Knolls West Post Acute LLC

Inspectors wroteBased on interview and record review, the facility failed to protect one (1) of 3 sampled Residents (Resident 1) from misappropriation of property (the deliberate misplacement, exploitation, or wrongful use of a resident's money without their consent) when a Licensed Vocational Nurse 1 (LVN 1) allegedly withdrew funds from Resident 1's bank account without Resident 1's knowledge or permission. This failure had the potential to cause Resident 1 financial loss, emotional distress, and a loss of confidence in the facility's ability to safeguard their personal property.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the policy and procedure (P&P) for change of condition was followed for one (1) of three (3) sampled residents (Resident 1), when one License Vocational Nurse (LVN 1) did not notify the physician and Resident 1's family promptly after Resident 1 eloped (Resident leaves facility without being officially discharged ) on June 11, 2026. This failure resulted in delayed communication regarding a significant change in Resident 1's condition and location placing Resident 1 at risk for injury without timely medical evaluation and follow-up.

Inspectors wroteBased on interview and record review, the facility failed to maintain a complete and accurate medical record for one (1) of three (3) sampled residents (Resident 1), When one Licensed Vocational Nurse (LVN 1) mistakenly documented that the physician was notified of Resident 1's elopement (Resident leaves the facility without being officially discharged ). This failure resulted in an inaccurate medical record and had the potential to affect communication among healthcare providers and the delivery of resident care.

Inspectors wroteBased on interview and record review, the facility failed to ensure medical records were processed and released in accordance with facility policy and federal regulations for one of four residents (Resident 1). This failure had the potential to jeopardize Resident 1's authorized representative's access to medical records through lawful authorization requests, potentially adversely impacting legal matters related to the resident. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure medical records were processed and released according to federal regulations for one of four residents (Resident 1). This failure had the potential to jeopardize Resident 1's authorized representative's access to medical records through lawful authorization requests, potentially adversely impacting legal matters related to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain food safety practices in the kitchen as required by facility's policy and procedure (P&P). The facility did not ensure food preparation areas, equipment, and storage were kept clean, labeled, and safe and failed to prevent cross-contamination, improper thawing and unsanitary conditions when: 1. One kitchen staff was not wearing a hairnet in the food prep area. 2. The juice machine nuzzle, and black rubber ring had dark grime, old stains, and residue. 3. Six red colored drink pitchers were left on a counter without date labels. 4. A large blue plastic container labeled ICE ONLY was found uncovered and filled with ice on a metal prep table. 5. Two dented cans (6 lbs.) of pears in light syrup were found in the kitchen ready to use. 6. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain essential kitchen equipment in safety operating condition when: 1. Two ovens located in the kitchen were observed to be non-functional not in use, yet they remained accessible and unmarked as out of order. This failure has the potential to result in limited cooking capacity, delays, and disruption in the kitchen's ability to deliver timely meals and maintain appropriate sanitation.

Inspectors wroteBased on interview, and record review, the facility did not ensure physician's visits were conducted or physician's orders were signed in a timely manner when: 1. Two of eight sampled residents (Residents 19 and 22) were missing required physician's visits for their Medicare Part A&B (Government hospital insurance and medical insurance) stay. This failure had the potential to result in transcription errors for Resident 19 and 22. 2. Four of eight sampled residents (Resident 14, 44, 56, and 43) had unsigned physician's orders in their chart. This failure had the potential to result in medical errors, and increased risk to resident's safety for Resident 14, 44, 56, and 43.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain resident dignity for one of seven sampled residents (Resident 311) reviewed for dignity practices by not providing a dignity bag (a cover placed over a urine collection bag so others cannot see the urine) for the foley catheter bag (a thin tube place in the bladder to drain urine into a bag) which exposed the urine contents to public view. This failure has the potential to cause Resident 311 embarrassment, and emotional distress (Feeling upset, anxious or humiliated), and loss of dignity (feeling disrespected or devaluated as a person).

