3 Reports · 1 Summary
Inspection Summary
5 inspections covered, April 2022 – March 2026.
Inspection Reports Summary
Visit Reason
State-compiled facility profile showing 5 inspections from April 2022 to March 2026 with deficiency history and enforcement summary.
Complaint Details
One inspection was a complaint survey conducted on August 15, 2024, which found no violations.
Findings
Across 5 inspections, 4 violations were cited related to records and reports, with 1 inspection finding no violations. No formal enforcement actions were taken during the reporting period.
Violations (1)
CFR 485.11 (b) — Records and reports: Violations related to recordkeeping and reporting requirements were cited in four inspections.
Report Facts
Inspections on page: 5
Total violations cited: 4
Inspections with violations: 4
Inspections without violations: 1
Enforcement actions: 0
Individual Reports
One document per inspection visit.
Inspection Report — Oct 16, 2023
Annual Inspection
Date: Oct 16, 2023
Visit Reason
The document is an annual inspection report for The Knolls nursing home conducted to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report — Jul 6, 2021
Annual Inspection
Date: Jul 6, 2021
Visit Reason
The inspection was a recertification survey to assess compliance with federal and state regulations for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to update and monitor care plans for drug interactions, failure to timely report and treat skin conditions, inaccurate measurement of resident fluid intake, failure to monitor medication lab levels as ordered, inadequate monitoring of psychotropic medication effects and drug interactions, improper food storage and labeling, lack of carbon monoxide detectors in required areas, and failure to maintain an updated Legionella Risk Assessment and Water Management Plan.
Violations (8)
Failure to ensure comprehensive person-centered care plans were reviewed and revised to reflect drug-drug interactions and monitor for adverse effects for Resident #63.
Failure to provide timely reporting and treatment of a change in skin condition for Resident #7.
Failure to accurately measure and monitor fluid intake for Resident #64 on fluid restriction.
Failure to ensure irregularities identified by the pharmacist, specifically missed Lithium lab monitoring, were communicated to the physician and acted upon for Resident #7.
Failure to provide ongoing monitoring of medication effects, side effects, and adverse reactions including drug-drug interaction monitoring for Resident #63.
Failure to ensure proper food storage including labeling, dating, discarding expired foods, and storing dry goods in closed containers.
Failure to install carbon monoxide detectors in areas with fuel-burning appliances as required by code.
Failure to provide and implement an infection prevention and control program including an annually assessed Legionella Risk Assessment and Water Management Plan.
Report Facts
Residents reviewed for unnecessary medications: 5
Residents reviewed for skin conditions: 1
Residents reviewed for hydration: 1
Fluid restriction: 1500
Medication orders: 3
Lab monitoring intervals: 3
Missed lab intervals: 5
Missed lab intervals: 4
Food items expired: 10
Weight of unlabeled frozen fish: 4.6
Weight of unlabeled frozen breaded cod: 2.33
Weight of unlabeled frozen breaded fish: 1.18
Weight of raw ground beef unlabeled: 10
Weight of raw chicken thighs unlabeled: 9.7
Weight of raw pork loin unlabeled: 6.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Interviewed regarding pharmacy drug-drug interaction documentation and monitoring for Resident #63. |
| Director of Nursing | Director of Nursing | Interviewed regarding responsibility for care plan updates and monitoring for Resident #63 and lab monitoring for Resident #7. |
| RN #2 | Registered Nurse | Interviewed regarding awareness of missed Lithium lab levels for Resident #7. |
| Cook #1 | Cook | Interviewed regarding responsibility for checking food expiration dates. |
| Cook #2 | Cook | Interviewed regarding labeling of pulled frozen foods. |
| Regional Manager | Regional Manager | Interviewed regarding food labeling and discarding expired items. |
| Dietary Aide | Dietary Aide | Interviewed regarding fluid measurement for Resident #64. |
| Registered Dietician | Registered Dietician | Interviewed regarding fluid restrictions and measurement for Resident #64. |
| Maintenance Director | Maintenance Director | Interviewed regarding carbon monoxide detector installation and Legionella program review. |
| Pharmacy Consultant | Pharmacy Consultant | Interviewed regarding communication of medication regimen review irregularities. |
Inspection Report — Sep 12, 2019
Annual Inspection
Date: Sep 12, 2019
Visit Reason
Annual survey inspection of The Knolls nursing home to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
3 CMS Surveys
CMS Survey — Sep 12, 2019
Sep 12, 2019
CMS Survey — Jul 6, 2021
Jul 6, 2021
CMS Survey — Oct 16, 2023
Oct 16, 2023
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