Health inspection·June 18, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to follow their Policy and Procedure when the licensed nurse failed to document the refusal of medication for one of three sampled Residents (Resident 1). Residents Affected - Few This failure had the potential to place a clinically compromised Resident (Resident 1) health and safety at risk. When not receiving the necessary medication as prescribed by the physician. Findings: During a review of Resident 1s admission Record (general demographics), indicates being admitted to facility April 15, 2024 with diagnosis (DX) of Polyneuropathy (multiple nerves are damage), gastroenteritis and colitis ( inflammation in the digestive tract), bipolar disorder (episodes of mood swings), muscle weakness ( decrease in strength), dysphagia ( difficulty in swallowing), type II diabetes mellitus (sugar imbalance in body), anxiety (feeling of worry), psychotic disorder ( disconnection from reality), and hepatomegaly (enlargement of liver). During interview of Resident 1 on June 18, 2022, at 1:50 pm, Resident in wheelchair, is alert and oriented. Resident 1 stated on June 16, 2024, the License Vocational Nurse (LVN 1) did not administer her 9:00 pm medications. Resident 1 stated that she spoke to LVN 1 asking for her scheduled medications. LVN1 stated that he will come back at around 9:00 pm to administer the medication. Resident 1 stated that LVN1 never showed up to give her medications. During a concurrent record review and interview with LVN1 on June 18, 2024, at 3:00pm. LVN 1 stated that Resident 1 refused to take her 9:00 pm medications. When LVN 1 asked if he documented the refusal, LVN 1 stated he forgot to document and admitted that he made a mistake for not documenting. During a concurrent record review and interview with Administrator (ADM), when ADM asked if LVN1 documented medication refusal on Resident 1's medication sheet on June 16, 2024, at 9:00 pm. ADM stated there were no documentation regarding Resident 1's refusal of medications. ADM stated facility's policy is for nurses to document when a resident refused to take their scheduled medication. During an interview with Registered Nurse Supervisor (RN) on June 25, 2024, at 10:10am, she stated when a resident refused to take their medication, licensed personnel are to document the refusal. RN states, there is a section on the back of the medication sheet to document as to why the medication was not given and risk and benefits of medication refusal. RN also stated that if the refusal of medication is not documented, it is considered not given. During a record review of the facility's Policy and Procedure titled, Medication and Treatment (continued on next page) 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 555251 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555251 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knolls West Post Acute LLC 16890 Green Tree Blvd Victorville, CA 92395 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)