Other·November 22, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated survey to investigate a Facility Reported Incident (FRI). Facility Reported Incident number CA00555065 Representing the California Department of Public Health: 33786 The inspection was limited to the specific FRI investigated and does not represent the findings of a full inspection of the facility. One deficiency was issued for FRI number CA00555065. On October 6, 2017 at 7:35 PM, after interviews, and records reviews, an Immediate Jeopardy (IJ, a situation that had threatened the health and safety of a resident) was called in the presence of the Administrator (ADM) and Director of Nursing (DON). The ADM and the DON were verbally notified of the IJ situation identified based on the facility failure to ensure one of three sampled residents (Resident A) was provided the necessary care and psychosocial support when Resident A verbalized he wanted to go home upon discharge and not be transferred to an assisted living facility. This failure negatively affected the mental health and well being of Resident A, which resulted in Resident A's death. Refer to Quality of Life 483.24 (F 309). LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LJ4R11 Facility ID: CA240000365 If continuation sheet 1 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555251 (X3) DATE SURVEY COMPLETED 10/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KNOLLS WEST POST ACUTE LLC 16890 Green Tree Blvd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During a record review conducted October 9, 2017 at 7:30 PM, the inservice's, interviews with staff, and record review, confirmed compliance with the Skilled Nursing Facility's (SNF) corrective action plan. The corrective action plan was reviewed and accepted on October 9, 2017 at 7:45 PM, in the presence of the administrator, and Director of Nurses. The IJ was lifted on October 9, 2017, at 7:45 PM, in the presence of the Administrator, Director of Staff Development, Director of Staff Development from Resource, a Registered Nurse (RN 1) , the Nurse from Resource and the Director of Nursing (DON). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LJ4R11 Facility ID: CA240000365 If continuation sheet 2 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555251 (X3) DATE SURVEY COMPLETED 10/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KNOLLS WEST POST ACUTE LLC 16890 Green Tree Blvd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F309 PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING CFR(s): 483.24, 483.25(k)(l)

F309 SS=J PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 11/09/2017 483.24 Quality of life Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident’s comprehensive assessment and plan of care. 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents’ choices, including but not limited to the following: (k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. (l) Dialysis. The facility must ensure that residents who require dialysis receive such FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LJ4R11 Facility ID: CA240000365 If continuation sheet 3 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555251 (X3) DATE SURVEY COMPLETED 10/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KNOLLS WEST POST ACUTE LLC 16890 Green Tree Blvd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident A) was provided the necessary care and psychosocial support when Resident A verbalized he wanted to go home upon discharge and not be transferred to an assisted living facility. This failure negatively affected the mental health and well being of Resident A, which resulted in Resident A's death. Findings: An unannounced visit was made to the facility on October 2, 2017 at 1:45 PM, to investigate a facility reported incident (FRI) regarding a resident's (Resident A) death. A review of the clinical record for Resident A revealed the admission record, dated July 9, 2017 at 8:20 PM, indicated that Resident A was admitted to the facility on July 9, 2017, with diagnoses which included: chronic obstructive pulmonary disease (a disease of the lungs), hypertension (high blood pressure), and depression (a mental disease that causes the person to feel sad and hopeless). A review of Resident A's care plan titled "Depression" dated July 10, 2017, indicated Resident A had depression. The interventions listed included: social services to interact as needed, listen attentively and attempt resolve or discuss a real of upset, and monitor episodes of depression. