Knopp Healthcare and Rehab Center Inc

Inspectors wroteBased on interviews and record review the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required for 1 of 1 kitchen reviewed. The facility failed to employ a qualified dietician or other clinically qualified nutrition professional either full-time, part-time, or on a consultant basis. A qualified nutrition professional last employed with the facility was in October 2025. The facility failed to employ a qualified dietician who designates a person to serve as a full-time director of food and nutrition services for the facility. [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency) in accordance with State law through established procedure. [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to have evidence all allegations of abuse, neglect, or mistreatment were thoroughly investigated and documented for 1 of 2 residents (Resident #1) reviewed for an injury of unknown origin. The facility failed to have evidence that a thorough investigation was conducted following the allegation Resident #1 had bruising to her left side of her face and right arm and origin was unknown on 12/29/2025. This deficient practice could place residents at risk for abuse and neglect by not investigating injuries of unknown origin.

Inspectors wroteBased on interview and record review, the facility failed to ensure all individuals with mental health disorders were provided with accurate Preadmission Screening and Resident Review (PASRR) Screenings for 1 of 4 residents reviewed for PASRR. The facility failed to ensure that Resident #7 had an accurate PASRR Level 1 Screening which indicated a diagnosis of mental illness (Bipolar Disorder) and refer Resident #7 to the state designated authority. This failure could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care, and specialized services to meet their needs.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure the residents' environment remains was free from accidents and hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents, for 1 of 8 residents (Resident #48) and 1 facility reviewed for a wander guard system (a wander management system used in healthcare facilities to prevent residents at risk of wandering, such as those with dementia, from leaving safe areas, offering them freedom while ensuring safety through wearable devices and automated alerts. [...]

Inspectors wroteBased on observations, interviews and record review the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 facility's reviewed for safe and functioning equipment in the laundry department. The facility had 3 commercial clothes washers with one of the three inoperable. The facility had 4 commercial clothes dryers with one of the four in-operable. This failure could place residents at risk for neglect by not having laundry services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for 1 of 1 kitchen reviewed for food service safety. The facility failed to recognize and dispose of food which had pests, including maggots on the food items. This failure could place residents who receive food and/or snacks from the kitchen at risk for food borne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an effective pest control program so that the facility is free of pests for 1 of 1 facility reviewed for physical environment. The facility was observed to have numerous crickets scattered throughout the floor of the facility both alive and dead. This failure could place residents at risk for not having a home free of pests, and a comfortable environment in which to live.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure its medication error rates were not 5% or greater. The facility had a medication error rate of 24%, based on 6 errors out of 25 opportunities which involved 1 of 3 residents (Resident #7) reviewed for medication administration and medication errors. 1. RN B crushed pills and capsules, 3 medications; bisacodyl 5mg delayed release, duloxetine 60mg delayed release, and divalproex 125mg delayed release, which should not be crushed per professional standards, and administered the crushed medications to Resident #7. 2. RN B administered acetaminophen 650mg, whole pill, to Resident #7 who was ordered by her physician to have crushed medications due to her swallowing difficulties. 3. RN B administered medication Carvedilol 6.25mg on 10/03/2024 at 10:01 AM, 1 hour late. 4. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 of the facility's laundry department reviewed for patient care equipment in safe operating condition. The facility presented 4 installed dryers of which 2 were inoperable and the facility presented with 3 washers of which 2 were inoperable. These failures could place residents at risk for harm by the facility's inability to provide clean sanitary linens.

Inspectors wroteBased on interviews and record reviews the facility failed to electronically transmit encoded, accurate, and complete MDS data to the CMS System, within 14 days, upon a resident's transfer, reentry, discharge, and death, for 1 of 8 residents (Resident #25) reviewed for transmitted MDS data to the CMS System. The facility failed to transmit a discharge MDS assessment to the CMS system for Resident #25. This failure could place residents at risk for not having their assessments transmitted timely which could cause a delay in treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, for 1 of 3 the residents (Resident # 3) reviewed for oxygen in that: The Facility failed to ensure Residents #3's, nebulizer tubing was bagged. This deficient practice could place residents who received oxygen therapy at risk for an increase in respiratory complications.

Inspectors wroteBased on observation , interview and record review, the facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days unless the attending physician or prescribing practitioner believed that it was appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record, and indicate the duration for the PRN order for 1 of 3 residents (Resident #150) reviewed for pharmacy services . The facility failed to ensure Resident # 150 had a stop date for PRN Lorazepam 0.5 mg (a medicine used to treat the symptoms of anxiety) This failure could affect residents who received antipsychotic/psychoactive medications and could place residents at risk of receiving unnecessary psychotropic medications.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure residents could call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside for 1 of 8 residents (Resident #16) reviewed for the ability to call for staff assistance. The facility failed to ensure Resident #16's call light was within reach while she was positioned in her wheelchair. This failure could place residents at risk for delay in care and services, and increased risk of falls and injuries.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse or serious bodily injury for 1 (Resident #4) of 4 residents reviewed for freedom from abuse, neglect, and exploitation. The nursing staff of the facility failed to report an allegation of resident abuse made by Resident #4, which occurred on 09/10/24, to the administrator immediately, per facility policy. This failure could place all residents at increased risk for potential neglect due to unreported allegations of neglect.

