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Complaint Investigation

Knollwood Healthcare

Inspection Date: September 11, 2025
Total Violations 6
Facility ID 015463
Location MOBILE, AL
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Inspection Findings

F-Tag F0577

Resident Rights Deficiencies
Harm Level: Potential for Minimal Harm

Federal health inspectors cited KNOLLWOOD HEALTHCARE in MOBILE, AL for a deficiency under regulatory tag F-F0577 during a standard health inspection conducted on 2025-09-11.

Category: Resident Rights Deficiencies

The facility was found deficient in the following area: Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

Scope/Severity Level C: pattern, no actual harm with potential for minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 6 deficiencies cited during this inspection of KNOLLWOOD HEALTHCARE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-30.

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F-Tag F0689

Quality of Life and Care Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Registered Nurse Practitioner (CRNP) was questioned regarding the incident involving RI #20. The CRNP indicated she first became aware of the incident concerning RI #20 on 09/09/2025 when she received a call reporting bruising, swelling, and an x-ray revealed a fracture. The CRNP said she wrote an order for RI #20 to be sent out for an evaluation. The CRNP stated she had not been informed on 09/05/2025 about any swelling or pain related to RI #20. The CRNP said, if a resident had reported on 09/05/2025 that someone had run over their foot with a wheelchair and swelling was observed she would expect the facility to conduct

an x-ray and inform her of the results. On 09/11/2025 at 10:00 AM the DON was asked when she became aware of RI #20's injury. The DON said, the morning of 09/09/2025, the x-ray was done at the facility at 10:00 until 10:40 AM; the results were reported at 1:30 showing a broken tibia; and she informed the doctor.

The DON said, RI #20 told them someone ran over his/her foot with a wheelchair. The DON said, during the facility investigation CNA #5 reported RI #20's leg was swollen on 09/05/2025.This citation was written as a result of Incident #2612850.

Event ID:

Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/11/2025

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)

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F-Tag F0695

Quality of Life and Care Deficiencies
Harm Level: Potential for More Than Minimal Harm

Federal health inspectors cited KNOLLWOOD HEALTHCARE in MOBILE, AL for a deficiency under regulatory tag F-F0695 during a standard health inspection conducted on 2025-09-11.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide safe and appropriate respiratory care for a resident when needed.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 6 deficiencies cited during this inspection of KNOLLWOOD HEALTHCARE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-30.

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F-Tag F0697

Quality of Life and Care Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

pain level before giving the pain medication LPN #6 indicated that she could not remember if such documentation had been made prior to the medication's administration. LPN #6 said, she believed that the pain level was no greater than three otherwise she would have contacted the medical doctor. LPN #6 said,

she could have documented in a progress note but if it was not in the record, she did not document an assessment. LPN #6 said, she did not see the need to document the assessment because she thought RI #20 was fine after receiving the acetaminophen. On 09/11/2025 at 4:51 PM the Certified Registered Nurse Practitioner (CRNP) was questioned regarding RI #20 receiving PRN pain medication. The CRNP stated, when PRN pain medication was administered the nurse should evaluate the pain level using a scale from 1 to 10, and then reassess the pain after 30 minutes of medication administration. The CRNP indicated she would expect the nurse to record the pain level. The CRNP said it would be important to determine the pain level to see if the medication was working and if further assessment was needed.On 09/11/2025 at 5:20 PM an interview was conducted with the Director of Nursing (DON). During the interview the DON was asked whether the nurse had performed a pain assessment before administering RI #20 pain medication

on 09/03/2025. The DON stated there was not any documentation in the medical record confirming that a pain assessment had been conducted. Furthermore, the DON stated the LPN should have been aware of

the necessity to carry out the pain assessment prior to administering the pain medication. The DON said

the significance of performing a pain assessment before the administration of pain medication was to evaluate its effectiveness and to ascertain whether the pain was a new occurrence or a chronic issue.

Additionally, the DON said, RI #20 was prescribed pain medication due to a history of surgeries on the right knee, right ankle, and right hip. When questioned about how nurses would assess pain in residents with dementia, she explained that the assessment would encompass observations of breathing patterns, negative vocalizations, facial expressions, body language, and the ability to be consoled. This citation was written as a result of Incident #2612850.

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Facility ID:

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F-Tag F0812

Nutrition and Dietary Deficiencies
Harm Level: Potential for More Than Minimal Harm

Federal health inspectors cited KNOLLWOOD HEALTHCARE in MOBILE, AL for a deficiency under regulatory tag F-F0812 during a standard health inspection conducted on 2025-09-11.

Category: Nutrition and Dietary Deficiencies

The facility was found deficient in the following area: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 6 deficiencies cited during this inspection of KNOLLWOOD HEALTHCARE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-30.

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F-Tag F0814

Nutrition and Dietary Deficiencies
Harm Level: Potential for More Than Minimal Harm

Federal health inspectors cited KNOLLWOOD HEALTHCARE in MOBILE, AL for a deficiency under regulatory tag F-F0814 during a standard health inspection conducted on 2025-09-11.

Category: Nutrition and Dietary Deficiencies

The facility was found deficient in the following area: Dispose of garbage and refuse properly.

Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 6 deficiencies cited during this inspection of KNOLLWOOD HEALTHCARE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-30.

📋 Inspection Summary

KNOLLWOOD HEALTHCARE in MOBILE, AL inspection on recent inspection.

Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.

What this means: Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. All deficiencies must be corrected within required timeframes and are subject to follow-up verification.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in MOBILE, AL, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from KNOLLWOOD HEALTHCARE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.
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