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LJ4R11 Facility ID: CA240000365 If continuation sheet 4 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555251 (X3) DATE SURVEY COMPLETED 10/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KNOLLS WEST POST ACUTE LLC 16890 Green Tree Blvd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident A's clinical record from the general acute care hospital (GACH) revealed when Resident A was admitted to the GACH, Resident A had a diagnosis of depression. A physician's order was obtained for a consultation with a Psychiatrist (a physician specializing in mental illness) due to Resident A having suicidal ideation (thoughts of killing or injuring one-self). A review of Resident A's ancillary and nursing transfer orders from the GACH, dated July 9, 2017, indicated Resident A had a one to one staff member at the bedside due to suicidal ideation during Resident A's admission at the GACH. Further review of the ancillary and nursing transfer orders discharge revealed, "Patient depressed and does not want to live..." A review of Resident A's discharge Home medication from the GACH, dated July 9, 2017, indicated Resident A had an order to continue to take Sertraline (antidepressant medication used for sadness) 50 mg (a unit of measurement) by mouth every day. A review of the SNF physician's admission orders for Resident A, dated 9, 2017 at 10 PM, indicated Resident A had an order for sertraline 50 mg by mouth every day. A review of Resident A's antidepressant medication form, undated and untimed, signed by the doctor, indicated a check mark in the box to monitor behaviors to include crying, inability to sleep, and suicidal ideations. A review of Resident A's antidepressant medication form clarification, dated July 10, 2017 at 9 AM signed by the doctor, indicated a check mark in the box to monitor behaviors of withdrawal and verbalization of depression. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LJ4R11 Facility ID: CA240000365 If continuation sheet 5 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555251 (X3) DATE SURVEY COMPLETED 10/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KNOLLS WEST POST ACUTE LLC 16890 Green Tree Blvd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The behaviors to include crying, inability to sleep, and suicidal ideation indicated were discontinued. A review of the licensed nurses' progress notes dated July 10, 2017 at 9 AM, indicated, "Clarification of sertraline order and depression manifestations..." There was no documented evidence to show the reason for the discontinuation of behaviors to include crying, inability to sleep and suicidal ideation. During an interview with the Director of nursing (DON) on October 6, 2017 at 2:10 PM, the DON reviewed the licensed nurses' progress notes dated July 10, 2017 at 9 AM, and the DON confirmed there was no documented evidence to show the reason for the discontinuing the behaviors of crying, inability to sleep, and suicidal ideation. The DON stated, "The nurse should have documented why those behavior monitoring were discontinued." A review of the Skilled Nursing Facility's (SNF) physician's history and physical for Resident A, completed on July 24, 2017, indicated Resident A does have the capacity to understand and make his own decisions. The history and physical did not show documented evidence by the SNF physician that Resident A had a diagnosis of depression and anxiety. During a telephone interview with the Certified Nursing Assistant (CNA 1), on October 4, 2017 at 10:30 AM, she stated, "On September 29, 2017, I went into the room at approximately 4 AM to provide care for the resident in Bed A (Resident A's roommate), and while I was providing care, that is when I found him (Resident A) on the floor. He (Resident A) had the call light tightly tied around his neck. I tried to loosen it but it was really tight. I pulled the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LJ4R11 Facility ID: CA240000365 If continuation sheet 6 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555251 (X3) DATE SURVEY COMPLETED 10/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KNOLLS WEST POST ACUTE LLC 16890 Green Tree Blvd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE call light from the wall. I immediately called the charge nurse. He came and we started CPR (cardiopulmonary resuscitation.)" During a review of the clinical record for Resident A, the licensed nurses' progress notes dated September 29, 2017 at 4:10 AM, indicated the Licensed Vocational Nurse (LVN 1) documented, "Called to room by CNA, patient found on the floor with call light tied around his neck with a knot, patient facing the floor unresponsive, unplugged call light right away to be able to remove call light quickly from his neck, unable to feel pulse per forearm, CPR code blue paged to the building, called paramedics for help, and further evaluation while performing CPR with RN (registered nurse)." During a telephone interview with the LVN 1 on October 11, 2017 at 1:27 PM, the LVN 1 stated, "The resident tied the call light around his neck. We started CPR immediately and called 911. He was still very warm but no pulse." A review of the licensed nurses' progress notes dated September 29, 2017 at 4:25 AM, revealed Resident A was transported out of the facility via 911 (ambulance). A review of Resident A's "Preadmission Screening and Resident Review" (PASRR- a tool used to screen the mental health status of a resident) dated, July 7, 2017, under section V-mental illness, indicated