Inspectors wroteBased on observation, interview, and record review the facility failed to review and revise Resident Care Plans after each assessment for 2 of 4 Residents (Resident #1 and Resident #3) whose records were reviewed for care plan revision/timing, in that:. 1. Resident #1's Care Plan was not updated after her annual MDS assessment reflected she was dependent on staff for ADL care . 2. Resident #3's Care Plan was not updated after she had a significant change and required a mechanical lift for transfers. These deficient practices could affect any resident and contribute to Residents not receiving the care and services they needed.

Inspectors wroteBased on interview and record review, the facility failed to utilize the services of a registered nurse for at least eight consecutive hours per day, seven days per week and the facility failed to designate a registered nurse to serve as the director of nursing on a full-time basis for 3 of the 13 months reviewed, in that: The facility did not employ a Director of Nursing and did not employ sufficient full-time registered nurses to utilize their services for at least eight consecutive hours per day, seven days per week from July 2022 to October 2022. This deficient practice could place all residents in danger of not receiving adequate care.

Inspectors wroteBased on interview and record review, the facility failed to include as part of its QAPI program, mandatory training that outlined and informed staff of the elements and goals of the facility's QAPI program, for 20 of the 25 staff members reviewed for mandatory training, in that: Twenty of the twenty-five staff members reviewed for mandatory training had not received training regarding the facility's QAPI program. This deficient practice could place residents at risk of receiving inadequate care from staff who are unfamiliar with the facility's QAPI program.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents' right to right to a safe, clean, comfortable and homelike environment for 3 of 3 communal shower rooms (shower room A located near the small dining room, shower room B located near conference room, and shower room C on 200 Hall) reviewed, in that: Barrels containing soiled linens and barrels containing trash were stored in three communal shower rooms, and equipment in Shower Room C was in disrepair. This deficient practice could place residents who utilize communal shower rooms at risk of psychosocial harm due to feeling disrespected or uncomfortable, with decreased self-esteem and quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 2 halls (disused hall near therapy gym and hall near conference room), and 1 shower room (Shower Room C) reviewed for environment, in that: Hazardous materials, sharp tools, and equipment in disrepair were found in areas accessible by facility residents. This deficient practice could place all residents at risk of injury due to exposure to hazardous materials, sharp tools, and equipment in disrepair.

Inspectors wroteBased on interviews, and record reviews, the facility failed to maintain medical records on each resident that are complete, accurately documented, readily accessible, and systematically organized for 3 of 8 residents (Resident #188, #28, and #33), reviewed for resident records, in that: 1. The facility failed to ensure the Advance Directive code status was updated for Resident #188's care plan; 2. The facility failed to ensure the diet order was updated for Resident #28's care plan and physician orders; and 3. The facility failed to ensure the care plan was updated for Resident #33 to include diet orders. This deficient practice could affect all residents whose records are maintained by the facility and could place them at risk for errors in care and treatment.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 2 of 8 residents (Resident #188 and #33), reviewed for comprehensive care plans in that: 1. The advance directive code status was not updated for (Resident #188's care plan; and 2. The diet order was not updated for Resident #33's care plan. These deficient practices could affect residents with comprehensive care plans and could result in missed or delayed continuity of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate administration of all drugs and biologicals, to meet the needs of two of 6 residents reviewed for pharmacy services (Residents #12 and #1), in that: 1. The facility failed to ensure vital signs were obtained immediately prior to the administration of medication, metoprolol [a medication for high blood pressure], for Resident #12. 2. The facility failed to ensure that liquid medications were dispensed into a graduated receptacle for accuracy of dosing for Resident #1. These deficient practices could place residents at risk of not receiving the intended therapeutic benefit of the medications, could result in a worsening or exacerbation of chronic medical conditions, hospitalization and or a diminished quality of life.

Inspectors wroteBased on observation, and interview, the facility failed to store all drugs and biologicals in locked compartments for one of four medication carts (200-wing treatment cart) reviewed for medication storage, in that: The facility failed to ensure the 200-wing treatment cart was unlocked and unattended at the nurses' station. This deficient practice could affect residents who have medications in the medication cart and could result in lost medications, drug diversion, or harm due to accidental ingestion or misuse of unprescribed treatments.

Inspectors wroteBased on interview and record review, the facility failed to designate a member of the facility's interdisciplinary team who was responsible for working with hospice representatives to coordinate care and failed to obtain documentation and information from the hospice company for 2 of 4 residents (Resident #7 and Resident #26) who received hospice services reviewed, in that: 1. There was not a designated member of the facility's interdisciplinary team who was responsible for working with hospice representatives to coordinate care. 2. The facility did not obtain documentation and information from the hospice company for Resident #7 and Resident #26 regarding their hospice services. [...]