Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Nursing Center during CMS and state inspections, most recent first.
Hand hygiene and food storage lapses were observed in the steam table service area and two unit kitchenettes. An FSD/Supervisor failed to change gloves or perform hand hygiene while handling food, clean dishes, cabinets, and a food thermometer, and multiple unlabeled, undated, expired, or improperly stored food items were found in Bayberry Lane and [NAME] Lane kitchenettes, contrary to facility policy.
Delayed Transcription of Wound Care Order: A resident with a chronic left lateral knee wound had worsening measurements and drainage, prompting a provider order for a new daily wound care regimen. An LPN received the order by electronic text but did not transcribe it into the chart until several days later, and the TAR showed the resident missed ordered daily wound care on two days before the order was entered.
A resident with dementia, urine retention, severe cognitive impairment, hospice services, and an indwelling urinary catheter had the drainage bag observed resting on the floor while the tubing hung over the bed. The resident’s care plan directed staff not to let any part of the drainage system touch the floor, but the assigned CNA and nurse both stated a basin should have been in place under the bag to prevent contamination.
Facility Assessment Did Not Address Dialysis Care Needs: The facility failed to include dialysis residents and related staff education/competency needs in its Facility Assessment. A resident with ESRD and a tunneled hemodialysis catheter had orders for outside dialysis and port-site monitoring, but staff stated no bedside emergency equipment was required and the DON said nurses did not need dialysis-port competency because the facility did not access the port. The Administrator acknowledged dialysis should have been included in the assessment and that there was no evidence nursing staff had received education or demonstrated competency for ESRD or dialysis care.
Failure to assess bed equipment for entrapment risk after an air mattress was placed on a resident’s bed. A resident with glaucoma, frailty, impaired mobility, a fall history, and moderate cognitive impairment used quarter-length bed rails and an air mattress, and surveyors observed a small gap between the mattress and raised rail. The Bedframe Checklist showed no evidence of an entrapment assessment after the mattress change, and the Maintenance Director could not recall completing one.
The facility failed to serve palatable food at appropriate temperatures on the Bayberry and Willow units. Residents reported concerns about hot foods arriving cold, which was confirmed by surveyors through test tray tastings. On both units, meal tray caddy doors were left open, and food temperatures were recorded as below the desired levels, with items such as eggs, sausage, and milk being cold or lukewarm to taste. The Food Service Director acknowledged the issue.
A resident with Orthostatic Hypotension and Tachycardia did not consistently receive care as per physician orders, which included wearing an abdominal binder at all times and TED stockings in the morning. Observations showed the resident without these devices, despite documentation indicating they were applied. Interviews confirmed the documentation was inaccurate, revealing a failure to adhere to professional standards.
A resident with Glaucoma did not receive necessary vision care services despite consent from their Health Care Proxy. The resident, admitted in December 2022, expressed concerns about vision loss, but no evidence of vision care was found in their records. Staff interviews revealed that the resident was not scheduled for an eye care visit, and a CNA observed increased use of reading glasses, indicating potential vision decline.
A resident with cognitive impairment was served hot cocoa without proper temperature checks, contrary to facility policy. CNAs reheated the beverage without using a thermometer, risking burns. The facility's policy required beverages to be reheated in 15-second intervals and checked for temperature, but staff did not adhere to these guidelines.
Two residents in a facility experienced significant medication errors. One resident received two doses of Trulicity on consecutive days due to a documentation error, while another resident was administered Humalog insulin outside the prescribed sliding scale parameters. These errors increased the risk of hypoglycemia for both residents.
The facility failed to follow proper sanitation and food handling practices in its kitchen, risking foodborne illnesses. Dietary staff did not perform hand hygiene after touching masks and used the same gloves for different food items, leading to potential cross-contamination. The Food Service Director acknowledged these practices as unsanitary and risky for residents with dietary restrictions.
The facility failed to maintain infection control measures for two residents. One resident's oxygen tubing was not changed weekly or stored properly, while another resident's urinary catheter drainage bag was observed in contact with the floor. Staff interviews confirmed these lapses, indicating non-compliance with facility policies and physician orders.
