Knollwood Nursing Center

MI Elder Abuse Free Legal ConsultationDid someone you love suffer elder abuse or neglect at Knollwood Nursing Center ? Our lawyers can help.

Abuse of the elderly is not acceptable and we fight hard in these types of cases. If you suspect a nursing home or caregiver has caused harm to your loved one in someone elses’ care, contact our law firm today for a free legal consultation.

Talking to us does not obligate you to anything, but we may be able to tell you if you have a claim and the value of your case. If we accept your case, you pay no fee unless we recover for you.

About Knollwood Nursing Center

Knollwood Nursing Center is a non-profit, 82-bed Medicare/Medicaid certified skilled nursing facility that provides services to the residents of Shrewsbury, Holden, Northborough, Clinton, Leicester, Millbury, Westborough, Grafton, Marlborough, and the other towns in and surrounding Worcester County, Massachusetts.

Knollwood Nursing Center
1225, 87 Briarwood Cir,
Worcester, MA 01606

Phone: 508-853-6910
Website: http://www.knollwoodnursingcenter.com/

CMS Star Quality Rating

The Centers for Medicare and Medicaid (CMS) rates all nursing homes that accept medicare or medicaid benefits. CMS created a 5 Star Quality Rating System—1 star is the lowest rating and 5 stars is the highest—that look at three areas.

As of 2018, Knollwood Nursing Center in Worcester, Massachusetts received a rating of 5 out of 5 stars.

Performance Area Rating
Overall Rating 5 out of 5 (Much Above Average)
State Health Inspections 4 out of 5 (Above Average)
Staffing 5 out of 5 (Much Above Average)
Quality Measures 5 out of 5 (Much Above Average)

Fines and Penalties

Our Nursing Home Accident Lawyers inspected government records and discovered Knollwood Nursing Center committed the following offenses:

Failed to immediately tell the resident, the resident's doctor and a family member of the resident of situations (injury/decline/room, etc.) that affect the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility staff failed to inform the Physician regarding a change in the time of medication administration on the days of [MEDICAL TREATMENT] treatments for one resident (#11) in a total sample of 15 residents.

Findings include:

Review of the Medication Administration Policy, date effective 12/1/99, indicated the following; Medications are administered in accordance with the written orders of the attending Physician. Resident #11 was admitted to the facility in 2/2017 with [DIAGNOSES REDACTED]. Review of the 2/2017 physician’s orders [REDACTED]., with pick up 5:30 A.M. Review of the 2/2017 physician’s orders [REDACTED].

-[MEDICATION NAME] 40 milligrams (mg.) (to control blood pressure (BP)) by oral route daily at 8:00 A.M.
-[MEDICATION NAME] 50 mg. (to control BP) by oral route daily at 8:00 A.M.
-[MEDICATION NAME] 10 mg. (to control BP) by oral route daily at 8:00 A.M.
-Renevla 2400 mg. (to lower blood phosphorous levels) by oral route 3 times a day at 8:00 A.M., 12:00 P.M. and 5:00 P.M.
-[MEDICATION NAME] 75 mg. (blood thinner) by oral route daily at 8:00 A.M.
-[MEDICATION NAME] 120 mg. (to treat depression) by oral route daily at 8:00 A.M.
-[MEDICATION NAME] 10 mg. (to treat heart burn) by oral route daily at 8:00 A.M.
-[MEDICATION NAME] Mix 70/30 100 units/milliliter solution (insulin),inject 4 units by subcutaneous (sc) route every 12 hours at 8:00 A.M. and 8:00 P.M. (On 2/15/17 at 1:02 P.M., the Physician increased the insulin dosage to 5 units).
-Senna 17.2 mg. (laxative) by oral route 2 times a day at 8:00 A.M. and 4:00 P.M.
-[MEDICATION NAME] 1 mg. (antipsychotic medication) by oral route daily at 8:00 A.M. (on 2/17/17 at 4:11 P.M., the Physician decreased the dose to .5 mg).

Review of the 2/2017 Medication Administration Record [REDACTED].M. on the days the resident was out of the facility at 5:30 A.M. for [MEDICAL TREATMENT] (2/15/17, 2/17/17, 2/20/17, 2/22/17 and 2/24/17), except for 8:00 A.M. insulin, which was not administered. During an interview on 2/23/17 at 3:10 P.M., Resident #11 said he/she went to [MEDICAL TREATMENT] 3 times a week, left the facility around 5:30-6:00 A.M. and returned around 10:45-11:00 A.M. He/she said some medications were given before he/she left and some when he/she came back.

