Knollwood Healthcare

Inspectors wroteBased on interview, resident record review, and review of a facility policy titled Abuse Policy, the facility failed to ensure an allegation of sexual abuse was reported to the State Agency in accordance with reporting requirements after the Administrator (ADM) was informed by a local hospital of a request for a rape kit to be performed on Resident Identifier (RI) #7, a vulnerable and cognitively impaired resident, due to semen found present in RI #7's urine sample. On 02/10/2026 at 9:04 AM the State Agency received an anonymous Complaint (number 2746917) alleging Resident Identifier (RI) #7 was sent to a local hospital and semen was found in his/her urine. On 10/03/2025 the facility transferred RI #7 to a local hospital due to coughing up blood. While RI #7 was at the hospital, a routine urinalysis resulted in the abnormal presence of semen in the urine. [...]

Inspectors wroteBased on interview, record review and review of a facility policy titled Accidents and Incidents - Investigating and Reporting the facility failed to thoroughly investigate the cause of a bruise observed on the left side of Resident Identifier (RI) #44's face which was observed by Licensed Practical Nurse (LPN) #10. Specifically, the facility failed to complete an incident report following an allegation of a fall reported by RI #44's family member on 02/10/2026. RI #44's family member alleged a new bruise was located on the left side of RI #44's face. This failure had the potential to affect the residents by limiting the facility's ability to evaluate the circumstances of the event and implement measures to reduce the risk of further accidents. This affected one of five residents reviewed for accidents and was cited as a result of the investigation of complaint #2747676. [...]

Inspectors wroteBased on interview, record review and review of facility policies titled Administering Medications and Controlled Substances, the facility failed to ensure controlled medications were were handled and documented as required including the recording of controlled medications on the Medication Administration Record (MAR) after controlled medications were administered to Resident Identifier (RI) #65, one of one resident reviewed for the accurate account of controlled medications. Specifically, RI #65's controlled substance inventory record documented Lorazepam and Morphine were given on 01/29/2026 and 01/30/2026; review of RI #65's MAR revealed no evidence the medications were administered to RI #65. This failure had the potential to affect the RI #65 by limiting the facility's ability to ensure accurate controlled medication administration, record keeping, and monitoring. [...]

Inspectors wroteBased on observations, interviews and review of facility policies titled, DATING AND LABELING POLICY, COMPLETING LOGS POLICY, and DISH WASHING AND POT WASHING, the failed to ensure:1) food items in dry storage and the freezer were dated and labeled,2) a styrofoam cup was not left in the flour bin,3) the freezer temperatures for the evening shift were recorded on 09/04/2025, 09/05/2025, and 09/06/2025 and;4) plates were free of food debris on the tray line. This had the potential to affect 54 of 55 residents who receive meals from the kitchen. Findings Include: 1) Review of an undated policy titled, DATING AND LABELING POLICY revealed: Policy: All foods are to be labeled and dated appropriately to ensure food safety regulations are followed. Procedure: 1. Upon receiving and storing all items must be labeled with the name of food and receive date. [...]

Inspectors wroteBased on observation, interviews and a review of a facility policy titled GARBAGE AND TRASH DISPOSAL POLICY, the facility failed to ensure the door of the trash dumpster on the front side was closed. This had the potential to affect 55 of 55 residents who reside at the facility. Findings Include: Review of an undated facility policy titled GARBABE AND TRASH DISPOSAL POLICY revealed: PURPOSE: To educate all new hires and current employees on the proper procedures for garbage and trash disposal. PROPER GARBAGE AND TRASH DISPOSAL: . Dumpsters should be properly maintained: Dumpster door . must be closed at all times when not in use. On 09/07/2025 at 3:01 PM, the surveyor and the evening [NAME] #1 toured the dumpster area. The dumpster door was opened on the front side. On 09/10/2025 at 8:57 AM, an interview was conducted with [NAME] #1. [NAME] #1 stated that the dumpster door was opened. [...]