Resident A did not have a diagnosis of depression. Further review of the PASRR indicated Resident A did not have psychotropic medications (medications used for mental illness and anxiety). A review of Resident A's care plan titled "Psychosocial" dated July 10, 2017, indicated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LJ4R11 Facility ID: CA240000365 If continuation sheet 7 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555251 (X3) DATE SURVEY COMPLETED 10/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KNOLLS WEST POST ACUTE LLC 16890 Green Tree Blvd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident A had depression and anxiety. The intervention listed included: Explain all care, validate feelings and demonstrate empathy (the ability to understand other's feelings)." During an interview with the DON on October 6, 2017 at 5:30 PM, the DON reviewed Resident A's PASRR and confirmed the PASRR was not done correctly. The facility failed to included diagnoses of depression. The DON stated, "The resident had depression and anxiety and was receiving anti-depressant medication from the acute hospital." During a review of the clinical record for Resident A, the IDT (interdisciplinary team- a team meeting of staff members discuss a resident care) conference review, dated August 22, 2017, indicated a care coordinator, social services, physical therapy assistant and Resident A's family members were in attendance. Further review of the IDT conference review indicated the family did not want Resident A to be discharged to home. The family wanted Resident A to be discharged to an assisted living facility. A review of the written statement by the Physical Therapy Assistant (PTA) who attended the IDT conference and interpreted for Resident A and Resident A's family on August 22, 2017, documented, "The patient's daughter stated they would like him to go to an assisting living facility since all the daughters work and are unable to help with his care. The patient expressed not being satisfied with this decision multiple times, and he stated he preferred to go home with a caregiver during the day...The patient continued to express not wanting to discharge anywhere else but home." During an interview with the Care Coordinator FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LJ4R11 Facility ID: CA240000365 If continuation sheet 8 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555251 (X3) DATE SURVEY COMPLETED 10/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KNOLLS WEST POST ACUTE LLC 16890 Green Tree Blvd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (CC), on October 9, 2017 at 5:10 PM, the CC stated, "I did not know what the resident and the PTA were talking about because I do not speak Spanish." The CC further stated, "I do not remember if it was communicated to the team that the resident did not want to be discharged to an assisted living facility. I do not know what was done about resident not wanting to be discharged to an assisted living facility." A review of the GACH's discharge summary, dated July 9, 2017 from the GACH discharging physician, revealed Resident A should follow up with a psychiatrist. A review of Resident A's physician's order dated August 15, 2017 at 2 PM, indicated Resident A had an order for a neuropsychological evaluation (an examination provided by a mental health professional to determine the emotional status of a resident). The order for neuropsychological evaluation was obtained 37 days after Resident A was admitted to the facility. A review of Resident A's neuropsychological consultation executive summary, dated August 25, 2017, indicated Resident A felt depressed, hopeless, and helpless. It indicated Resident A's family and his returning to house motivated him to rehabilitate. Further review of Resident A's neuropsychological consultation executive summary indicated Resident A was reporting significant depressive and anxiety symptoms. The recommendation listed included anticipate and prevent fear producing stimuli (an event that triggers behaviors). A review of the licensed nurses' progress notes from August 25, 2017 through September 29, 2017, indicated no documented evidence that Resident A's physician was notified that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LJ4R11 Facility ID: CA240000365 If continuation sheet 9 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555251 (X3) DATE SURVEY COMPLETED 10/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KNOLLS WEST POST ACUTE LLC 16890 Green Tree Blvd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident A was feeling depressed, hopeless, and helpless. A review of the Nurse Practitioner Notes dated September 9, 2017 and September 16, 2017, indicated there is no documented evidence that Resident A's Nurse Practitioner was aware Resident A was feeling depressed, hopeless, and helpless. During an interview with the DON on October 6, 2017 at 3:10 PM, the DON reviewed the licensed nurse's progress notes from August 25, 2017 through September 29, 