During an interview on 2/23/17 at 3:15 P.M., Unit Manager (UM) #2 said the patient received medications before he/she left for [MEDICAL TREATMENT]. During an interview on 2/24/17 at 7:30 A.M., UM #2 said she did not know if the Physician was aware the medications ordered for 8:00 A.M. were being administered at a different time, or not administered at all, on the days the resident left the facility for [MEDICAL TREATMENT] treatments.

During an interview on 2/24/17 at 10:00 A.M., UM #2 said she had notified the Physician (during survey) about the concern with administration times on [MEDICAL TREATMENT] days. The medication administration times were changed from 8:00 A.M. to 11:00 A.M. on [MEDICAL TREATMENT] treatment days.

Failed to provide care by qualified persons according to each resident's written plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility staff failed to follow Physician orders [REDACTED].#2, #4, #8 and #10) residents in a total sample of 15 residents.

Findings include:

1. For Resident #2, the facility staff failed to ensure a Wanderguard was affixed to a walker per a physician’s orders [REDACTED].>Resident #2 was admitted to the facility in 8/2016 with [DIAGNOSES REDACTED]. Review of a physician’s orders [REDACTED]. During an observation on 2/22/17 at 11:00 A.M., the resident was observed in his/her room lying on top of the bed. A walker was at the bedside, but no Wanderguard was observed affixed to the walker. During an interview on 2/22/17 at 11:10 A.M. with Unit Manager (UM) #1 and the Rehabilitation Director, they said there was no Wanderguard on the walker. The Rehabilitation Director said they had been working with the resident yesterday, and had left the Wanderguard on a different walker.

2. For Resident #10, the facility staff failed to follow the plan of care for fall prevention. Resident #10 was admitted to the facility in 7/2016 with [DIAGNOSES REDACTED]. Review of the care plan for fall prevention, entered 7/5/16, indicated the resident was at risk for injury related to falls and [MEDICAL CONDITION] drug use. An intervention, entered 9/5/16, was for a bed pad alarm. Review of an Incident/Accident Report, dated 9/11/16, indicated the resident was heard calling for help and was found on the floor next to the bed. Review of a witness statement signed by Certified Nurses’ Aide (CNA) #1 on 9/12/16, said that the resident was put back to bed and the bed pad alarm had not been attached to the resident. During an interview with the Director of Nurses on 2/23/17 at 12:15 A.M., she said CNA appeared to have forgotten to attach the bed pad alarm.

3. For Resident #4, the facility staff failed to correctly implement the use of alarms as care planned for two falls. Resident #4 was admitted to the facility in 8/2014 with [DIAGNOSES REDACTED]. Review of the resident’s Fall Care Plan, date effective 8/13/14, indicated the following interventions:
-Alarms: tab alarm at all times.
-Hipsavers at all times (effective 9/16/14).
-Bed pad alarm (effective 9/23/14).
-Alarmed Velcro belt to wheelchair (effective 1/7/16).

Review of the Incident/Accident Report, dated 1/4/16, indicated the resident had an unwitnessed fall in the bedroom at 1:50 P.M. The report indicated the alarm was on but not ringing. The new intervention added was an alarmed Velcro seatbelt to the wheelchair. Review of the Incident/Accident Report, dated 3/26/16, indicated the resident had an unwitnessed fall in another resident’s bedroom at 11:50 A.M. The report indicated the alarm was not ringing. The new intervention added was to maintain 15 minute checks and add a clip alarm until Velcro belt was evaluated by maintenance and functioning properly. During an interview on 2/23/17 at 8:35 A.M., The Director of Nurses (DON) said the alarms were part of the plan of care to help prevent falls and was unsure why they were not sounding at the time of the resident’s two falls.

4. For Resident #8, the facility staff failed to ensure the plan of care was followed for safe transfers. Resident #8 was readmitted to the facility in 6/2013 with [DIAGNOSES REDACTED]. Review of the resident’s Fall Care Plan, date effective 6/3/14, indicated the following interventions:

-Ambulate with 2 assist and gait belt.
-Out of bed to wheelchair with 2 assist-wheelchair with assist.

Review of the Incident/Accident Report, dated 8/2/16, indicated the resident had a witnessed fall in the bedroom at 8:30 A.M. The report indicated the CNA was transferring the resident from bed to the wheelchair and did not get a second person to assist, nor was a gait belt used. The new intervention was to provide employee counseling. During an interview on 2/23/17 at 8:30 A.M., the DON said the CNA transferred the resident without assistance or a gait belt as care planned. She said the fall care plan interventions were not followed and the employee had received counseling.

