Knollwood Healthcare

F-F580 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.

This deficient practice affected residents on the second and third floors at the facility who were receiving medications.

This deficiency was cited as the result of the investigation of complaint/report number AL00050173.

Findings Include:

Cross-Reference

F-F600- Free from Abuse and Neglect.

The IJ began on 01/21/2025 and continued until 03/26/2025 when the facility implemented corrective action to remove the immediacy. On 03/27/2025 the immediate jeopardy was removed, F 600 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.

This deficient practice affected all residents at the facility who received medications.

This deficiency was cited as the result of the investigation of complaint/report number AL00050173.

The facility further failed to protect Resident Identifier (RI) #15's right to be free from verbal abuse perpetrated by Certified Nursing Assistant (CNA) #10.

Specifically, on 01/30/2025, the facility failed to ensure RI #15 was not verbally abused by CNA #10, who stated she was tired and frustrated from working a double the day before, and who called RI #15 a stupid mother fucker while providing assistance to RI #15 who needed assistance to stand. RI #15 said, he/she was shocked when CNA #10 spoke to him/her that way.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 46 015463 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 015463 B. Wing 03/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Knollwood Healthcare 3151-A Knollwood Drive Mobile, AL 36693

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 This deficient practice was cited as the result of the investigation of complaint/report number AL00050214 and affected RI #15, one of three residents sampled for abuse, and did not rise to the jeopardy level. Level of Harm - Immediate jeopardy to resident health or Findings Include: safety 1) Cross-Reference

F-F658.

Review of the facility's policy titled, Administering Medications, with a revised date of 04/2019, revealed the following:

Policy Statement

Medications are administered in a safe and timely manner, and as prescribed.

Policy Interpretation and Implementation .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 46 015463 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 015463 B. Wing 03/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Knollwood Healthcare 3151-A Knollwood Drive Mobile, AL 36693

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 4. Medications are administered in accordance with prescriber orders, including any required time frame .

Level of Harm - Immediate 7. Medications are administered within one (1) hour of their prescribed time . jeopardy to resident health or safety 22. The individual administering the medication initials the resident's MAR . after giving each medication .

Residents Affected - Many RI #12 was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnosis to include Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease and Hyperglycemia. RI #12 resided on the Third Flood of the facility.

RI #12's January 2025 Order Summary Report (Physicians Orders) revealed RI #12 had orders for: sliding scale Insulin Aspart Injection Solution subcutaneous four times a for hyperglycemia related to Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease; and 6 units of Novolin N FlexPen Subcutaneous Suspension Pen-Injection subcutaneously at bedtime related to Type 2 Diabetes Mellitus with Other Specific Complication.

A review of RI #12's January 2025 eMAR revealed RI #12's Insulin Aspart injection per sliding scale was not administered on 01/21/2025 at 5:00 PM, 01/21/2025 at 9:00 PM, 01/22/2025 at 7:30 AM, 01/22/2025 at 11:30 AM, 01/22/2025 at 5:00 PM, and 01/22/2025 at 9:00 PM. The eMAR further revealed Novolin N 6 units was not administered to RI #12 on 01/21/2025 at 9:00 PM and 01/22/2025 at 9:00 PM.

On 03/22/2025 at 5:47 PM an interview was conducted with RN #16. During the interview RN #16 said she worked on the Third Floor on the 2 PM to 10 PM and 10 PM to 6 AM shift on 01/21/2025. RN #16 said if anyone required blood glucose monitoring such as a sliding scale, she could not have administered it, because the facility did not have the paper MAR or eMAR while the internet was down. RN #16 said she could administer residents with scheduled doses of insulin because she knew which residents were routine.

On 03/20/2025 at 4:49 PM an interview was conducted with Licensed Practical Nurse (LPN) #18 who reported she worked on the Third Floor on the 6 AM to 2 PM and 2 PM to 10 PM shifts on 01/22/2025. She reported when the facility lost internet that she connected to a hotspot and passed medications as ordered.

RI #15 was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses to include Type 2 Diabetes Mellitus, Localization-Related (Focal) (Partial) Symptomatic Epilepsy, and Essential (Primary) Hypertension. RI #15 resided on the Second Floor of the facility.