Inspectors wroteBased on observations, interviews, medical record review and facility policies titled, Oxygen Administration and Oxygen Tubing and (&) Humidification Change Policy, the facility failed to ensure Resident Identifier (RI) #'s 9, #15, #42 and #54 Oxygen (O2) tubing was labeled/dated. The facility further failed to ensure RI #42 and RI #54's O2 concentrator water bottle was not empty during the administration of oxygen on 09/07/2025. This deficient practice affected RI #9, RI #15, RI #42 and RI #54 four of four residents sampled for respiratory care. Findings Include: Review of a facility policy titled, Oxygen Administration with a revision date of 2010, revealed: Purpose The purpose of this procedure is to provide guidelines for safe oxygen administration . Steps in the Procedure 12. Check the mask . humidifying jar, . to be sure they are in good working order . [...]

Inspectors wroteBased on interviews, resident record review, review of a Facility Reported Incident (FRI), review of the facility investigative file, and review of a facility policy titled Accidents and Incidents, the facility failed to ensure Certified Nursing Assistant (CNA) #5 immediately reported an incident/accident to licensed nurses on 09/05/2025 when Resident Identifier (RI) #20 voiced discomfort during care and told CNA #5 someone ran over his/her foot with a wheelchair. CNA #5 failed to report to anyone RI #20's voiced discomfort and observed swelling to RI #20's foot. The incident/accident was not reported or investigated until 09/09/2025 when RI #20 was observed with bruising and swelling to the right knee and leg and x-ray results revealed an acute proximal tibia fracture. [...]

Inspectors wroteBased on interviews, resident record review, and facility policies titled Pain Assessment and Management and Administering Pain Medications, the facility failed to ensure Licensed Practical Nurse (LPN) #6 conducted a pain assessment to include the location of pain or other pain characteristics prior to administering as needed (PRN) pain medication to Resident Identifier (RI) #20 on 09/03/2025. This deficient practice had the potential to result in inadequate evaluation of the resident's pain and inappropriate treatment and affected RI #20 one of two resident sampled for pain. Findings Include:A facility policy titled Pain Assessment and Management with revision date of October 2022 documented: [...]

Inspectors wroteNumber of residents sampled:Number of residents cited Based on observations and interviews the facility failed to ensure the most recent Survey Results were readily accessible and visible for residents and visitors to review. Further, on 09/09/2025 during resident council, 10 out of 10 residents were not aware of how to access the Survey Results. The surveyor observed no Survey Results book in the front lobby area, or on the units on four out of the five days of survey. This deficient practice had the potential to affect 55 out of 55 residents residing in the facility and any visitor. Findings Include: Upon entering the facility on 09/07/2025 at 2:00 PM, the surveyor observed there were not any Survey Results posted, visible, or accessible in the lobby area for residents and visitors. [...]

Inspectors wroteBased on interviews, resident record review, the facility investigative file, and a facility policy titled, Abuse Policy, the facility failed to protect the resident's right to be free from physical abuse on 04/30/2025 when Resident Identifier (RI) #2 hit RI #21. The facility's staff failed to supervise RI #2 and intervene to prevent the incident. RI #2 had a history of verbal and physical behaviors. RI #2 was observed irritable, cursing, and upset as staff were attempting to take RI #2 to his/her bed. The Certified Nursing Assistant (CNA) left RI #2 at his/her doorway and another CNA witnessed RI #2 hit RI #21 on the arm. Staff said someone in that situation being hit would feel shocked. This deficient practice affected RI #21 one of three residents sampled for abuse and was cited as a result of the investigation of complaint/report number AL00051090.