Failed to provide necessary care and services to maintain the highest well being of each resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility staff failed to provide the necessary care and services to maintain the highest practicable physical well-being relative to [MEDICAL TREATMENT] management for 1 resident (#11) in a total sample of 15 residents.

Findings include:

For Resident #11, the facility staff failed to manage medication administration on the days of [MEDICAL TREATMENT] treatment. Resident #11 was admitted to the facility in 2/2017 with [DIAGNOSES REDACTED]. Review of the 2/2017 physician’s orders [REDACTED]., with pick up at 5:30 A.M. Review of the 2/2017 physician’s orders [REDACTED].
-[MEDICATION NAME] 40 milligrams (mg.) (to control blood pressure (BP)) by oral route daily at 8:00 A.M.
-[MEDICATION NAME] 50 mg. (to control BP) by oral route daily at 8:00 A.M.
-[MEDICATION NAME] 10 mg. (to control BP) by oral route daily at 8:00 A.M.
-Renevla 2400 mg. (to lower blood phosphorous levels) by oral route 3 times a day at 8:00 A.M., 12:00 P.M. and 5:00 P.M.
-[MEDICATION NAME] 75 mg. (blood thinner) by oral route daily at 8:00 A.M.
-[MEDICATION NAME] 120 mg. (to treat depression) by oral route daily at 8:00 A.M.
-[MEDICATION NAME] 10 mg. (to treat heart burn) by oral route daily at 8:00 A.M.
-[MEDICATION NAME] Mix 70/30 100 units/milliliter solution (insulin), inject 4 units by subcutaneous (sc) route every 12 hours at 8:00 A.M. and 8:00 P.M. (On 2/15/17 at 1:02 P.M., the Physician increased the insulin dosage to 5 units).
-Senna 17.2 mg. (laxative) by oral route 2 times a day at 8:00 A.M. and 4:00 P.M.
-[MEDICATION NAME] 1 mg. (antipsychotic medication) by oral route daily at 8:00 A.M. (on 2/17/17 at 4:11 P.M., the Physician decreased the dose to .5 mg). Review of the 2/2017 Medication Administration Record [REDACTED].M. on the days the resident was out of the facility at [MEDICAL TREATMENT] at 6:30 A.M. (2/15/17, 2/17/17, 2/20/17, 2/22/17 and 2/24/17) except for the 8:00 A.M. insulin which was not administered on 2/15/17.

During an interview on 2/23/17 at 3:10 P.M., Resident #11 said he/she went to [MEDICAL TREATMENT] 3 times a week, left the facility around 5:30-6:00 A.M. and returned around 10:45-11:00 A.M. He/she said some medications were given before he/she left and some when he/she came back. During an interview on 2/23/17 at 3:15 P.M., Unit Manager (UM) #2 said the resident had medications administered before he/she left for [MEDICAL TREATMENT]. During an interview on 2/24/17 at 7:20 A.M., the Director of Nurses said she was unsure if the resident’s 8:00 A.M. medications were held on the days he/she went for [MEDICAL TREATMENT] treatments.

During an interview on 2/24/17 at 7:30 A.M., UM #2 said she was unsure if the resident’s 8:00 A.M. medications were held on the days of [MEDICAL TREATMENT] treatments. When reviewing the MAR for 2/22/17, she said the medications ordered for 8:00 A.M., were administered after the resident returned from [MEDICAL TREATMENT] (after 10:30 A.M.). During an interview on 2/24/17 at 10:00 A.M., UM #2 said the medication administration times were changed from 8:00 A.M. to 11:00 A.M. (during survey) on the days of [MEDICAL TREATMENT] treatments.

Failed to make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility staff failed to maintain adequate supervision and assistive devices to prevent accidents for 4 residents (#4, #8 #10 and #12) of 9 applicable residents with falls, in a total sample of 15 residents.

Findings include:

Review of the Fall Prevention Policy, date effective 6/21/05, indicated the following;

-Maintain a safe environment in order to reduce the risk of fall and injuries related to falls.
-Enable staff to recognize those residents who have an established history of falls and are at increased risk.

1. For Resident #4, the facility staff failed to correctly implement the use of alarms for two falls. Resident #4 was admitted to the facility in 8/2014 with [DIAGNOSES REDACTED].