RI #15's January 2025 Physicians Orders revealed RI #15 had orders for Carvedilol 25 mg two times a day related to Hypertension, Hydralazine 50 mg two times a day related to Hypertension, Insulin Glargine 30 units subcutaneous in the evening related to Diabetes, Lacosamide 50 mg two times a day related to Seizures, and Insulin Lispro per sliding scale before meals related to Diabetes.

A review of RI #15's January 2025 eMAR revealed RI #15's was not administered:

Hydralazine 50 milligram (mg) 01/21/2025 at 5:00 PM, 01/22/2025 at 8:00 AM, and 01/22/2025 at 5:00 PM;

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 46 015463 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 015463 B. Wing 03/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Knollwood Healthcare 3151-A Knollwood Drive Mobile, AL 36693

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Lacosamide 50 mg on 01/21/2025 at 5:00 PM, 01/22/2025 at 8:00 AM, and 01/22/2025 at 5:00 PM;

Level of Harm - Immediate Carvedilol 25 mg on 01/21/2025 at 8:00 PM, 01/22/2025 at 8:00, and 01/22/2025 at 8:00 PM; jeopardy to resident health or safety Glargine Insulin 30 units on 01/21/2025 at 5:00 PM and 01/22/2205 at 5:00 PM; and

Residents Affected - Many Insulin Lispro sliding scale on 01/21/2025 at 4:00 PM, 01/22/2025 at 7:30 AM, 01/22/2025 at 11:00 AM and 01/22/2025 at 4:00 PM.

RI #30 was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses to include Type 2 Diabetes Mellitus with Diabetic Neuropathy, Chronic Diastolic (Congestive) Heart Failure, Essential Hypertension, Atherosclerotic Heart Disease of Native Coronary Artery, and Long Term (Current) Use of Insulin. RI #30 resided on the Second Floor.

RI #30's January 2025 Physicians Orders revealed RI #30 had orders for blood glucose monitoring twice a day related to Type 2 Diabetes, Carvedilol 12.5 mg every morning and at bedtime for Beta Blockers, Furosemide 40 mg two times a day for Diuretics, Novolog 8 units before meals related to Type 2 Diabetes, and Rivaroxaban 2.5 mg two times a day for Anticoagulants.

A review of RI #30's January 2025 eMAR revealed RI #30 was not administered:

Lasix 40 mg 01/21/2025 at 5:00 PM, 01/22/2025 at 8:00 AM, 01/22/2025 at 5:00 PM;

Rivaroxaban 2.5 mg 01/21/2025 at 5:00 PM, 01/22/2025 at 8:00 AM, 01/22/2025 at 5:00 PM;

Coreg 12.5 mg 01/21/2025 at 8:00 PM, 01/22/2025 at 8:00 AM, 01/22/2025 at 8:00 PM;

Novolog 8 units on 01/21/2025 at 4:00 PM, 01/21/2025 at 9:00 PM, 01/22/2025 at 7:30 AM, 01/22/2025 at 11:00 AM, 01/22/2025 at 4:00 PM, and 01/22/2025 at 9:00 PM.

RI #30's January 2025 eMAR also indicated his/her blood glucose was not monitored on 01/21/2025 at 5:00 PM, 01/22/2025 at 8:00 AM, or on 01/22/2025 at 5:00 PM.

RI #308 was admitted to the facility on [DATE REDACTED] and discharged on [DATE REDACTED]. RI #308 had diagnoses that included Epilepsy, Unspecified, Conversion Disorder with Seizures or Convulsions and Localization-Related (Focal) (Partial) Symptomatic Epilepsy and Epileptic Syndrome with Complex Partial Seizures. RI #308 resided on the Second Floor.

RI #308's January 2025 Physicians Orders revealed RI #308 had orders for Clobazam 10 mg two times a day for Anticonvulsants, Lacosamide 50 mg two times a day for Anticonvulsants, Lamotrigine 100 mg two times a day for Anticonvulsants, Oxcarbazepine 300 mg two times a day for Anticonvulsant, and Topiramate 300 mg two times a day for Anticonvulsant.