Inspectors wroteBased on interviews and record review the facility failed to ensure the physician was notified when residents on the second and third floors did not receive their medications and treatments as ordered when the facility experienced an internet outage preventing access to the Electronic Health Record (EHR) system on 01/21/2025 and 01/22/2025. Nurses did not have access to pre-printed paper documentation forms such as physician orders and MARs (Medication Administration Record) to administer medications on 01/21/2025 and 01/22/2025. The facility staff failed to notify the Director of Nursing (DON), residents, and resident representatives of residents not receiving their ordered medications and treatments on 01/21/2025 and 01/22/2025. [...]

Inspectors wroteBased on interviews, record review and review of facility policies titled, Abuse Policy and Policy on Computer or Internet Downtime and EHR (Electronic Health Record) Access, the facility failed to protect the resident's right to be free from neglect when systems were not in place to ensure continuity of care and operations when the facility experienced a forecasted winter storm which caused internet outage preventing access to the EHR system on 01/21/2025 and 01/22/2025. The facility failed to ensure pre-printed paper documentation forms such as physician orders and MARs were available and accessible for the licensed nursing staff to utilize for resident care, treatment, and medication administration prior to the internet outage. The nurses and nurse supervisor on duty during that time failed to ensure residents received medications as ordered by the physician. [...]

Inspectors wroteBased on interviews, record review, review of facility policies titled Administering Medications, and Policy on Computer or Internet Downtime and EHR (Electronic Health Record) Access, the facility failed to ensure Licensed Practical Nurse (LPN) #14, Registered Nurse (RN) #15, RN #16, RN #20, and LPN #18 followed standards of practice and facility's policies. Specifically, LPN #14 and RN #15 failed to follow standards of practice to administer medications and perform Capillary Blood Glucose (CBG) monitoring as ordered by the physician on 01/21/2025 during the 2 PM to 10 PM shift on the Second Floor. The nurses did not notify the residents' physician, DON, or the Administrator that medications were not being administered and CBG checks were not being performed. [...]

Inspectors wroteBased on interviews, record review, and review of a facility policy titled Administering Medications the facility failed to ensure residents were free of significant medication errors when licensed nursing staff failed to administer medications including insulin and other significant medications. Specifically, on 01/21/2025 during a forecasted snowstorm the facility lost internet connection sometime after lunch which resulted in inability to access residents Electronic Health Record (EHR)/Electronic Medication Administration Record (eMAR) until the evening of 01/22/2025. Resident Identifier (RI) #12, RI #15, RI #30, and RI #308 were not administered significant medications from 01/21/2025 at 5:00 PM until 01/22/2025 at 9:00 PM. [...]

Inspectors wroteBased on observations, interviews and a review of the facility policie's titled, DATING AND LABELING POLICY, ICE MACHINE SANITATION POLICY, And HAND WASHING POLICY. The facility failed to ensure: 1) food items in the freezer and cooler was labeled and dated; 2) the ice machine was free of a black substance; 3) a staff did not work on the dirty and clean side of the dish room without changing gloves and aprons. This had the potential to affect 53 of 53 residents who received meals from the kitchen. Finding Includes: 1) A review of a policy titled, DATING AND LABELING POLICY, with no date revealed: POLICY: All foods are to be labeled and dated appropriately to ensure food safety regulations are followed. PROCEDURE: . Once opened, the label must be updated with the current date and a use by date . (including date opened) . [...]

Inspectors wroteBased on observations, interview, record review and review of a facility policy titled, Answering the Call Light, the facility failed to ensure Resident Identifier (RI) #43's call light was in reach on 03/18/2025 and 03/19/2025 for RI #43 to be able to summon staff as needed. This deficient practice affected RI #43, one of 18 sampled residents. Findings Include: Review of a facility policy titled, Answering the Call Light, with a revised date of 10/2010, revealed the following: . The purpose of this procedure is to respond to the resident's request and needs. General Guidelines . 5. When the resident is in bed . be sure the call light is within easy reach of the resident . RI #43 was admitted to the facility on [DATE] and had a diagnosis of Vascular Dementia. [...]