Review of the 10/15/15 Fall Risk Assessment indicated the resident was high risk for falls. Review of the resident’s Fall Care Plan, date effective 8/13/14, indicated the following interventions:
-Alarms: tab alarm at all times. -Hipsavers at all times (effective 9/16/14).
-Bed pad alarm (effective 9/23/14).
-Alarmed Velcro belt to wheelchair (effective 1/7/16).

Review of the Incident/Accident Report, dated 1/4/16, indicated the resident had an unwitnessed fall in the bedroom at 1:50 P.M. and was uninjured. The report indicated the resident was found lying on the floor near the bed. The report indicated the alarm was on but not ringing. The new intervention added was an alarmed Velcro seatbelt to the wheelchair. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 1/7/16, indicated the resident had severe cognitive impairment as evidenced by a score of 6 out of 15 on the Brief Interview for Mental Status (BIMS), required extensive assistance with bed mobility, transfers, ambulation, dressing, toileting, hygiene and bathing, and had two or more falls without injury.

Review of the Fall Risk Assessment, dated 1/7/16, indicated the resident was a high fall risk. Review of the Incident/Accident Report, dated 3/26/16, indicated the resident had an unwitnessed fall in another resident’s bedroom at 11:50 A.M. The resident was uninjured. The report indicated the alarm was not ringing. The new intervention added was to maintain 15 minute checks and add a clip alarm until Velcro belt was evaluated by maintenance and functioning properly. Review of the Annual MDS Assessment, dated 6/23/16, indicated the resident had severe cognitive impairment as evidenced by a score of 6 out of 15 on the BIMS, required extensive assistance with bed mobility, transfers, ambulation, dressing, toileting, hygiene and bathing, and had no falls. On 2/22/17 at 2:00 P.M., the resident was observed sitting in a wheelchair, dressed and alert. The resident was able to release the alarmed seat belt when requested by a staff member. The resident requested to lie down on the couch in the dayroom and staff assisted him/her to the couch. An alarm was placed when the resident was on the couch. During an interview on 2/23/17 at 8:35 A.M., The Director of Nurses (DON) said she was unsure why the alarms did not sound during the two falls.

2. For Resident #8, the facility staff failed to ensure the plan of care was followed for transfers. Resident #8 was readmitted to the facility in 6/2013 with [DIAGNOSES REDACTED]. Review of the resident’s Fall Care Plan, date effective 6/3/14, indicated the following interventions:
-Ambulate with 2 assist and gait belt.
-Out of bed to wheelchair with 2 assist-wheelchair with assist.

Review of the Annual MDS Assessment, dated 3/29/16, indicated the resident had moderate cognitive impairment as evidenced by a score of 9 out of 15 on the BIMS, required extensive assist of 2 for bed mobility, transfers, ambulation and toileting and had no falls.

Review of the Fall Risk Assessment, dated 6/16/16, indicated the resident was a high fall risk. Review of the Incident/Accident Report, dated 8/2/16, indicated the resident had a witnessed fall in the bedroom at 8:30 A.M. The resident was uninjured except for a red mark to the forehead. The report indicated the Certified Nursing Assistant (CNA) was transferring the resident from bed to the wheelchair and did not get a second person to assist, nor use a gait bet. The new intervention was to provide employee counseling. On 2/22/17 at 7:45 A.M., the resident was observed sitting in a highback wheelchair in his/her room with feet on the foot rests. During an interview on 2/23/17 at 8:30 A.M., the DON said the CNA transferred the resident without assistance or a gait belt as care planned.

3. For Resident #12, the facility staff failed to provide adequate supervision when fall interventions, an alarm, had been disengaged for care, for 1 of 4 falls. Resident #12 was admitted to the facility in 10/2014 with [DIAGNOSES REDACTED]. Review of the resident’s Fall Care Plan, date effective 10/28/14, indicated the following interventions; -Alarms: Tab alarm, bed pad alarm. -Keep call light in reach at all times. Review of the Annual MDS Assessment, dated 8/18/16, indicated the resident had severe cognitive impairment as evidenced by a score of 0 out of 15 on the BIMS, required extensive assistance with bed mobility, transfers, ambulation, dressing, toileting, hygiene and bathing and had no falls. Review of the clinical record indicated the resident sustained [REDACTED]. Review of the Incident/Accident Report, dated 9/21/16, indicated the resident had an unwitnessed fall in the bathroom at 10:15 P.M. The resident was uninjured. The report indicated the resident was found on the bathroom floor. The report did not indicate whether the call bell was within, or not within, the resident’s reach, however the report indicated the call bell was not on. Further review of the report indicated the CNA left the resident in the bathroom to attend to another resident. On 2/23/17 at 10:50 A.M., the resident was observed lying in bed, the head of the bed was slightly elevated and left side of the bed was against the wall. There was an alarm in place and a fall mat on the floor to the right side of the bed. During an interview on 2/24/17 at 7:40 A.M., Unit Manager (UM) #2 said the CNA toileted the resident and left him/her in the bathroom alone to attend to another resident. UM #2 said the CNA had taken off the tab alarm before toileting the resident. The resident attempted to get off the toilet and fell before the nurse could get to the bathroom.