A review of RI #308's January 2025 eMAR revealed RI #308 was not administered his/her:

Clobazam 10 mg on 01/21/2025 at 5:00 PM, 01/22/2025 at 8:00 AM, and 01/22/2025 at 5:00 PM;

Lacosamide 50 mg on 01/21/2025 at 5:00 PM, 01/22/2025 at 8:00 AM, and 01/22/2025 at 5:00 PM;

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 46 015463 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 015463 B. Wing 03/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Knollwood Healthcare 3151-A Knollwood Drive Mobile, AL 36693

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Lamotrigine 100 mg on 01/21/2025 at 5:00 PM, 01/22/2025 at 8:00 AM, and 01/22/2025 at 5:00 PM;

Level of Harm - Immediate Oxcarbazepine 300 mg on 01/21/2025 at 5:00 PM, 01/22/2025 at 8:00 AM, and 01/22/2025 at 5:00 PM; jeopardy to resident health or safety Topiramate 300 mg on 01/21/2025 at 5:00 PM, 01/22/2025 at 8:00 AM, and 01/22/2025 at 5:00 PM.

Residents Affected - Many On 03/25/2025 at 11:05 AM an interview was conducted with RI #308 who said he/she was scheduled to receive medications for seizures twice a day. RI #308 said there was a few shifts that he/she did not receive any of his/her medications.

On 03/21/2025 at 11:58 AM an interview was conducted with Registered Nurse (RN) #15. RN #15 reported

she worked a double shift from 6 AM to 10 PM on 01/21/2025 on the Second Floor. RN #15 said something happened during the evening shift on 01/21/2025 and she was unable to pass any medications because she did not have access to residents' eMAR.

On 03/22/2025 at 1:43 PM an interview was conducted with LPN #14 who reported she worked a double shift from 6 AM to 10 PM on 01/21/2025 on the Second Floor and was assigned to RI #15's rooms for medication passes. LPN #14 reported that RN #15 was assigned to RI #30 and RI #308's medication passes. LPN #14 said the facility's internet stopped functioning around 2 PM on 01/21/2025. LPN #14 said

she was unable to access residents' eMAR. RN #15 said she did not administer medications or monitor resident blood glucose because the internet was down. LPN #14 said she did not know who needed their blood glucose checked off the top of her head, so she did not check.

On 03/25/2025 at 1:32 PM, a telephone interview was conducted with the Medical Director (MD) and RI #12, 308, 40 and 15's physician. Regarding RI #12's missed medications the MD said, the likelihood of harm was that resident's blood sugars could go up if a resident did not receive their scheduled insulin and their blood sugars were not monitored as ordered. The MD said other things that could result from a person not receiving their insulin and not having their blood sugars checked as ordered would be short term DKA (Diabetic Ketoacidosis) and being placed on an insulin drip if blood sugars were too high. Regarding RI #308's missed medications, the MD said there was a likelihood of reoccurrence of seizures if a resident did not receive their seizure medications as ordered. Regarding RI #40's missed medications, the MD said a person with a history of diabetes, hypertension and stroke, and congestive heart failure not receiving their scheduled medications as ordered could cause their blood sugars to go up, fluid retention, and reoccurrence of heart failure. Regarding RI #15's missed medications the MD was asked, what was likely to occur if a resident did not receive their insulin, blood pressure, and seizure medications as ordered. The MD said there could be a reoccurrence of seizures, elevated blood pressures, and a person's blood sugars could go up.

*******************************************************

On 03/26/2025, the facility submitted an acceptable removal plan, which documented:

******************************************************

1) Process: To ensure that in the event of a power/internet outage the most updated Medical Record Administration (MAR) will be available for nurses that provide care to the residents:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 46 015463 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 015463 B. Wing 03/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Knollwood Healthcare 3151-A Knollwood Drive Mobile, AL 36693

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 The medication administration Record (MAR) will be printed monthly by the Director of Nursing Assistant Director of Nursing or Unit Manager, by the 1st of each month. The paper MAR will be updated at the time Level of Harm - Immediate the order is received or confirmed for all current resident and new admits by the RN/LPN who receives the jeopardy to resident health or order or confirms the new order for any medication changes including all new orders for new admits. safety

The updated MAR will be located by the nursing stations. All, 100% of LPNs and RNs were in-serviced and Residents Affected - Many completed on March 26th, 2025. Inservice was to ensure nurses know where the paper MAR is located and to update it as soon as a new admission or whenever the physician changes an order in the MAR.