Inspectors wroteBased on interview, and record review, the facility failed to ensure a copy of the notice of transfer or discharge were sent to the Ombudsman for one of two sampled residents (Resident 106) reviewed for hospitalization when Resident 106 was sent to the hospital on February 9, 2025, and there was no copy of notice of transfer or discharge sent to the Ombudsman. This failure had the potential for Resident 106 to be inappropriately transferred or discharged .

Inspectors wroteBased on interview, and record review, the facility failed to accurately code the Resident Assessment Instrument-Minimum Data Set (RAI-MDS - a computerized resident assessment tool) for two sampled residents (Resident 84 and Resident 99) when: 1. For Resident 84's RAI-MDS assessment was not coded to indicate she had a diagnosis of schizophrenia (a chronic mental disorder that affects how a person thinks, feels, and behaves). 2. For Resident 99's RAI-MDS assessment was not coded to indicate she had a stage 1 pressure ulcer (bed sore). These failures resulted in the MDS assessments for Resident's 84 and 99 to inaccurately reflect their current medical status which had the potential to result in unmet care needs for the residents.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the accuracy of the Minimum Data Set, (MDS- a federally required resident assessment tool used to plan care and track clinical status) for one of seven sampled residents (Resident 64) reviewed for MDS coding accuracy when the facility inaccurately, documented Resident 64 received antibiotics in February 2025, despite no physician's orders showing antibiotic use. This failure has the potential to cause poor care planning and inaccurate understanding of Resident 64's health, increasing the risk Resident 64's needs will not be met.

Inspectors wroteBased on interview, and record review, the facility failed to update Resident 84's Pre-admission Screening and Resident Review (PASRR - a federally mandated program that requires all individuals seeking admission to a Medicaid-certified nursing facility to be screened to ensure individuals who are identified to have a significant mental illness [SMI], intellectual or developmental disability [I/DD] are not inappropriately placed in nursing homes for long term care) when Resident 84 did not have her diagnosis of schizophrenia (a chronic mental disorder that affects how a person thinks, feels, and behaves) included in the PASRR assessment used to admit Resident 84 into the skilled nursing facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physical therapy services were provided to one of three residents (Resident 59) sampled for rehabilitative and restorative services when Resident 59 did not receive physical therapy five times a week as ordered by the physician. This failure had the potential to cause a decrease in Resident 59 overall functioning or the inability for Resident 59 to reach his/her highest level of functioning.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the physician's orders for heel protector boots for one of seven sampled residents (Resident 64) reviewed for skin integrity when Resident 64 was observed without the ordered heel protectors and was documented to have develop a deep tissue injury (DTI). This failure has the potential to contribute to Resident 64 delayed wound healing (slower recovery of injured skin and tissue), pain (physical discomfort), and further skin breakdown (worsening skin condition leading to open wounds).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the attending physician conducted an initial comprehensive visit within the first 30 days after admission, for two sampled residents under a Medicare Part A&B stay (Resident 19 and 22). This failure has the potential to place Residents 19 and 22 at risk for serious harm or death.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure staff signed the narcotic reconciliation log when discrepancies were found in two of four narcotic reconciliation logbooks. This failure had the potential to result in improper administration of medication and dosage, increasing risk of adverse drug reactions, and possible harm to 106 vulnerable patients.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure secure storage of medications when: 1. One Medication Storage room and one Medication Refrigerator located at Nursing station 4 was found unlocked, and 2. One medication refrigerator located at Nursing station 1 was found unlocked. This failure has the potential for medications to be accessed and dispersed by an unauthorized person, in a vulnerable population of 103 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure it followed its infection control program when: 1. A Registered nurse Supervisor 3 (RNS 3) did not perform hand hygiene (hand washing or the use of alcohol based hand sanitizer) after performing a blood glucose check (procedure done to check the level of sugar in the blood and requires a pinprick blood sample). This failure had the potential for the spread of infectious blood borne pathogens (bacteria and viruses which can cause disease and illness) and the spread of infectious microorganisms from one patient to another in a vulnerable population of 106 patients. 2. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure quarterly (every 3 months) Payroll Based Journal (PBJ) Staffing Data (data combining census and staffing information) report required by Centers of Medicare and Medicaid Services (CMS), was transmitted (submitted) to CMS in accordance with federal submissions timeframes, for quarter 2 (January 1 through March 31 of 2024. This failure resulted in inadequate monitoring of staffing information to be transmitted to CMS.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow its policy and procedure to ensure a comprehensive care plan was developed for one of four sample residents (Resident 1) when Resident 1 was not provided a plan of care to meet Resident 1 ' s nutritional needs. This failure had the potential to place a clinically compromised resident (Resident 1 ' s) overall health and safety at risk.

