Deficiency Records for Knolls West Post Acute LLC

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Updated as of March 01, 2024

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?
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
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2021-09-13 2021-09-30 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2021-08-30 2021-09-10 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
Develop Emergency Preparedness policies and procedures. Fire Safety 2018-05-17 2018-06-05 N
Develop a communication plan. Fire Safety 2018-05-17 2018-06-05 N
Establish emergency prep training and testing. Fire Safety 2018-05-17 2018-06-05 N
Use approved construction type or materials. Fire Safety 2018-05-17 2018-06-05 N
Have properly located and lighted "Exit" signs. Fire Safety 2018-05-17 2018-06-05 N
Provide properly protected cooking facilities. Fire Safety 2018-05-17 2018-06-05 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2018-05-17 2018-06-05 N
Install corridor and hallway doors that block smoke. Fire Safety 2018-05-17 2018-06-05 N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2018-05-17 2018-06-05 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2018-05-17 2018-06-05 N
Have simulated fire drills held at unexpected times. Fire Safety 2018-05-17 2018-06-05 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2018-05-17 2018-06-05 N
Ensure proper usage of power strips and extension cords. Fire Safety 2018-05-17 2018-06-05 N
Have proper medical gas storage and administration areas. Fire Safety 2018-05-17 2018-06-05 N
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2018-03-29 2018-04-24 N
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Health 2018-03-29 2018-04-24 N
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Health 2018-03-29 2018-04-24 N
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Health 2018-03-29 2018-04-24 N
Ensure services provided by the nursing facility meet professional standards of quality. Health 2018-03-29 2018-04-24 N
Ensure each resident?s drug regimen must be free from unnecessary drugs. Health 2018-03-29 2018-04-24 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 2018-03-29 2018-04-24 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2018-03-29 2018-04-24 N