2) In services

On 3/20/2025 - 03/26/2025 the Director of Nursing and Assistant Director of Nursing began to educate all nurses, all physical therapy staff and administrative staff (receptionist, Admissions Coordinator, Staffing Coordinator and Human Resources) and provided the education with 1:1 in-service to LPN #14, RN #15, LPN #11, RN #20, and RN #16. The in-services included:

a) the policy titled Policy on Computer or Internet Downtime and EHR,

b) the standard of practice to:

i) administer medication,

ii) monitor blood glucose,

iii) the implementation of the prescribing physicians' orders

iv) the importance of documenting medication administration at the time of administration.

c) Inservice included calling the physician as well as notify the Director of Nursing or Designee if staff including nurses are unable to carry out a physician's order.

d) Inservice included how it led to neglect and the facility's Abuse Policy titled Abuse Policy.

The in-service was completed on March 26th, 2025 for 21 of 21 nurses, 9/9 PT staff, 16/16 of administrative staff.

On 3/26/2025, 21 of 21 of the nursing staff were all educated by the Director of Nursing or Assistant Director of Nursing and 1:1 in-service to LPN #14, RN #15, LPN #11, RN #20, and RN #16. The in-service included that a printed MAR will be ready for the 1st of each month. A copy of the paper MAR will be kept at each nurses' station for use during downtime. Education included that RNs and LPNs who receives an order or confirms a new order for any medication changes including all new orders for new admits will update the paper medication administration records at the time the order is received or confirmed for all current resident and new admits.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 46 015463 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 015463 B. Wing 03/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Knollwood Healthcare 3151-A Knollwood Drive Mobile, AL 36693

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 The Administrator educated the Director of Nursing and the Assistant Director of Nursing on 03/26/2025 that both of them are responsible to print the paper MAR to be ready for the 1st of each month and will be placed Level of Harm - Immediate by each of the nurse's station. A monthly MAR print out schedule was created for clarity. The education jeopardy to resident health or included that the DON and the ADON will confirm that an accurate MAR for all residents is printed and safety available for use in the event of a forecasted severe storm such as tropical depression, tropical storm, hurricane, or winter snow storm or other reason to expect downtime. Residents Affected - Many

A mock drill was conducted on 3/21/25 for the nursing personnel on shift.

2) Assessment

Due to the failure of functionality of the router which caused the internet outage in the facility, the facility replaced the router on January 30th, 2025 through its internet provider.

On 3/26/25 The entire Medical Record Administration was reprinted in the event of outage and nurses were all educated that any medication changes or new admissions will need to be updated in the paper medical administration records.

All residents that had the potential of being affected by this deficient practice from January 21st 2025 to January 22nd 2025. A report was generated from the electronic medical records to see which residents could have been affected during 1/21/25 - 1/22/25.

There was a total of 56 of 56 residents were assessed by the medical director and completed on March 26th, 2025. No adverse effects were identified by the physician due to this deficient practice and no recommendations were made.

2) Quality Assurance

An ad-hoc Quality Assurance meeting which included the entire IDT team ( Director of Nursing, Administrator, Rehab Director, Business Office Manager, Social Worker Director, Governing Body, Medical Director, Business Office Manager, Assistant Director of Nursing, Staffing Coordinator, Unit Manager, Dietary Director, Admissions Director) was conducted on March 25, 2025 in response to

F-F760 and on the Policy

on Computer or Internet Downtime and EHR access. The QA team discussed the needed in services/education for LPN #14, RN #15, LPN #11, RN #20, and RN #16.

This plan was completed on March 26th, 2025.

********************************************************

After review of the information provided in the facility's Removal Plan, in-service/education records, as well as staff interviews, and observations, the survey team determined the facility implemented the immediate corrective actions as of 03/26/2025.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 46 015463 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 015463 B. Wing 03/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Knollwood Healthcare 3151-A Knollwood Drive Mobile, AL 36693

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 34019

Residents Affected - Many Based on observations, interviews and a review of the facility policie's titled, DATING AND LABELING POLICY, ICE MACHINE SANITATION POLICY, And HAND WASHING POLICY. The facility failed to ensure:

1) food items in the freezer and cooler was labeled and dated;

2) the ice machine was free of a black substance;

3) a staff did not work on the dirty and clean side of the dish room without changing gloves and aprons.