Inspectors wroteBased on interviews, record review, and review of a facility policy titled, Confidentiality of Information and Personal Privacy, the facility failed to ensure personal privacy and confidentiality were maintained for Resident Identifier (RI) #52. Specifically, on 01/29/2025, licensed staff provided medication, belonging to RI #52 and labeled with RI #52's information, to RI #308 upon discharge home from the facility. This deficient practice affected RI #52, one of 18 sampled residents. This deficient was cited as a result of the investigation or complaint/report number AL00050173. Findings Include: Review of a facility policy titled, Confidentiality of Information and Personal Privacy, with a revised date of 10/2017, revealed the following: Policy Statement Our facility will protect and safeguard resident confidentiality and personal privacy. Policy Interpretation and Implementation . 2. [...]

Inspectors wroteBased on interview, record review, review of a facility policy titled Abuse Policy, and review of a Facility Reported Incident (FRI), the facility failed to report to the State Agency an allegation of verbal abuse within two hours after the allegation was reported to the Administrator at approximately 11:20 AM on 01/30/2025. The State Agency did not receive the FRI alleging Certified Nursing Assistant (CNA) #10 verbally abused Resident Identifier (RI) RI #15, calling RI #15 a stupid mother fucker, until after 3:00 PM on 01/30/2025. This deficient practice affected RI #15; one of three residents sampled for Abuse. Findings Include: A facility policy titled Abuse Policy, updated 8/2022, documented: . The following table describes the different reporting requirements. What is to be reported. All alleged violations of abuse, neglect, . When . [...]

Inspectors wroteBased on interviews, resident record review, review of a facility policy titled Abuse Policy, Facility Reported Incidents (FRIs) received by the State Agency, and review of the facility's investigative files, the facility failed to conduct a thorough investigation for an incident of verbal abuse and take appropriate corrective actions to prevent recurrence. On 01/30/2025 during resident care Resident Identifier (RI) #15 was verbally abused by Certified Nursing Assistant (CNA) #10 who at the time of the verbal abuse, voiced being frustrated and tired from working double shifts the day prior. Because the facility's investigation failed to identify potential contributing factors of the verbal abuse, the facility was unable to develop and implement any new measures or actions to prevent recurrence. [...]

Inspectors wroteBased on observations, interview, and resident record review, the facility failed to ensure care was provided in a manner to prevent skin breakdown. The facility failed to ensure a care planned preventive measure to prevent skin breakdown was implemented for Resident Identifier (RI) #43, a resident with a potential for impaired skin integrity, when unpadded oxygen (O2) tubing was observed behind RI #43's ears. This was observed on 03/18/2025 and 03/19/2025, and had the potential to affect RI #43, one of 18 sampled residents. Findings Include: RI #43 was admitted to the facility on [DATE]. RI #43's care plan with a need of POTENTIAL FOR IMPAIRED SKIN INTEGRITY had an approach initiated 07/23/2024 for licensed staff to . PAD TUBING AROUND EARS WHEN O2 IS IN USE . [...]

Inspectors wroteBased on interviews, review of the facility Online Incident Report (FRI), review of Resident Identifier (RI) #15's medical records, and review of a facility policy titled, Abuse Policy, the facility failed to provide appropriate social services to meet RI #15's needs after Certified Nurse Assistant (CNA) #10 verbally abuse RI #15 on 01/30/2025. The facility's Social Services Director (SSD) was not aware the abuse policy instructed her to monitor residents' reactions to an incident of abuse and she was not aware that RI #15 had been verbally abused by a CNA. This deficient practice affected RI #15; one of three residents sampled for abuse. This deficiency was cited as a result of the investigation of complaint/report number AL00050214. Findings Include: Review of a facility policy titled, Abuse Policy, updated 08/2022, revealed the following: . [...]