The facility failed to accurately code MDS assessments for two residents, one receiving oxygen therapy and another discharged home. A resident with respiratory conditions was not documented as receiving oxygen therapy, and another resident's discharge to home was incorrectly recorded as a hospital discharge. These errors were confirmed by the DON and MDS Nurse.
Hand Hygiene and Food Storage Lapses in Dining Areas and Kitchenettes
Penalty
Summary
The facility failed to follow professional standards of practice for food safety on the steam table service area and in two kitchenettes, Bayberry Lane and [NAME] Lane. During breakfast meal service, [NAME] Supervisor #1 stepped away from serving food to open a cabinet drawer, retrieve a knife, and cut sausage links without changing gloves or performing hand hygiene, then continued serving food and touching clean plates and utensils. Later, she removed her gloves and did not perform hand hygiene before stacking clean plates into cabinets, and again removed gloves without hand hygiene before touching clean plates, cabinets, and the food thermometer. During interview, [NAME] Supervisor #1 stated she should have washed her hands after removing her gloves and was unaware that she had not done so; the Food Service Director stated she should have washed her hands after removing her gloves. In the Bayberry Lane and [NAME] Lane kitchenettes, surveyors found multiple food items stored in refrigerators, freezers, and cabinets that were unlabeled, undated, expired, or otherwise not stored according to the facility's policy. Items included opened and resealed foods, frozen soda, containers of cheese, coffee creamer, pumpkin pie, pasta with meat sauce, yogurt, applesauce, pecan pie, muffins, noodle soup, take-out meals, pastries, grilled cheese, and a microwaveable pasta bowl stored in the refrigerator. The Administrator stated the kitchenettes were supposed to be checked for expired food every morning, and the Food Service Director stated dietary aides should clean out the refrigerators every morning and that food brought in by family members or ordered by residents should be labeled and discarded after three days or by the expiration or best-by date; the FSD said these items had not been thrown away and should have been.
Delayed Transcription of Wound Care Order
Penalty
Summary
The facility failed to ensure that Resident #59 received treatment and care according to a provider order for wound care after the resident’s left lateral knee wound worsened. Resident #59 was admitted with diagnoses including Adult Failure to Thrive and Pressure Ulcer, had moderate cognitive impairment, and had a chronic left lateral knee wound that had healed and reopened multiple times. On 12/12/25, the wound was documented as deteriorated, with increased measurements of 1.7 cm by 2 cm by 0.3 cm compared with 1 cm by 2 cm by 0.1 cm on 12/5/25, and the wound record noted follow-up with the NP for a new treatment change and possible wound consult. Nurse #3 stated she provided the wound care on 12/12/25, contacted the provider the same day, and received a new treatment order by electronic text for cleansing with Normal Saline, applying collagen, then Calcium Alginate and an Optifoam dressing daily. She said she forgot to transcribe the order that day and did not enter it into the medical record until 12/15/25. Review of the TAR showed Resident #59 did not receive the ordered daily wound care on 12/13/25 and 12/14/25. The DON stated the order should have been transcribed immediately on 12/12/25 and that electronic receipt of orders such as text messages or e-mails were considered verbal orders.
Urinary catheter drainage bag left on floor
Penalty
Summary
The facility failed to maintain professional standards of practice for Resident #7’s indwelling urinary catheter when the drainage bag was observed resting directly on the floor. Resident #7 was admitted with diagnoses including dementia and urine retention, had severe cognitive impairment with a BIMS score of 2, was receiving hospice services, and was dependent for toileting and personal hygiene. The resident had an indwelling urinary catheter, with physician orders for catheter care every shift and a care plan directing staff not to allow tubing or any part of the drainage system to touch the floor. Surveyors observed Resident #7 in bed with the catheter tubing hanging freely over the edge of the bed and the drainage bag laying flat on the floor on multiple occasions. During an observation, the assigned CNA stated the resident was dependent for all care and said a basin was supposed to be used under the drainage bag to prevent germs from getting on it, but it had not yet been provided from the overnight shift. The assigned nurse stated a basin should be placed under the drainage bag to avoid contact with the floor and said the system was at risk for contamination with germs and could make the resident sick with an infection or sepsis. The Infection Preventionist stated staff had implemented the use of basins under drainage bags and that Unit Managers, Nurses, and CNAs were all responsible for ensuring a basin was in place for Resident #7.