2017 and the Nurse Practitioner notes dated September 9, 2017 and September 16, 2017. The DON confirmed there was no documented evidence to show Resident A's Physician or Nurse Practitioner were notified about the results of the neuropsychological consultation executive summary which indicated, Resident A was feeling depressed, hopeless, and helpless. The DON stated, "The consultation reports are put in the medical record chart under the consultation tab. When the doctor comes in, it is up to the doctor to look at the consultation report." The DON further stated, "The Doctor or the Nurse Practitioner should have been notified about the results and documented." A review of social services notes dated September 28, 2017 indicated, "Social Services returned call from daughter {name of daughter}regarding anticipated discharge date..stated father could not come home due to being unable to take care of him. Requested assisted living placement." Further review of the Social Services notes, indicated no documented evidence to show any interventions were done for Resident A's expressed feelings of dissatisfaction with the family decision of being discharged to an assisted living facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LJ4R11 Facility ID: CA240000365 If continuation sheet 10 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555251 (X3) DATE SURVEY COMPLETED 10/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KNOLLS WEST POST ACUTE LLC 16890 Green Tree Blvd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The social worker was not available for interview During an interview with the DON on October 6, 2017 at 5 PM, the DON reviewed the Social Services notes for the months of August 2017 and September 2017, and confirmed there was no documented evidence to show interventions for Resident A's expressed feelings of dissatisfaction with the family decision of being discharged to an assisted living facility. The DON stated, "The Social Worker should have been working with the resident to cope with his feelings of not wanting to go to an assisted living facility." The DON further stated, "It is about what the resident wants. There should have been interventions." During a review of the policy and procedure titled, "Social Services Responsibilities" dated November 2008, indicated under the section titled "psychotropic's/behavior management: lead the IDT to identify possible medical, environmental, and psychosocial causal factors of behaviors." The facility failed to ensure that one of three sampled residents (Resident A) was provided necessary care and psychosocial support when Resident A verbalized he wanted to go home upon discharge and not be transferred to an assisted living facility. This failure negatively affected the mental health and well being of Resident A which resulted in Resident's A death. On October 6, 2017 at 7:35 PM, after interviews, and records reviews, an Immediate Jeopardy (IJ, a situation that had threatened the health and safety of a resident) was called in the presence of the Administrator and Director of Nursing. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LJ4R11 Facility ID: CA240000365 If continuation sheet 11 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555251 (X3) DATE SURVEY COMPLETED 10/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KNOLLS WEST POST ACUTE LLC 16890 Green Tree Blvd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The corrective action plan provided by the facility included: "A. The facility began the immediate correction on October 6, 2017 by assessing all residents in the facility to identify any residents that have thoughts of harming self, depression, and anxiety. On October 8, 2017 at 6:00 PM, one resident (Resident B) was identified with suicidal ideation, stating, "When he first arrived he wished he had a gun to shoot himself." Resident B was immediately placed on one to one supervision, his attending physician was called immediately. The physician returned the call at 9:00 PM and the physician gave an order to monitor closely and to transfer the Resident B to the acute care hospital for a psychiatric evaluation. Resident B was transferred to [name of the hospital] at 10:00 PM. Resident B returned on October 9, 2017 at 1:20 AM. B. The one resident (Resident B) that was identified during the assessment to be at risk for harming self has had a Patient Care Conference on October 9, 2017. Resident B stated, that he was talking past tense on his intent to harm himself back when he was getting a divorce and that he was happy now that he had a new truck, apartment and a cat that talks. C. IDT (inter disciplinary team- Nursing, Social Services Designee, Activities, dietary, and Therapy) members were in-serviced on October 7, 2017 and on going on the new care conference process and communication. Beginning October 8, 2017 all care conference will be reviewed by the IDT. Any concerns regarding to harm self, depression and/or anxiety will be brought to the attention of the director of nursing/ Registered