This had the potential to affect 53 of 53 residents who received meals from the kitchen.

Finding Includes:

1) A review of a policy titled, DATING AND LABELING POLICY, with no date revealed: POLICY: All foods are to be labeled and dated appropriately to ensure food safety regulations are followed. PROCEDURE: . Once opened, the label must be updated with the current date and a use by date . (including date opened) .

On 03/18/2025 at 8:39 AM, an during the initial tour of a large clear bag of okra and about six chicken fingers

in a bag were observed in the freezer with no open or use by the date. Corn beef was observed in the cooler with no open or use by date.

On 03/20/2025 at 12:43 PM, an interview was conducted with the Food Service Director (FSD). The FSD stated that corn beef in the cooler did not have an open and a use by date on it. She stated that the chicken tenders and okra in the freezer did not have an open or use by date on it. She stated staff should label and date food items before putting them back in the freezer or cooler. She continued to say it should be labeled with an opened and use by date on the item. She stated that the food items should have the name of the item on it. On the label it should be the date, the name of the item, the opened date or prepared date, the use by date, and the initial of the person who put it in the freezer. The FSD stated that food should be labeled and dated to keep in within the time line of safe food. She stated that the person who opened the food was responsible for dating and labeling it. The FSD stated that food that was not dated and label could cause food borne illness. The FSD stated that food was supposed to be labeled and dated.

2) A review of a facility's policy titled, ICE MACHINE SANITATION POLICY, with no date revealed: POLICY: kitchen staff will wash, rinse and sanitize the ice making machine .

On 03/18/2025 at 8:39 AM, black substance was observed on the ice guard and lid on the inside of the ice machine in the kitchen.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 46 015463 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 015463 B. Wing 03/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Knollwood Healthcare 3151-A Knollwood Drive Mobile, AL 36693

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 On 03/20/2025 at 12:52 PM, an interview was conducted with the FSD. The FSD was asked what was on the lid and guard on the inside of the ice machine. She stated that it was dirty with debris. She was asked why Level of Harm - Minimal harm or was it there and she said the machine had not been serviced. The FSD said she was responsible for making potential for actual harm sure the ice machine was clean on the inside. The FSD stated that it was important that the ice machine was clean on the inside to make sure no bacteria or infection disease got into the ice that was served to the Residents Affected - Many residents. The FSD said the ice machine lid and guard was cleaned monthly.

3) A review of an undated facility policy titled, HAND WASHING POLICY . revealed: . When to Wash Hands .

Before and in between switching tasks.

On 03/20/2025 at 8:59 AM, during an observation in dishware washing in the kitchen, one staff taking dirty trays and plates out of a cart and another staff was at the dish machine rinsing dishes. Dietary Aide (DA) #23 was on the dirty side of the dish room wearing gloves and an apron. She was rinsing off dishes, washing plates, trays, and plates covers. Her apron was touching dirty trays. She pulled dish ware out of the dish machine on the clean side of the dish room without changing the dirty apron or gloves. She removed dish ware on the clean side from the dish machine with the same gloves she used on the dirty side of the dish room. She was touching clean dishes, cups, plate covers, trays. She did not change her gloves or apron when she moved from the dirty side to the clean side to put clean items up. She was working both sides of

the dish room. At the same time, DA #24 was observed not wearing gloves. He was on the dirty side washing out glasses to be placed in the dish machine. He left the dirty side with the same apron on and began putting up dishes on the clean side. DA #24 carried plate covers and plates out of the clean side of

the dish room. The clean dishes were touching his apron as he put up the dishes.

On 03/20/2025 at 9:12 AM, an interview was conducted with DA #23 who said she did she use the same gloves on the dirty and clean side of the dish room. She was asked why did she use the same gloves on the dirty side and clean side of the dish room. She stated she was a new employee. She stated that she worked both side of the dish room when someone was out. DA #23 said she did not change her apron from the dirty side to the clean side of the dish room. DA #23 stated that when she finished washing the dishes she should have changed her gloves. DA #23 was asked why should kitchen staff not work on the clean and dirty side of

the dish room with the same gloves and apron. DA #23 stated because of cross-contamination

03/20/2025 at 12:31 PM, an interview was conducted with DA #24 who said he did not change his apron

before went to the clean side after he rinsed out dishes on the dirty side. DA #24 stated he did not change

the apron because he was so busy he did not think about it.