Facility Assessment Did Not Address Dialysis Care Needs
Penalty
Summary
The facility failed to conduct and document a facility-wide assessment that accurately reflected the resident population and care needs for day-to-day operations and medical emergencies. The Facility Assessment Tool, updated 6/30/25, stated that the facility accepted residents with renal insufficiency, renal failure, and ESRD, that the DON would ensure nursing staff received appropriate education and supervision, and that policies would be reviewed and education provided as needed for new clinical procedures. However, the assessment did not identify residents who received dialysis care as part of the population served and did not include evidence of a competency or education plan for the dialysis population's needs. Resident #5 was admitted in May 2025 with diagnoses including acute kidney failure and fluid overload. The resident's care plan identified chronic renal failure and included interventions for outpatient dialysis care, education regarding dialysis treatments, and monitoring labs, vital signs, and weight. The MDS indicated the resident had ESRD and received dialysis. Physician orders directed dialysis at an outside facility on Monday, Wednesday, and Friday, and also directed monitoring of the left chest wall port site for signs and symptoms of infection, keeping the dressing clean, dry, and intact, and notifying the physician if infection signs were present. During observation, the resident was seen sitting in a wheelchair in the bedroom with a dialysis port on the left chest. No clamp or emergency equipment was observed in the room or drawers for potential dialysis access complications. Nurse #2 stated that no emergency equipment was required at the bedside and that none was present in the bedroom. The DON stated that nurses were not required to have competency or training in the care or monitoring of the dialysis port because the facility did not access the port or change the dressing, and that the resident would not require emergency supplies at the bedside. The Administrator stated that dialysis should have been included in the Facility Assessment and that there was no evidence nursing staff had received education or demonstrated competency to care for residents with ESRD or on dialysis.
Failure to Assess Bed Equipment for Entrapment Risk After Air Mattress Change
Penalty
Summary
The facility failed to inspect the mattress and bed rail for entrapment risk for one resident after the resident’s mattress was changed from a standard pressure reducing mattress to an air mattress. The resident was admitted with diagnoses including glaucoma, frailty, and impaired mobility and ADLs. The resident’s care plan indicated use of quarter length bed rails to increase bed mobility and transfers, and physician orders included an air mattress with checks for setting and function. The resident also had a history of falls, was on medication requiring increased safety precautions, and had moderate cognitive impairment with a BIMS score of 8 out of 15. Survey observations showed the resident in bed with an air mattress in place and the left quarter length bed rail raised, with a small gap of approximately one inch between the air mattress and the raised bed rail. This same condition was observed again later, with the bed positioned against the wall on one side, the left quarter length bed rail raised, and the same small gap between the air mattress and the rail. Review of the facility’s Bedframe Checklist did not show any evidence that the bed equipment had been assessed for entrapment risk after the air mattress was placed on the bed. The DON stated that nursing staff were not responsible for changing mattresses and that mattress changes were completed by the Maintenance Director. The Maintenance Director stated that he was responsible for assessing bed equipment for entrapment risk when an air mattress was placed, and that he was required to document the assessment on the Bedframe Checklist. He could not recall when the air mattress was placed on the resident’s bed and could not say that he remembered assessing for entrapment risk when it was placed. He also stated there was no evidence logged on the Bedframe Checklist that the resident’s bed was assessed for entrapment risk after the air mattress was placed.
Deficiency in Serving Palatable Food at Appropriate Temperatures
Penalty
Summary
The facility failed to serve palatable food at an appetizing temperature for residents on the Bayberry and Willow units. During a Resident Council meeting, several residents expressed concerns about hot foods arriving at cool or cold temperatures. Surveyors conducted test tray tastings on both units, which confirmed the residents' complaints. On the Bayberry Unit, the meal tray caddy doors were left open between tray removals, and the last resident tray was served at 8:28 A.M. The test tray temperatures were recorded as follows: eggs at 95.3 degrees Fahrenheit, sausage at 91 degrees Fahrenheit, and toast at 87 degrees Fahrenheit, all of which were noted to be cold or cool to taste. Similarly, on the Willow Unit, the meal tray caddy doors were intermittently left open, and the last resident tray was served at 8:34 A.M. The test tray temperatures were recorded as follows: hard-boiled egg at 94.6 degrees Fahrenheit, pureed egg at 90.8 degrees Fahrenheit, ground sausage at 88.7 degrees Fahrenheit, and milk at 61.8 degrees Fahrenheit, all of which were noted to be lukewarm or cold to taste. The Food Service Director acknowledged the issue, emphasizing the importance of serving hot foods hot and cold foods cold for palatability.