Inspectors wroteBased on interview and record review, the facility failed to ensure proper care was provided to prevent a pressure ulcer/injury (injury to skin/tissue from prolonged pressure on the skin) for one of three sampled residents (Resident 1). This failure resulted on resident 1 acquired pressure ulcer to coccyx left and right buttocks (lower back/spine) developed while in the facility.

Inspectors wroteThe facility failed to follow their policy and procedure on medication administration when a Licensed Vocational Nurse failed to administer Nifedipine (medication use to lower blood pressure) ordered by physician to one of three sampled Residents (Resident 1). This failure has a potential to place a clinically compromised Resident 1 ' s health and safety at risk.

Inspectors wroteBased on observation, interview and record review, facility failed to follow their policy by not following physician ' s order to provide physical therapy five times a week for one of three sampled residents (Resident 1). This failure had the potential to cause contractures (a condition of shortening and hardening of muscles, tendons, or other tissues, often leading to deformity and rigidity of joints) and decreased mobility to Resident 1, by negatively affecting his physical health, mental and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure licensed vocational nurse (LVN 1) perform medications administration according to the facility's policies and procedures (P&P) for one of four sample residents (Resident 1) when during resident 1's medication pass, the surveyor noticed that the LVN pre-signed the medication before administering it, failed to check the medication's expiration date, and failed to record on Resident 1's MAR the reason why Amlodipine (a medication used to treat high blood pressure) not available, believing that she could have borrowed Amlodipine from another resident for Resident 1. This deficient practice had the potential to adversely affect the health and safety of Resident 1 who is clinically compromised.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that an allegation of physical abuse for one of three sampled residents (Resident 1) was reported to the local, state, and federal agencies immediately in accordance with their facility's policy. This failure had the potential for the alleged abuse to go uninvestigated and unreported thereby increasing the chances of health, safety, and psychosocial harm to Resident 1.

Inspectors wroteBased on interview, and record review, the facility failed to protect residents from potential abuse and mistreatment, in a universe of 112 residents, when the facility employed a Licensed Vocational Nurse (LVN 1) with a disciplinary action (a formal process that imposes consequences or corrective measures for misconduct or violations of professional standards), in effect, against her professional license. This failure had the potential to cause residents to suffer abuse and mistreatment.

Inspectors wroteBased on interview and record review the facility failed to follow their Policy and Procedure when the licensed nurse failed to document the refusal of medication for one of three sampled Residents (Resident 1). This failure had the potential to place a clinically compromised Resident (Resident 1) health and safety at risk. When not receiving the necessary medication as prescribed by the physician.

Inspectors wroteBased on observation, interviews, and facility policy review, the facility failed to properly store and date foods items in 1 (Unit 1 and Unit 2) of 2 nourishment refrigerators in the facility.

Inspectors wroteBased on record reviews, document review, and interviews, the facility failed to ensure timely completion of comprehensive Minimum Data Set (MDS) assessments for 3 (Residents #16, #69, and #79) of 8 sampled residents reviewed for resident assessments.