Inspectors wroteBased on interviews and resident record review, the facility failed to ensure Resident Identifier (RI) #52's Cyclobenzaprine (Flexeril) medication was retrieved from RI #308's home, for proper storage and/or disposal, after the medication was accidentally sent home with RI #308 on 01/29/2025. This deficient practice affected RI #52, one of 18 sampled residents. This deficiency was cited as a result of the investigation of complaint/report #AL00050173. Findings Include: RI #308 was admitted to the facility 01/09/2025 and discharged on 01/29/2025. RI #52 was admitted to the facility on [DATE]. RI #52's Order Summary Report (Physician Orders) revealed RI #52 was prescribed Flexeril (Cyclobenzaprine HCL (Hydrochloric)) Oral Tablet 5 MG (milligrams) by mouth three times a day for muscle spasms for 14 days. This order had a start date of 01/16/2025. [...]

Inspectors wroteBased on interviews, record review, review of facility policies titled Abuse Policy and Quality Assurance Performance Improvement Process, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee reviewed and analyzed an allegation of abuse in a manner to determine causes and implement appropriate corrective actions to prevent recurrence. The committee failed to identify concerns with reporting and investigation for an allegation of abuse reported to the State Agency (SA) on 01/30/2025. This deficient practice affected RI #15, one of 18 sampled residents. This deficiency was cited as a result of the investigation of complaint/report number AL00050214.

Inspectors wroteBased on interviews, record review, and review of a Facility Reported Incident (FRI), the facility failed to provide and have evidence of abuse prevention training to staff to identify and address factors that may precipitate abuse/neglect/exploitation, to include signs of staff burnout, frustration, and stress. On 01/30/2025 Certified Nursing Assistant (CNA) #10 verbally abused Resident Identifier (RI #15) while providing care. CNA #10 voiced she was tired from working a double shift the day before. Further, the facility had failed to provide the Social Serviced Director (SSD) with training on the abuse policy and the SSD did not know to monitor RI #15 after incident of staff on resident verbal abuse. This affected RI #15 one of 18 sampled residents.

Inspectors wroteBased on observation, interviews, and a review of a facility policy titled Garbage and Trash Disposal Policy the facility failed to ensure the grounds around the kitchen were free of discarded pallets during initial tour of the kitchen on 10/08/2024. This had the potential to attract rodents and pests and to affect all 49 residents residing in the facility.

Inspectors wroteBased on observation, interviews, and review of a facility policy titled Maintenance Service the facility failed to ensure kitchen equipment were maintained in working order and kept in good repair. The steamer and a plate warmer were observed in non-working order on 10/09/2024. This had the potential to affect all residents receiving meals from the facility's kitchen, 49 of 49 residents.

Inspectors wroteBased on observations, interviews, review of a facility policy titled Menus and Adequate Nutrition, review of a facility report titled Diet Type Report, and review of facility menus, the facility failed to ensure Pureed Chocolate Cream Pie was prepared and served to residents as planned. This affected Resident Identifier (RI) #9, RI #2, RI #30, and RI #48, all four of (4) residents in the facility with orders for a pureed diet.

Inspectors wroteBased on resident record review, interviews, and review of the facility admission Agreement, the facility failed to ensure the binding arbitration agreement within the admission agreement contained a statement, in a clear and detailed manner explaining to recipients, neither the resident or their representative was required to sign the agreement as a condition of admission or to receive care in the facility and the resident or resident's representative had the right to rescind the agreement within thirty (30) days of signing the agreement. This affected Resident Identifier (RI) #3, RI #29 and RI #40, all three (3) residents reviewed for arbitration agreements and had the potential to affect all residents who signed a binding arbitration agreement issued by the facility.

Inspectors wroteBased on resident record review, interviews, and review of the facility admission Agreement, the facility failed to ensure the binding arbitration agreement within the admission agreement contained a statement, in a clear and detailed manner, explaining the provision for selection of a neutral arbitrator agreed upon by both parties and the selection of a venue that was convenient to both parties. This affected Resident Identifier (RI) #3, RI #29 and RI #40, all three (3) residents reviewed for arbitration agreements and had the potential to affect all residents who signed a binding arbitration agreement issued by the facility.