Nurse (RN) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LJ4R11 Facility ID: CA240000365 If continuation sheet 12 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555251 (X3) DATE SURVEY COMPLETED 10/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KNOLLS WEST POST ACUTE LLC 16890 Green Tree Blvd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE immediately. D. In services for all departments were immediately initiated on October 7, 2017 and ongoing to staff on the identification of depression, anxiety and suicidal ideation and will be contingent on those employees as they report to work or return from any leaves. E. Facility will receive complete patient information from transferring facility in order to accurately assess each patient for proper placement and accurate completion of PASRR (preadmission screening and resident review) prior to review and acceptance of the patient by the director of nursing and or nursing home administrator beginning October 9, 2017. F. In servicing to Patient Care Coordinators/MDS (Minimal data sheet- a assessment tool) was initiated on October 9, 2017 and ongoing to staff responsible for completing the PASRR no later than on admission to assure accuracy and inclusion of diagnoses and medication to be monitored by Director of Nurses (DON) as well as Medical Records during the admission audit. G. All current PASRR's will be audited by Patient Care Coordinator/MDS for accuracy and correction will be made as deemed necessary beginning on October 9, 2017. H. Physicians will promptly be notified once requested psychology/neuropsych consultant reports are received by the facility and will be monitored by DON/administrator. All executive mental Health Consultation from the last 5 months were faxed to Physician's or reviewed by the Physician in the facility immediately on October 8, 2017. All psychological/neuropsych consultations will be reviewed by the IDT (inter disciplinary team-Nursing,SSD, ACT, Dietary FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LJ4R11 Facility ID: CA240000365 If continuation sheet 13 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555251 (X3) DATE SURVEY COMPLETED 10/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KNOLLS WEST POST ACUTE LLC 16890 Green Tree Blvd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE and Therapy) for appropriate follow up recommendation on October 9, 2017." During an interview with the DON on October 9, 2017 at 7:20 PM, the DON stated the following: "A. All residents in the facility were assessed to identify any residents that have thoughts of harming self, depression and anxiety. B. The interdisciplinary team members were inserviced on the new care conferences process. C. In services for all departments were initiated to staff on identification of depression, anxiety, and suicidal ideation. D. The facility will receive complete patient information from the transferring facility in order to accurately assess each patient for proper placement. E. Inservice's to patient care coordinators/ MDS responsible for completing the PASRR, all current PASRR were audited by patient care coordinator for accuracy. F. The physician will be promptly notified once psychology/neuropsychological consultant reports are received by the facility." On October 9, 2017 at 7:30 PM, for the purpose of compliance with the corrective action plan, a record review and interviews with the staff were conducted. It was revealed the staff are assessing the residents for thoughts of suicide ideations, the staff are being inserviced on signs and symptoms of suicide ideations, the interdisciplinary team members are being inserviced on the new care conference FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LJ4R11 Facility ID: CA240000365 If continuation sheet 14 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555251 (X3) DATE SURVEY COMPLETED 10/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KNOLLS WEST POST ACUTE LLC 16890 Green Tree Blvd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE process, and the PASRR audit sheets were reviewed and they indicated compliance with the facility's corrective action plan. The corrective action plan was reviewed and accepted on October 9, 2017 at 7:45 PM, in the presence of the Administrator, and Director of Nurses. The IJ was lifted on October 9, 2017 at 7:45 PM , in the presence of the Administrator, Director of Staff Development, Director of Staff Development from Resource, Registered Nurse (RN 1), the nurse from Resource and Director of Nurses (DON). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LJ4R11 Facility ID: CA240000365 If continuation sheet 15 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555251 (X3) DATE SURVEY COMPLETED 10/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KNOLLS WEST POST ACUTE LLC 16890 Green Tree Blvd Victorville, CA 92395 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LJ4R11 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA240000365 (X5) COMPLETE DATE If continuation sheet 16 of 16