Failure to Apply Medical Devices as Ordered
Penalty
Summary
The facility failed to provide care in accordance with professional standards for a resident diagnosed with Orthostatic Hypotension and Tachycardia. The resident had physician orders for an abdominal binder to be worn at all times and TED stockings to be applied in the morning and removed at bedtime. However, observations by the surveyor revealed that the resident was not consistently wearing the abdominal binder and TED stockings as ordered. On multiple occasions, the resident was found without the abdominal binder and TED stockings, despite the resident expressing no refusal to wear them. The facility's documentation inaccurately indicated that the abdominal binder and TED stockings were applied as ordered, with no refusals noted. Interviews with the Unit Manager and Director of Nursing confirmed that staff should not document the application of these devices unless they were actually applied. The discrepancy between the documentation and the actual care provided highlights a failure in adhering to the physician's orders and ensuring the resident's medical needs were met.
Failure to Coordinate Vision Care for Resident with Glaucoma
Penalty
Summary
The facility failed to coordinate vision care services for a resident diagnosed with Glaucoma, a condition that can lead to vision loss and blindness. The resident was admitted in December 2022 and had a consent form signed by their Health Care Proxy in January 2023 for vision care services. Despite this, there was no evidence in the clinical record that the resident received any vision care services since admission. The resident expressed concern about vision loss over the past few months, indicating a lack of appropriate follow-up care. Interviews with facility staff revealed that residents are typically seen for eye care every six months to a year, but the resident in question had not been seen or offered an appointment. Medical Records Staff confirmed that the consent form should have been sent to the Eye Center, but the resident was not added to the list for a visit. Additionally, a CNA noted that the resident had been using reading glasses more frequently, suggesting a decline in vision. This oversight highlights a failure in the facility's process to ensure timely and necessary vision care for residents with specific medical needs.
Failure to Ensure Safe Beverage Temperature
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards for Resident #61, who was at risk of being burned by a hot beverage. The facility's policy required beverages to be reheated at 15-second intervals and checked for temperature before serving, but this guidance was not followed. On two separate occasions, Certified Nurses Aides (CNAs) reheated hot cocoa for Resident #61 without checking the temperature before serving. CNA #1 heated the beverage for one minute and an additional 20 seconds without using a thermometer, while CNA #5 reheated the beverage in 30-second intervals and also failed to check the temperature. Resident #61, who had moderate cognitive impairment and required assistance with eating, was admitted with diagnoses including memory loss and hypertension. The facility's policy and signage indicated that beverages should be reheated in 15-second intervals and checked with a thermometer, but staff interviews revealed a lack of adherence to these procedures. CNA #5 believed the thermometer was only for checking refrigerator temperatures, and Unit Manager #1 confirmed that all beverages should be tested with a thermometer to prevent burns, highlighting a gap in staff training and policy implementation.
Medication Errors in Insulin and Trulicity Administration
Penalty
Summary
The facility failed to ensure that two residents were free from significant medication errors. For Resident #57, the staff did not adhere to the physician's order for Trulicity, a medication used to manage diabetes and reduce cardiovascular risks. The resident was supposed to receive a one-time dose of Trulicity after missing a scheduled dose. However, due to a failure in recording the administration of the medication, the resident received two doses on consecutive days, increasing the risk of hypoglycemia. For Resident #8, the facility staff did not follow the physician's order for sliding scale insulin administration. The resident, who had a diagnosis of Type Two Diabetes Mellitus and Alzheimer's Disease, received Humalog insulin for a blood sugar reading of 177 mg/dL, which was below the threshold for insulin administration according to the sliding scale. This administration was not required and constituted a medication error, increasing the risk of hypoglycemia. The facility's policy on medication errors, which defines such errors as deviations from physician's orders or accepted standards, was not followed in these instances. Interviews with staff revealed lapses in communication and documentation, leading to these errors. The staff involved acknowledged the errors and the potential risks associated with the incorrect administration of medications.