Inspectors wroteBased on record reviews, document review, and interviews, the facility failed to ensure timely completion of quarterly Minimum Data Set (MDS) assessments for 3 (Residents #58, #96, and #109) of 8 sampled residents reviewed for resident assessments.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to change oxygen tubing weekly as ordered by the physician and store respiratory equipment when not in use as directed by the facility's policy for 1 (Resident #188) of 1 sampled resident reviewed for respiratory care.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to indicate the duration of an as-needed anti-anxiety medication for 1 (Resident #20) of 5 sampled residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility's policy and procedure titled Policy and Procedure on Pressure Ulcers (wounds caused by prolonged pressure on a bony prominence that may be superficial (Stage 1) to involving damage which includes all layers of skin down to the bone (Stage IV), dated August 22, 2017, for two of two sampled residents (Residents 3 and 44) was followed when: 1. The facility did not provide documented evidence for Resident 3 who had a Stage 4 pressure (involves all layers of skin down to the bone) ulcer on the sacrum (located above the tailbone) and a Stage 3 pressure (Involves all layers of skin down to the muscle) ulcer on the left hip to show the resident had been repositioned at least every two hours to prevent further pressure on the wounds. 2. For Resident 44: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to uphold residents' rights for visitation for all 105 residents residing within the facility when the facility was restricting visitors by requiring visitors to be tested for COVID-19 (an illness caused by a virus) prior to entering the facility, charging visitors five dollars for COVID-19 tests, limiting visitation time to 1 hour, and by posting limiting visitation hours as was all specified by the Visiting Policy posted at the reception desk (main entrance) of the facility. These failures resulted in the infringement of the rights for visitation of all 105 residents by potentially deterring visitors as a result of the posted requirements. In addition, this failure resulted in the visitor of one resident (Resident 162) to demonstrate verbal frustration regarding the visitation restrictions.

Inspectors wroteBased on interview and record review the facility failed to designate a qualified Director of Food Services to provide the daily oversight of the dietary department which includes, implementing menus, purchasing food, training of staff, and ensuring compliance with all state and federal regulations. This failure had the potential to result in a lack of oversight in the operations of the dietary department and supervision of staff which could lead to poor quality of services in the department.

Inspectors wroteBased on observation, interview and record review, the facility failed to label and discard medications for three of three sampled residents (Residents 20, 5 and 56) when: 1. For Resident 20 there were two vials of Humulin R (a short-acting insulin that starts to work in 30 minutes and lasts for several hours to control a resident's blood sugar) 100 units (a unit of measurement)/ (in) one ml (milliliters-a unit of measurement) insulin which had not been labeled or removed as follows: a. Vial #1 (a small container of glass for holding liquids, number one) indicated an opened date of September 19, 2022. On December 8, 2022, Vial #1 was in the medication cart and available for use. Vial #1 had not been discarded 28 days after the opened date as indicated on the pharmacy label. b. Vial #2 was open but did not indicate an opened date. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the menu when pureed (smooth, pudding consistency food that does nt require chewing) peaches were served instead of the pureed peach cobbler as indicated in the lunch menu for 4 of 109 residents. This failure had the potential to disregard resident's food choices when a dessert substitute was served during lunch.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services for the ordered number of frequencies for specialized rehabilitative services as determined by Physical Therapy for 2 Residents (29 and 358) as ordered by the physician. These failures had the potential to cause a decline in the residents' functional status and/or prohibit the optimization of their functional status.

Inspectors wroteBased on interview and record review, the facility failed to complete a Minimum Data Set (MDS) (a computerized clinical assessment) Significant Change assessment within 14 days for one resident, Resident 8, reviewed for hospice services. This failure had the potential to delay identification and implementation of the resident's care and support needs.