Inspectors wroteBased on interviews, resident record review, review of a facility policy titled Abuse Policy, review of a Facility Reported Incident (FRI) received by the State Agency, and review of the facility's investigative file, the facility failed to protect Resident Identifier (RI) #1 and RI #2 from physically abusing each other on 07/30/2024. This deficient practice affected RI #1 and RI #2; two residents reviewed for resident-to-resident altercation. Findings Include: Review of a facility policy titled Abuse Policy, updated 08/2022, revealed the following: Our residents have the right to be free from abuse . Policy Interpretation and Implementation Definitions To help with recognition of incidents of abuse, the following definitions of abuse are provided: 1. [...]

Inspectors wroteBased on interviews and review of the Administrator job description, the facility's Administrator, responsible for the day-to-day operation of the facility failed to ensure the QAPI (Quality Assurance and Performance Improvement) committee met to identify all concerns using root cause analysis to ensure corrective actions needed with plans to prevent further occurrence including ongoing monitoring after Resident Identifier (RI) #1 eloped from the facility on 02/05/2023. This failure placed all 53 residents residing in the facility at risk for immediate jeopardy, as it was likely to result in serious injury, serious harm, serious impairment, or death, due to the ongoing risk of elopement. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. [...]

Inspectors wroteBased on record review, interviews and the facility policy Governing Body Duties and Responsibilities, the governing body failed to provide oversight to the QAPI committee. The Governing Body failed to provide guidance to the QAPI committee to use root cause analysis to determine all concerns and to make a determination of corrective actions needed with plans to prevent further occurrence after Resident Identifier (RI) #1 eloped from the facility on 02/05/2023. On 02/05/2023, RI #1 told the staff he/she wanted to leave the facility around 1:10 PM. RI #1 was given a psychotropic medication at 2:21 PM, then was not supervised. RI #1 left the facility through an unsecured door. [...]

Inspectors wroteBased on record review, the facility policy Quality Assurance and Performance Improvement (QAPI) Program, and the facility's policy Quality Assurance and Performance Improvement (QAPI) Program - Analysis and Action the facility's QAPI committee failed to thoroughly review all factors related to Resident Identifier (RI) #1's elopement on 02/05/2023. The facility further failed to develop and implement effective plans and interventions to prevent recurrence and ensure the facility was secured. On 02/05/2023 RI #1 exited the facility through an unsecured side door without staff's knowledge. RI #1 was further left by staff unsupervised in an unsafe area 2,640 feet from the facility. The failure of the QAPI committee to thoroughly review all factors and implement effective interventions following an adverse event had the potential to affect all 53 residents. [...]

Inspectors wroteBased on interviews, medical record review, review of the facility's policies titled Wandering and Elopements, and Elopement Guideline and review of a facility document summarizing the facility's investigation into Resident Identifier (RI) #1's elopement, facility failed: 1) to supervise RI #1 after he/she stated he/she had a desire to leave and was given a one-time dose of Ativan, 2) to ensure all doors in the building were secure and closed properly to prevent residents leaving the facility without staff's knowledge, and 3) to ensure RI #1 was not left by a staff member in an unsafe environment. On 02/05/2023, RI #1 told the staff he/she wanted to leave the facility around 1:10 PM. RI #1 was given Ativan, a psychotropic medication, at 2:21 PM, then was not supervised nor observed. RI #1 left the facility through an unsecured door. [...]

