Knollwood Healthcare: Missed Insulin, Seizure Meds - AL
Federal inspectors who arrived in late March rated the lapse Immediate Jeopardy, the most serious classification available, affecting many residents.
One nurse on the Third Floor, RN #16, later explained her reasoning to inspectors. She said she could not administer sliding-scale insulin — the kind calibrated to a resident's actual blood sugar reading — because she couldn't access the electronic medication administration record while the internet was down. She said she could give scheduled insulin doses to residents she already knew by memory, because those were routine. But anything requiring her to look up a record, she did not give.
Nobody checked blood sugar either.
On the Second Floor, RN #15 worked a double shift from 6 AM to 10 PM on January 21. She told inspectors that something happened during the evening shift and she was unable to pass any medications because she did not have access to residents' eMAR. LPN #14, who also worked a double shift that day and was assigned to a separate group of residents, said the internet stopped working around 2 PM. She said she did not know who needed their blood glucose checked off the top of her head, so she did not check.
The facility's own policy stated that medications are administered in a safe and timely manner, and as prescribed, and within one hour of their scheduled time.
The residents who went without medication were not healthy people who could absorb a missed dose without consequence. They were nursing home residents with serious, unstable conditions.
One resident, identified in the inspection report as RI #12, had Type 2 Diabetes with Diabetic Chronic Kidney Disease and Hyperglycemia. She had orders for sliding-scale insulin four times a day and a nightly dose of Novolin N. The eMAR showed she received none of her sliding-scale insulin on the evening of January 21 or at any of the four scheduled times on January 22. She also missed her Novolin N on both nights.
RI #15 had diabetes, epilepsy, and hypertension. Over the same stretch, she missed three doses of Hydralazine for her blood pressure, three doses of Lacosamide for her seizures, three doses of Carvedilol for her heart, two doses of long-acting Glargine insulin, and four doses of sliding-scale Lispro insulin before meals.
RI #30 had diabetes, chronic heart failure, hypertension, and coronary artery disease, and was on long-term insulin. He or she missed three doses of Lasix, the diuretic that keeps fluid from building up in the lungs and body of someone with heart failure. Three doses of Rivaroxaban, a blood thinner. Three doses of Carvedilol. Six doses of mealtime Novolog insulin. Blood glucose was not checked on the afternoon of January 21, the morning of January 22, or the afternoon of January 22.
RI #308 had epilepsy — multiple overlapping seizure conditions — and was prescribed five separate anticonvulsant medications twice a day: Clobazam, Lacosamide, Lamotrigine, Oxcarbazepine, and Topiramate. Every one of those medications was missed at the 5 PM pass on January 21, the 8 AM pass on January 22, and the 5 PM pass on January 22. That is fifteen missed doses of seizure medication across three medication passes.
When inspectors interviewed RI #308 directly on March 25, the resident said there were a few shifts where he or she did not receive any medications.
The facility's Medical Director, who was also the treating physician for several of these residents, spoke with inspectors by phone on March 25. His assessment was direct. If a resident with diabetes did not receive their insulin and their blood sugars were not monitored, he said, the short-term risk was Diabetic Ketoacidosis and the possible need for an insulin drip if blood sugars climbed too high. For RI #308, he said missing seizure medications created a likelihood of seizure recurrence. For RI #15, who had both epilepsy and hypertension, the risks were elevated blood pressure and seizure recurrence. For RI #30, with heart failure layered onto diabetes and hypertension, missing doses could cause fluid retention and recurrence of heart failure.
None of the nurses who withheld medications called a physician. None notified the Director of Nursing. None found an alternative way to access medication records — a personal hotspot, a paper backup, a phone call to the pharmacy. One nurse on the Third Floor, LPN #18, told inspectors she had connected to a hotspot and passed medications as ordered during the same outage. The others did not.
There was no paper backup in place. The facility had no printed medication administration records available when the internet failed.
The facility submitted a removal plan to inspectors on March 26, two months after the outage. The plan described a new procedure: the Director of Nursing or a designee would print paper MARs by the first of each month, keep copies at nursing stations, and update them whenever orders changed. All 21 nurses were given in-service training that same day. A mock drill was conducted for nursing staff on shift on March 21.
The facility also reported that the router that caused the outage had been replaced on January 30, nine days after the medications were missed.
The Medical Director assessed all 56 residents who could have been affected by the outage, completing those assessments on March 26. The facility reported that no adverse effects were identified.
What the inspection report does not say is whether any of those residents were hospitalized, experienced a seizure, or went into diabetic crisis during the days and weeks after January 21 and 22. The medical assessments happened two months later. RI #308, who missed fifteen doses of five seizure medications across three shifts, described the experience to inspectors in their own words: there were a few shifts where they did not receive any medications at all.
The facility's in-service training, completed the day before inspectors finished their survey, classified what happened as neglect under the facility's own abuse policy.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Knollwood Healthcare from 2025-03-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 5, 2026 · Our methodology
KNOLLWOOD HEALTHCARE in MOBILE, AL was cited for violations during a health inspection on March 27, 2025.
Federal inspectors who arrived in late March rated the lapse Immediate Jeopardy, the most serious classification available, affecting many residents.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.