Inspectors wroteBased on interview and record review, the facility failed to accurately identify on three different Minimum Data Set (MDS) (a computerized clinical assessment) assessments for one resident, Resident 8, that the resident was receiving hospice (a program providing services for the care of terminally ill residents and their family) services. This failure had the potential to delay identification and implementation of the resident's care and support needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an individualized comprehensive care plan was initiated for one out of 32 residents (Resident 57) for care and precautions to be taken for a resident with a gastrostomy (insertion of tube through the abdomen wall through which liquid nourishments and medications can be administered) feeding . This failure had the potential for Resident 57 to develop nutritional risks from unidentified care concerns or place him at risk for aspiration (inhalation of food or fluid into the lungs) if preventive measures were not care planned.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide colostomy (an opening for the large intestine through the abdomen where stool is passed) care for one out of 32 residents (Resident 67). This failure had the potential to cause Resident 67 to suffer increased infection, pain, and unpleasant odors due to the colostomy bag not being emptied or skin not being cleansed to prevent breakdown. FINIDNGS During a review of Resident 67's admission Record, (contains demographic and medical information), undated, indicated Resident 67 was admitted to the facility on [DATE], with diagnoses that included heart failure (a condition in which the heart does not pump blood adequately), end stage renal disease (a condition in which the kidney does not function), dysphagia (inability to swallow) and bed confinement status (inability to tolerate activity out of bed). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain acceptable parameters of nutritional status for one of one sampled resident (Resident 44) when: For Resident 44, a significant weight loss of 5.65% (percent) in 1 (one) month and a continued weight loss of 11.29% in approximately two plus months was identified, but a Weight Change Review, was not documented, Resident 44's care plan was not updated to address Resident 44's refusal to eat, or the impact of nutritional deficits on wound healing for a Deep Tissue Injury (DTI- a form of pressure ulcer. Pressure ulcers are localized areas of tissue damage that develop because of prolonged pressure on bony prominences-areas of bone that are close to the skin's surface). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the physician of a missed dialysis (a process of filtering out the blood through a machine, when the kidneys are unable to do it by themselves) treatment for one resident, Resident 408. This failure had the potential for the resident to experience serious side effects due to the build up of toxins in the blood that the dialysis filters out, high blood pressure and fluid retention.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one Licensed Vocational Nurse (LVN 7) demonstrated competency when she prepared insulin (a medication used to help control blood sugar levels) in accordance with manufacturers recommendations when she drew up insulin from a prefilled insulin syringe into a separate insulin syringe for administration to Resident A. This failure had the potential for the increased risk of medication errors, and to alter the efficacy (ability to produce desired effects) and accuracy of the prefilled insulin pen for subsequent injections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one staff member (Licensed Vocational Nurse 5 - LVN 5) followed the facility policy and procedure for medication administration when the nurse did not review the pharmacy medication label (a label applied to the medication with information regarding who the medication belongs to, the name of the medication, the dose etc) for insulin (a medication used to help regulate blood sugar levels) prior to attempting to administer the medication to Resident 56. This failure had the potential to result in physical harm to Resident 56 as a result of the increased risk of a medication error when the five rights of medication administration (five principles used to help prevent medication errors by verifying: [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure clinical records for six residents (Residents 3, 28, 64, 67, 78, and 161) were complete and accurate when: 1. The Physician's Orders for Life Sustaining Treatment (POLST - Written medical orders that addresses a limited number of critical medical decisions) for five of five residents (Residents 3, 28, 64, 67, and 78) reviewed for advance directives (a legal document that explains how an individual wants medical decisions to be made if the individual is incapable of making their own decisions) was left blank regarding whether or not an advance directive existed for the residents. This failure had the potential to result in a delay of treatment for the residents as related to advance directives, or for life sustaining measures to be rendered against what the resident wanted. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide evidence the Medical Director or a designee, attended Quality Assurance and Process Improvement (QAPI) meetings for the first quarter (January 1 - March 31) and second quarter (April 1 - June 30) of 2022. This failure resulted in the facilities inability to provide evidence the Medical Director or designee (a required QAPI member) had participation in, and had an opportunity to provide meaningful insight, during required quality assurance meetings regarding facility operations.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control practices when: 1. The Facility did not ensure that visitors of Resident 158, who had clostridium difficile (C-Diff- a bacteria causing diarrhea and infection in the intestines) were educated about isolation precautions, proper protective equipment, and hand hygiene. 2. The facility did not ensure that proper hand hygiene was done before and after providing direct care for Residents 409 and 72. 3. The facility did not remove Resident 49's Peripherally Inserted Central Catheter (PICC - a thin, long catheter that is inserted through a vein in the upper arm and passed through to the larger veins near the heart, for administration of medications or liquid nutrition) after an intravenous (IV) antibiotic was completed. [...]

Inspectors wroteBased on interview and record review the facility failed to report accurate Payroll Based Journal (PBJ) data when there was a discrepancy between the staffing hours reported and the actual staffing hours worked. This failure had the potential for staffing hours to not be met which could delay care needed by 109 residents in the facility.