Inspectors wroteBased on observation, interview, medical record review, the facility's Spring/Summer 2024 Menu, the facility's standardized recipe for Chili - 4042, and the facility's policies for Menus, and Standardized Recipes the facility failed to ensure portion sizes listed on the menu for 07/23/2024 and 07/24/2024 were provided to residents, the portion of Sliced Ham Steak served on 07/23/2024 was at least three ounces (oz.), the portion to be served as listed on the Chili recipe was reflected on the menu for the Puree diet for 07/24/2024, and puree bread was provided to the Puree diets as listed on the menu for 07/23/2024 and 07/24/2024. This had the potential to affect 52 of 52 residents receiving meals from the kitchen including Resident Identifier (RI) #35 one of six residents receiving Puree diets. The deficient practice caused actual harm that was not immediate jeopardy to RI #35. [...]

Inspectors wroteBased on interviews, record review, review of a facility policy titled GHC Abuse Policy, review of the Facility Reported Incident(FRI) received by the Alabama State Survey Agency, and review of the facility's investigative file, the facility failed to protect the Resident Identifier (RI) #3's right to be free from verbal abuse by Certified Nursing Assistant (CNA) #16 and CNA #17. On 10/11/2023, at approximately 4:27 PM, RI #3's daughter was visiting and requested assistance from staff. RI #3's daughter left her cellphone on record in the room as CNA #16 and CNA #17 entered the room to provide care. After CNA #16 and CNA #17 finished providing care, the daughter returned to the room and stopped the recording. RI #3's daughter listened to the recording and heard both CNA's making multiple derogatory statements and threats of punishment toward RI #3. [...]

Inspectors wroteBased on interviews, resident record review, review of a facility policy titled, Resident-to-Resident Altercations, review of a Facility Reported Incident (FRI) received by the State Agency, and review of the facility's investigative file, the facility failed to ensure the abuse policy was implemented to take steps to protect Resident Identifier (RI) #2 from further abuse on 05/15/2024 when RI #2 was being physically abused by RI #1. Certified Nursing Assistant (CNA) #3 heard RI #2 yelling and saw RI #1 sitting on RI #2's arm and slapping RI #2 in the face. Instead of providing immediate protection and supervision for the residents, CNA #3 left the room, leaving RI #1 alone in the room with RI #2, who according to interview may have been afraid or in pain, while the CNA went to the nurses' station to get the nurse. This deficient practice affected RI #2, one of six sampled residents. [...]

Inspectors wroteBased on observation, interviews, medical record review, the facility's Spring/Summer 2024 Menu, the facility's standardized recipe for Chili - 4042, and the facility policies for Weight Assessment and Intervention, Menus, and Standardized Recipes the facility failed to ensure (RI) Resident Identifier #35 received appropriate food portions as defined by the Registered Dietitian's (RD) approved menu for Puree diets and did not suffer significant weight loss of 10.7 % (percent) over 180 days. RI #35 lost 21 pounds from 01/02/2024 to 07/09/2024. The deficient practice caused actual harm that was not immediate jeopardy to RI #35, one of six residents who received Puree diets. This deficient practice was cited as a result of the investigation of complaint/ report #AL00048377. Cross-Reference F 803. Findings Include: [...]

Inspectors wroteBased on observation, interview, the 2022 Food Code of the United States (U.S.) Food and Drug Administration (FDA), and the facility's policies for Floors, Food Storage, and Sanitation the facility failed to prevent the potential for food borne illness by not labeling leftovers with a use by date and failed to prevent the potential for cross-contamination by when flies were observed in the kitchen for four of four days of the survey; the walk-in cooler storage racks and floor was observed to be dirty; ceiling vents were observed to be dirty; ceiling tiles had brown water stains and circular dark spots; drainpipes from the dishwashing machine, the scrap sink, and the Three-compartment Pot and Pan Sink extended into the floor drains did not have air gaps, and food was stored on a broken rack touching the floor in the Walk-in Cooler. [...]

Inspectors wroteBased on staff interview and review of the facility policy titled, Quality Assurance and Process Improvement Committee , the facility failed to maintain minutes of all QAPI meetings to document its ongoing Quality Assurance and Performance Improvement (QAPI) program. This had the potential to affect all 53 residents of the facility.

