Knollwood Nursing Center

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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 . [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that Minimum Data Set (MDS) Assessments were accurately coded to reflect the Residents' status for two Residents (#25 and #73) out of a total sample of 18 residents. Specifically, the facility failed to ensure that the MDS assessment: 1. For Resident #25, was accurately coded relative to the use of Oxygen (a drug that is a vital and essential medication, usually prescribed to treat cardiac and respiratory conditions). 2. For Resident #73, was accurately coded relative to being discharged to home.

Inspectors wroteBased 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.