4. For Resident #10, the facility staff failed implement fall prevention interventions identified to prevent injury. Resident #10 was admitted to the facility in 7/2016 with [DIAGNOSES REDACTED]. Review of the care plan for fall prevention, entered 7/5/16, indicated the resident was at risk for injury related to falls and psychotropic drug use. An intervention, entered 7/7/16, was for a bed pad alarm. Review of an Incident/Accident Report, dated 9/11/16, indicated the resident was heard calling for help and was found on the floor next to the bed. Review of a witness statement signed by Certified Nurses’ Aide (CNA) #1 on 9/12/16, said that the resident was put back to bed and the bed pad alarm had not been attached to the resident. Review of the Significant Change in Status MDS Assessment, dated 11/25/16, indicated the resident had severe cognitive impairment as evidenced by a BIMS score of 3 of 15, did not ambulate, required extensive assistance with toileting and had one fall with no injury. During an interview with the DON on 2/23/17 at 12:15 A.M., she said CNA #1 appeared to have forgotten to attach the bed pad alarm.

Failed to keep accurate, complete and organized clinical records on each resident that meet professional standards

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility staff failed to maintain a complete and accurate clinical record for 1 (#2) resident in a total sample of 15 residents.

Findings include:

1. For Resident #2, the facility staff failed ensure a Treatment Administration Record (TAR) accurately reflected the implementation of a physician’s orders [REDACTED].>Resident #2 was admitted to the facility in 8/2016 with [DIAGNOSES REDACTED]. Review of a physician’s orders [REDACTED].

During an observation on 2/22/17 at 11:00 A.M. the resident was observed in his/her room lying on top of the bed. A walker was at the bedside, but no Wanderguard was observed. During an interview on 2/22/17 at 11:10 A.M. with Unit Manager (UM) #1 and the Rehabilitation Director, they said there was no Wanderguard on the walker. The Rehabilitation Director said they had worked with the resident yesterday, and the Wanderguard was left on a different walker. Review of the 2/2017 TAR indicated the Wanderguard was observed by a nurse to be in place as ordered on [DATE] on the 11:00 P.M. to 7:00 A.M. shift, and on 2/22/17 on the 7:00 A.M. to 3:00 P.M. shift. During an interview with Unit Manager #1 on 2/22/17 at 11:10 A.M., she said the Wanderguard should not have been documented as being in place on the above shifts because it wasn’t on the walker as ordered.

Knollwood Nursing Center, Nursing Home Neglect and Elder Abuse Lawyers

If someone you love has suffered neglect or elder abuse by a senior caregiver, nursing home, or other care facility, our lawyers may be able to help. Regardless of whether or not criminal charges are filed against an alleged abuser, you may still be able to pursue compensation in a civil claim. Compensation in elder abuse cases may be awarded if someone in the care of another suffers harm due to intentional or negligent actions (including failure to take action).

Abuse of the elderly is not acceptable and we fight hard in these types of cases. If you suspect a nursing home or caregiver has caused harm to your loved one in someone elses’ care, contact our law firm today for a free legal consultation. Talking to us does not obligate you to anything, but we may be able to tell you if you have a claim and the value of your case. If we accept your case, you pay no fee unless we recover for you.

Oftentimes, victims of abuse either cannot or will not speak up for themselves out of fear. If you notice any warning signs or symptoms of neglect of abuse an an elderly person, it is important you contact an elder abuse lawyer immediately. Not only are there statute of limitations on filing a claim, but the sooner we start helping you, the easier it will be to collect evidence and talk to any witnesses before important details are lost, hidden, or forgotten.

Boston Personal Injury Lawyers for Elder Abuse Cases

We offer a free, no-obligation legal consultation to help you understand your rights and the value of your case. Our personal injury law firm takes cases involving elder abuse and neglect. We offer legal service to clients in Massachusetts, Rhode Island and New Hampshire.


Sources:

Medicare Nursing Home Profiles and Reports – Knollwood Nursing Center

Inspection Report for Knollwood Nursing Center – 02/24/2017

Page Last Updated: April 9, 2018

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