On 03/20/2025 at 12:52 PM, an interview was conducted with the FSD. The FSD was asked why did the dietary aide work on the clean side and dirty side of the dish room. The FSD stated the person on the dirty side work both side because the new people were slow. The FSD said she was responsible for training kitchen staff on infection control in the kitchen. The FSD said it was cross-contamination when staff was worked on the clean and dirty side of the dish room with the same gloves and apron. The FSD said residents could get sick from the cross-contamination.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 46 015463 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 015463 B. Wing 03/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Knollwood Healthcare 3151-A Knollwood Drive Mobile, AL 36693

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Level of Harm - Minimal harm or potential for actual harm 47408

Residents Affected - Few Based on interviews, record review, review of facility policies titled Abuse Policy and Quality Assurance Performance Improvement Process, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee reviewed and analyzed an allegation of abuse in a manner to determine causes and implement appropriate corrective actions to prevent recurrence.

The committee failed to identify concerns with reporting and investigation for an allegation of abuse reported to the State Agency (SA) on 01/30/2025.

This deficient practice affected RI #15, one of 18 sampled residents.

This deficiency was cited as a result of the investigation of complaint/report number AL00050214.

Findings include:

Cross-reference

F-F943.

The facility's policy titled Abuse Policy, updated 8-2022 documented: . Response:

The facility ensures that any incidents of substantiated abuse are reported and analyzed and the appropriate corrective, remedial or disciplinary action occurs, in accordance with applicable local state or federal law .

7. When an incident of resident abuse of resident abuse is suspected or confirmed, the incident must be immediately reported to facility management regardless of the time lapse since the incident occurred.

Cause Identification.

1. The staff with the physicians input (as needed) will investigate alleged occurrence of abuse . to clarify what happened and identify the possible causes.

The facility policy titled Quality Assurance and Process Improvement (QAPI) Committee updated 08/04/2022 documented: Purpose: The QAPI committee will monitor systematic, comprehensive, data driven, proactive approach to performance management and improvement that focuses on indicators of the outcome of care and quality of life.

1. The QAPI oversees the quality and effectiveness of living center operations and systems to meet the needs of the customers; to monitor and analyze facility key performances indicators .

10. The QAA Committee to determine if . abuse allegations are:

Thoroughly investigated.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 46 015463 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 015463 B. Wing 03/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Knollwood Healthcare 3151-A Knollwood Drive Mobile, AL 36693

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 Whether the resident is protected.

Level of Harm - Minimal harm or Whether an analysis was conducted as to why the situation occurred . potential for actual harm

The facility Quality Assurance and Performance Improvement (QAPI) Meeting for 02/21/2025, documented Residents Affected - Few the facility reviewed a Reportable Incidents for RI #15 who was verbally abused by a CNA. The QAPI documentation indicated that investigations were started, abuse in-services were conducted, the resident was fine, and the CNA was terminated.

The QAPI committee failed to identify and develop an action plan for the late reporting of the FRI which was not reported to the SA within the two-hour time frame for abuse. The QAPI committed failed to identify and develop an action plan for failure to conduct a thorough investigation and root cause analysis. The QAPI committee failed to identify all contributing factors of the verbal abuse against RI #15 including the CNA stating that she was tired and frustrated after working a double shift the previous day. The QAPI committee failed to identify any contributing factors associated with staff who may be burned out, tired, or frustrated

after working double shifts.

On 03/21/2025 at 5:38 PM the ADM was asked about QAPI and root cause analysis, the ADM said, root cause analysis was not done for the incident of staff on resident verbal abuse involving RI #15. When asked about the QAPI committee review and action plan, the ADM said, he did not know they were to write out a plan.

During an interview with ADM on 03/22/2025 at 2:17 PM he stated, they reviewed the incident and investigation in Quality Assurance and Performance Improvement (QAPI) and felt like they handled it appropriately. According to QAPI meeting conducted 02/21/2025: Resident is fine. Abuse In-services conducted. CNA has been terminated .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 46 015463