Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Knollwood Hsc during CMS and state inspections, most recent first.
A resident with multiple risk factors and on high fall risk medications experienced three unwitnessed falls in one month, including one with injury, due to inadequate monitoring and lack of documented rounding by staff. Despite facility policy requiring regular documented rounds and medication review, staff did not maintain written logs or adjust medications after the initial fall, resulting in continued risk and harm.
Facility staff did not follow policy requiring removal of a CNA from resident care during an abuse investigation. A resident with multiple medical and psychiatric conditions reported that a CNA was verbally rough and handled her belongings harshly. Despite the ongoing investigation, the CNA continued to work and provide care to the resident, contrary to facility policy.
A resident with multiple chronic conditions was discharged to assisted living without a required physician discharge summary, which should have included a recapitulation of the stay, final status, and medication reconciliation. Nursing and social work notes documented the discharge process, but the physician's summary was missing from the medical record.
Facility staff did not update care plan interventions for a resident with a history of aggressive behaviors after two separate incidents of aggression toward another resident. Despite documented behavioral issues and psychiatric involvement, the care plan lacked new approaches to prevent further inappropriate contact, and the DON acknowledged that updates should have been made after each event.
A resident with multiple diagnoses was incorrectly administered Lorazepam due to a transcription error by an RN, who failed to mark the medication as PRN in the electronic record. This resulted in the resident receiving the medication routinely without signs of agitation or restlessness.
Failure to Monitor and Document Supervision for High Fall Risk Resident
Penalty
Summary
Facility staff failed to adequately monitor and supervise a resident identified as high fall risk, resulting in three unwitnessed falls within a single month. The resident had multiple diagnoses, including osteoarthritis, psychotic disorder, syncope, muscle weakness, and a history of falls, and was prescribed several high fall risk medications such as Ambien, Eliquis, Depakote, and Clonazepam. Despite these risk factors, there was no documented evidence that staff maintained a written log of regular monitoring or rounding as required by facility policy, nor were medication regimens reviewed or adjusted after the initial fall. The facility's policies required a fall risk assessment on admission and at least quarterly, with additional assessments after any fall, and mandated regular rounding with documentation of date, time, staff, and observations. However, staff interviews revealed that while CNAs and nurses claimed to round on the resident every one to two hours, there was no documentation in the electronic health record or written logs to verify these rounds. The lack of documentation persisted across all three falls, and staff acknowledged that there was no system in place for CNAs to record their rounds, contrary to policy requirements. After each fall, assessments indicated the resident remained at high risk, but no changes were made to the medication regimen until after the second fall. The third fall resulted in a significant injury, with the resident sustaining fractures to the right ankle. Throughout these incidents, the facility did not provide evidence of consistent monitoring or timely response as outlined in their own procedures, nor did they document interdisciplinary team actions to address the resident's ongoing fall risk.
Failure to Remove Alleged Abuser from Resident Care During Abuse Investigation
Penalty
Summary
Facility staff failed to implement their written policies and procedures for investigating incidents of abuse for one of eight sampled residents. According to the facility's policy, when an abuse allegation is made, the alleged abuser must be removed from resident care pending the investigation. However, documentation and staff interviews revealed that the certified nurse assistant (CNA) accused of being verbally rough with a resident continued to work and provide care to the resident during the investigation period. The incident involved a resident with multiple diagnoses, including chronic diastolic congestive heart failure, schizophrenia, unspecified dementia, and major depressive disorder, who was assessed as having intact cognition and requiring extensive assistance for daily activities. The resident reported that a CNA was verbally rough and handled her belongings in a manner she found upsetting. The facility's investigation included statements from the CNA, the former Director of Nursing (DON), and interviews with other residents, but the CNA remained on duty and assigned to the resident throughout the investigation. A review of assignment sheets and timesheets confirmed that the CNA continued to work on the unit and care for the resident during the period in which the abuse allegation was being investigated. Both the current DON and the CNA acknowledged in interviews that, according to facility policy, the staff member should have been removed from resident care during the investigation, but this did not occur.