Inspectors wroteBased on observation, interview, the facility's policy for Sanitation, and the facility's Maintenance Request Orders; the facility failed to ensure kitchen equipment was maintained in working order and kept in good repair. This had the potential to affect all residents receiving meals from the facility's kitchen, 52 of 52 residents. This deficient practice was cited as a result of the investigation of complaint/ report #AL00048377.

Inspectors wroteBased on interviews, a third party complaint and the facility's policy titled EMPLOYEE RESPONSIBLITY ON-THE JOB, the facility failed to ensure residents' Protected Health Information (PHI) was protected when the Director of Rehabilitation (DOR) used her personal computer to review and chart notes for rehabilitation therapy residents. This had the potential to affect 12 residents that received therapy in the month of October. This deficient practice was cited as a result of the investigation of complaint/ report #AL00048377. Findings Include: An anonymous complaint dated 07/19/2024 alleged that the facility's governing body failed to provide adequate computers and staff were using personal laptops and creating a potential for HIPPA violations. [...]

Inspectors wroteBased on observations, interviews, and facility policies titled, Homelike Environment and Resident Rights the facility failed to ensure: 1) Baseboards on the 400 hall were not missing leaving white sheet rock with peeled paint exposed; 2) Ceiling tiles were not missing in the Physical Therapy (PT) room; 3) Scuffs and holes were not on the wall outside of the PT room; 4) Handrails around the 400 hall were not missing pieces on the corners and easily removable; 5) RI #19 and #27's room did not have electrical box hanging from the ceiling with excessive wire hanging out; 6) The linen room on the 400 unit was not missing a ceiling tile exposing the main drain line; 7) RI #21's room did not have a ceiling tile with brown color stain; 8) RI #26's room did not have cable wire loosely hanging from the ceiling. [...]

Inspectors wroteBased on observations, interviews, record review and a facility policy titled Answering the Call light, the facility failed to accommodate the needs of Resident Identifier (RI) #'s 21, 26, 31 and 34 by failing to ensure the call light was accessible on three of six days of the survey. This affected RI #'s, 21, 26, 31 and 34, four of 34 sampled residents. This deficient practice was cited as a result of investigation of complaint/report number AL00046050. Findings Include: Review of a policy titled Answering the Call Light, revised September 2022, documented: . The purpose of this procedure is to ensure timely responses to the resident's requests and needs . 5. Ensure that the call light is accessible to the resident . RI #21 was readmitted to the facility on [DATE] with diagnoses to include Weakness and Dysphagia. [...]

Inspectors wroteBased on interviews, record reviews, facility policy GHC Abuse Policy and review of an ADPH Online reporting form, the facility failed to ensure allegation of abuse was reported to the Alabama Department of Public Health (ADPH) within two hours on 10/11/2023 for Resident Identifier (RI) #3. On 10/11/2023 at 5:40 PM facility staff reported an allegation of verbal abuse for RI #3. The facility reported the allegation of verbal abuse at 8:24 PM on 10/11/2024 to ADPH. This failure affected one (RI #3) of fifteen sampled residents reviewed for abuse. This deficient practice was cited as a result of the investigation of complaint/report number AL00045846 and AL00047519.

Inspectors wroteBased on record review, interviews and review of facility policies Antipsychotic Medication Use, and Administering Medications, the facility failed to ensure Resident Identifier (RI) #1 was assessed and monitored by licensed staff after receiving a onetime dose of Lorazepam (Ativan), when RI #1 became agitated and expressed he/she was going to leave the facility. This occurred on 02/05/2023 and affected RI #1. This deficient practice was cited as a result of investigation of complaint/report number AL00043280. Findings Include: Review of a facility policy Antipsychotic Medication Use with a revised date of July 2022 documented . Policy Interpretation and Implementation . 2. The attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others. 17. [...]