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Deficiency Records for Knolls West Post Acute LLC
A list of the most recent deficiencies for Knolls West Post Acute LLC. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Knolls West Post Acute LLC. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-06-18 | 2024-07-08 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2024-05-23 | 2024-06-14 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2024-05-23 | 2024-06-14 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-05-23 | 2024-06-14 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2024-05-23 | 2024-06-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-05-23 | 2024-06-14 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2024-06-04 | 2024-06-14 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2024-06-04 | 2024-06-14 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2024-06-04 | 2024-06-14 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2024-06-04 | 2024-06-14 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-06-04 | 2024-06-14 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-06-04 | 2024-06-14 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-06-04 | 2024-06-14 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2024-06-04 | 2024-06-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-06-04 | 2024-06-14 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-06-04 | 2024-06-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-06-04 | 2024-06-14 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-06-04 | 2024-06-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-06-04 | 2024-06-14 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-06-04 | 2024-06-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-06-04 | 2024-06-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-06-04 | 2024-06-14 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-06-04 | 2024-06-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-21 | 2023-07-24 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-05-17 | 2023-05-30 | Y |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2023-03-14 | 2023-03-22 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-02-03 | 2023-02-17 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-03 | 2023-02-17 | Y |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2022-12-15 | 2023-02-13 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-12-15 | 2023-02-13 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-12-15 | 2023-02-13 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2022-12-15 | 2023-02-13 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-12-15 | 2023-02-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-15 | 2023-02-13 | Y |
| Assess the resident when there is a significant change in condition | Health | 2022-12-15 | 2023-01-13 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-12-15 | 2023-01-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-15 | 2023-01-13 | N |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2022-12-15 | 2023-01-13 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-12-15 | 2023-01-13 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-12-15 | 2023-01-13 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-12-15 | 2023-01-13 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2022-12-15 | 2023-01-13 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-12-15 | 2023-01-13 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2022-12-15 | 2023-01-13 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-12-15 | 2023-01-13 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-12-15 | 2023-01-13 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-12-13 | 2023-01-12 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-12-13 | 2023-01-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-13 | 2023-01-12 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-12-13 | 2023-01-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-12-13 | 2023-01-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-12-13 | 2023-01-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-12-13 | 2023-01-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-12-13 | 2023-01-12 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-02-17 | 2022-03-07 | Y |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-06-13 | 2019-07-02 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-06-13 | 2019-07-02 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-06-13 | 2019-07-02 | N |
| Use approved construction type or materials. | Fire Safety | 2019-06-13 | 2019-07-02 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-06-13 | 2019-07-02 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-06-13 | 2019-07-02 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2019-06-13 | 2019-07-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-13 | 2019-07-02 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-06-13 | 2019-07-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-06-13 | 2019-07-02 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-06-13 | 2019-07-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-06-13 | 2019-07-02 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-06-13 | 2019-07-02 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-04-26 | 2019-05-20 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-04-26 | 2019-05-20 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-04-26 | 2019-05-20 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-04-26 | 2019-05-20 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-04-26 | 2019-05-20 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2019-04-26 | 2019-05-20 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-04-26 | 2019-05-20 | N |
| Dispose of garbage and refuse properly. | Health | 2019-04-26 | 2019-05-20 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-04-26 | 2019-05-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-26 | 2019-05-20 | N |
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