 2 of 30 residents reviewed for Comprehensive Care Plan (Resident #11 and Resident #168). These deficient practices were evidenced by the followinga. Resident #11 On 02/4/26 at 10:45 AM, the surveyor observed Resident #11 in their room. A review of the medical records revealed Resident #11 had diagnoses which included but were not limited to; [...]

Inspectors wroteBased on observation, interview and review of facility policy, it was determined that the facility failed to maintain the confidentiality of the resident information and properly dispose of paperwork with resident information. This deficient practice was observed during kitchen observation around the dumpster area of the building. On 2/4/26 at 9:30 AM, during observation of the garbage/dumpster area and in the presence of the Food Service Director (FSD), the surveyor observed an open carboard box with multiple papers. [...]

Inspectors wroteBased on observation, interview, and review of facility policy, it was determined that the facility failed to provide a homelike environment in resident rooms. The deficient practice was observed on 1 of 3 nursing units (3rd floor) and was evidenced by the following:On 2/4/26 at 11:53 AM, the surveyor toured the 3rd floor nursing unit on the 3rd floor nursing unit and observed the following: In room [ROOM NUMBER], the heater was heavily rusted, the heating vent cover was missing, and theCove base molding was pulled away from the wall. In room [ROOM NUMBER] D, the electrical outlet was cracked. In room [ROOM NUMBER] B, the cove base molding under the sink was pulled off. In room [ROOM NUMBER], the wall behind the bed by the door had chipped paint, and the molding along the wall was cracked. The bathroom door had a large crack at the bottom. [...]

Inspectors wroteBased on the interview and record review, it was determined that the facility failed to complete and transmit a Minimum Data Set (MDS, an assessment tool used to facilitate the management of care) in accordance with federal guidelines. This deficient practice was identified for 5 of 30 residents (Resident #9, #39, #111, #131 and #134) during the review of resident assessment. The MDS is a comprehensive tool, a federally mandated process for clinical assessment of all residents that must be completed and transmitted to the Quality Measure System. The facility must electronically transmit the MDS within 14 days of completing the assessment. After the MDS is transmitted, a quality measure will be transmitted to enable a facility to monitor the residents' decline or progress. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure that a low air loss mattress was accurately set and monitored according to the resident's weight and or comfort. This deficient practice was identified for 4 of 5 residents reviewed (Resident #15, # 92, 152, and #163. This deficient practice was evidenced by the following:1. On 2/4/26 at 11:09 AM, the surveyor interviewed Resident #163 in their room. Resident stated their air mattress was very stiff and caused back pain. The surveyor observed the air mattress setting at 380 lbs. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide assessments of the resident's condition and to monitor for complications after dialysis treatments were received at a certified dialysis facility for 1 of 2 residents (Resident #55) reviewed for dialysis. This deficient practice was evidenced by the following:Based on observation, interview and record review, it was determined that the facility failed to provide assessments of the resident's condition and monitoring for complications after dialysis treatments were received at a certified dialysis facility for 1 of 2 residents (Resident #55) reviewed for dialysis. This deficient practice was evidenced by the following: On 02/04/2026 at 12:15 PM, the surveyor observed Resident #55 in bed with their eyes closed. [...]

Inspectors wroteRepeat deficiencyBased on observation, interview, and record review, it was determined that the facility failed to a). properly label, store and dispose of medications in 2 of 7 medication carts and 1 of 3 medication room refrigerators inspected and b). failed to secure 1 of 3 emergency crash carts observed. This deficient practice was evidenced by the following: This deficient practice was evidenced by the following:a). On 02/04/26 at 09:40 AM, the surveyor inspected the 2nd floor medication cart #1 in the presence of a Licensed Practical Nurse (LPN#1). The surveyor observed two (1) loose medications in tablet form (not in pharmaceutical packaging) in the 2nd drawer of the medication cart and one (1) loose medication in tablet form in the 3rd drawer of the medication cart. [...]

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to provide information on how to file an anonymous grievance for six of six residents (Residents (R) 18, R88, R94, R97, R95, and R128) reviewed for the grievance process of 40 sample residents. The failure had the potential to affect residents' ability to safely report concerns without fear of retaliation.

Inspectors wroteBased on record review, interviews, and policy review, the facility failed to provide written notice of their bed hold policy and the cost of a bed hold when residents were transferred to the hospital for five of five residents (Resident (R) 119, R87, R83, R29, and R67) reviewed for hospitalization of 40 sample residents. This failure had the potential to cause confusion or distress regarding the cost to hold a room and whether or not a resident would be able to return to the facility after hospitalization.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure food prepared by the facility was served at a palatable temperature for five of six residents (Resident (R) 97, R18, R88, R94, and R128) reviewed for palatability of 40 sample residents. As a result of this deficient practice the residents had the potential for poor nutrition and weight loss.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure a resident's safety during transport to an outside appointment when the resident was dropped off at his personal residence instead of a safe facility return for one of three residents (Resident (R) 298) and the facility failed to ensure safe resident transfers with use of a gait belt for two of three residents (R119 and R121) reviewed for accident hazards of 40 sample residents. This had the potential to place all residents who are dependent on the facility at risk.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents received alternative measures and informed consent with explained risks and benefits was obtained prior to installation for one of one resident (Resident (R) 30) reviewed for side rails of 40 sampled residents. The lack of alternate side rail measures and proper assessment/consent could lead to potential restraint or side rail entrapment.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure medication containers were labeled specific to the resident for two of six medication carts reviewed for correct labeling of medications. As a result of this deficient practice the residents had the potential for residents to receive the wrong medication.

Inspectors wroteBased on interviews, record review, facility policy review, and review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, it was determined the facility failed to complete quarterly Minimum Data Set (MDS) assessments within 14 days of the assessment reference date (ARD) for 2 (Resident #5 and Resident #15) of 4 sampled residents reviewed for timeliness of MDS assessments.

Inspectors wroteBased on interviews, record review and facility policy review, the facility failed to ensure a Level II Preadmission Screening and Resident Review (PASRR) was completed when a new mental illness was diagnosed for 1 (Resident #55) of 3 sampled residents reviewed for PASSR.

Inspectors wroteBased on interviews, record review, and facility policy review, it was determined the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR) accurately reflected the presence of mental illness diagnoses upon admission for 1 (Resident #121) of 4 sampled residents reviewed for PASRR.

Inspectors wroteBased on interviews, record review, and facility policy review, it was determined the facility failed to ensure the medical record was free of discrepancies regarding code status for 1 (Resident #103) of 3 sampled residents reviewed for advance directives.