Missing Physician Discharge Summary for Discharged Resident
Penalty
Summary
Facility staff failed to provide a physician discharge summary for one of eight sampled residents who was discharged home. The resident had multiple diagnoses, including chronic diastolic congestive heart failure, schizophrenia, unspecified dementia, major depressive disorder, and a history of tobacco use. Documentation in the medical record included nursing and social work progress notes detailing the resident's admission, ongoing care, and discharge process. The notes indicated that the resident was alert, verbally responsive, and discharged in stable condition to an assisted living apartment, with personal belongings and care instructions transferred accordingly. Despite these records, there was no documented evidence of a physician discharge summary that included a recapitulation of the resident's stay, a final summary of the resident's status, or a reconciliation of all pre-discharge medications. The absence of this required documentation was confirmed during a face-to-face interview with the Director of Nursing, who acknowledged the deficiency in the resident's medical record.
Failure to Update Care Plan Interventions Following Resident-to-Resident Aggression
Penalty
Summary
Facility staff failed to update care plan interventions for a resident with a known history of aggressive behaviors, resulting in two separate staff-witnessed incidents where this resident acted aggressively toward another resident. The first incident involved one resident hitting another on the shoulder while being escorted to the hair salon. The affected resident displayed pain cues but denied pain or discomfort upon assessment, and no physical injuries were observed. The care plan for the resident who was hit was updated to include monitoring for injury and providing emotional support, but the care plan for the resident who exhibited aggression was not revised with new interventions to prevent further incidents. The resident with aggressive behaviors had a documented history of Alzheimer's Disease, depression, and agitated dementia, and was already under psychiatric care for these behaviors prior to the incidents. Medical records and psychiatric notes indicated ongoing issues with aggression, particularly after lunch, and described the resident as having a quick temper and being physically aggressive at times. Despite these documented behaviors and the occurrence of the first incident, there was no evidence that the care plan was updated with new approaches or interventions to address the risk of further aggression toward the other resident. A second incident occurred in which the same resident was reported to have slapped the other resident on the face. Staff investigation found that a threat was made, but no physical contact was confirmed by witnesses. The care plan for the resident who was threatened was updated to include monitoring and a psych consult, but again, the care plan for the resident with aggressive behaviors was not revised with new interventions after this second event. The Director of Nursing acknowledged during interview that the care plan should have been updated with new approaches after each incident, but this was not done.
Medication Transcription Error Leads to Incorrect Lorazepam Administration
Penalty
Summary
Facility staff failed to accurately transcribe a physician's order for Lorazepam, leading to a significant medication error for a resident. The resident, who was admitted with multiple diagnoses including cerebral infarction and hemiplegia, was prescribed Lorazepam 0.5mg every 4 hours as needed for anxiety and restlessness. However, the order was incorrectly entered into the electronic Medication Administration Record as a routine medication instead of PRN (as needed), resulting in the resident receiving the medication five times in one day without documented evidence of agitation or restlessness. The error was identified when a Facility Reported Incident was submitted, revealing that the nurse responsible for entering the order did not check the PRN box, causing the medication to appear as a routine order. The Director of Nursing confirmed that the transcription error was made by an RN, who admitted to the mistake during an interview, acknowledging the failure to indicate the medication as PRN. This transcription error led to the resident receiving unnecessary doses of Lorazepam, despite being on hospice services for comfort care.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Washington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ingleside At Rock Creek | 0.8 mi | ★★★★★ | 0 | 0 |
| Forest Hills Of Dc | 1.5 mi | ★★★★★ | 6 | 0 |
| Fox Chase Healthcare | 1.8 mi | ★★★★★ | 5 | 0 |
| Lisner Louise Dickson Hurthome | 1.8 mi | ★★★★★ | 2 | 0 |
| Autumn Lake Healthcare At Chevy Chase | 2 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.