Failure in Sanitation and Food Handling Practices
Penalty
Summary
The facility failed to adhere to proper sanitation and food handling practices in its main kitchen, which could lead to foodborne illnesses. During an observation, Dietary Staff #3 was seen touching her mask with bare hands while handling resident food trays without performing hand hygiene afterward. This action was against the facility's hand hygiene policy, which requires handwashing or sanitizing after touching contaminated equipment or surfaces. Dietary Staff #3 acknowledged the oversight during an interview, and the Food Service Director confirmed that not performing hand hygiene in such situations is unsanitary. Additionally, the facility did not prevent cross-contamination during food handling. Dietary Staff #1 was observed using the same gloved hand to serve both sausage links and toast without changing gloves or using separate utensils for each food item. This practice was contrary to the facility's food storage and handling policy, which mandates the prevention of contamination and cross-contamination. Dietary Staff #1 admitted to not using separate utensils to save time, and Dietary Staff #2 recognized the risk of cross-contamination. The Food Service Director also noted that this practice could pose a risk to residents with specific dietary restrictions, such as pork allergies or religious diets.
Infection Control Deficiencies in Oxygen and Catheter Management
Penalty
Summary
The facility failed to maintain proper infection control measures for two residents, leading to potential risks of contamination and infection. For one resident, the staff did not appropriately store the oxygen tubing and nasal cannula when not in use, nor did they change the oxygen tubing weekly as ordered by the physician. The resident, who was cognitively intact and required oxygen therapy due to conditions such as Acute Respiratory Failure and Chronic Obstructive Pulmonary Disease, was observed with oxygen tubing that had not been changed according to the schedule and was improperly stored, hanging between a wall and a dresser. Another resident, who had an indwelling urinary catheter due to urine retention and was being treated for a urinary tract infection, was observed with the urinary catheter drainage bag in contact with the floor. The facility's policy required that catheter tubing and drainage bags be kept off the floor to prevent infection. However, the surveyor observed the drainage bag in direct contact with the floor in the dining room and under the resident's bed, indicating a failure to adhere to infection control protocols. Interviews with nursing staff confirmed the deficiencies, acknowledging that the oxygen tubing should have been changed weekly and stored in a plastic bag, and that urinary catheter drainage bags should not contact the floor. These lapses in infection control measures were identified during the survey, highlighting the facility's failure to follow its own policies and physician orders, thereby placing residents at risk for infection.
Inaccurate MDS Coding for Oxygen Therapy and Discharge Destination
Penalty
Summary
The facility failed to ensure accurate coding of Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in reflecting their actual medical status. Resident #25, who was admitted with acute respiratory failure and chronic conditions such as COPD and emphysema, was prescribed oxygen therapy to maintain adequate oxygen saturation levels. Despite receiving continuous oxygen therapy during the MDS observation period, the assessment did not reflect this treatment. The Director of Nursing confirmed that the MDS assessment was inaccurately coded, failing to indicate the resident's use of oxygen therapy. Similarly, Resident #73, admitted with a diagnosis of Respiratory Syncytial Virus, was discharged to home with family as per physician's orders and nursing progress notes. However, the MDS discharge assessment inaccurately recorded the resident's discharge destination as a short-term stay general hospital. The MDS Nurse acknowledged the error, stating that the discharge should have been coded as home/community. These inaccuracies in MDS assessments highlight the facility's failure to ensure that residents' statuses were correctly documented.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Illustrative
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Nursing homes near Worcester
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Regalcare At Worcester | 1.5 mi | ★★★★★ | 0 | 0 |
| Odd Fellows Home Of Massachusetts | 1.8 mi | ★★★★★ | 10 | 0 |
| Holy Trinity Eastern Orthodox N & R Center | 1.9 mi | ★★★★★ | 2 | 0 |
| Notre Dame Long Term Care Center | 2.1 mi | ★★★★★ | 0 | 0 |
| Christopher House Of Worcester | 3 mi | ★★★★★ | 9 | 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.