Health inspection·September 12, 2024

F 0606 Not hire anyone with a finding of abuse, neglect, exploitation, or theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to protect residents from potential abuse and mistreatment, in a universe of 112 residents, when the facility employed a Licensed Vocational Nurse (LVN 1) with a disciplinary action (a formal process that imposes consequences or corrective measures for misconduct or violations of professional standards), in effect, against her professional license. Residents Affected - Few This failure had the potential to cause residents to suffer abuse and mistreatment. Findings: An unannounced visit was made to the facility on September 10, 2024, at 10:46 AM, to investigate a facility reported incident regarding an allegation of physical abuse and deprivation of services by LVN 1. During a concurrent interview and record review on September 10, 2024, at 12:39 PM, with a Director of Staff Development (DSD), LVN 1 ' s personnel file and professional license was reviewed. The DSD stated LVN 1 ' s date of hire was February 14, 2024. A review of LVN 1 ' s professional license, dated expiration January 31, 2025, indicated, DISCIPLINARY ACTIONS START: JULY 31, 2023, ACTION: A FORMAL STATEMENT OF CHARGES FILED AGAINST A LICENSEE. PUBLIC RECORD ACTIONS PUBLIC DOCUMENTS (1), CASE NUMBER 4302023000964, DOCUMENT TYPE: ACCUSATION, DOCUMENT POSTED: JULY 31, 2023. A review of LVN 1 ' s Disciplinary Action, dated July 31, 2023, indicated, FACTUAL ALLEGATIONS: 9. While working as a licensed vocational nurse at [name of a nursing facility] on November 30, 2022, Respondent verbally and physically mistreated Patient Y.C., an [AGE] year-old woman suffering from dementia. Specifically, multiple witnesses observed Respondent become angry with Patient Y.C., telling her to shut the fuck up and stating, I hate you and I'm going to kill you. Multiple witnesses also observed Respondent push Patient Y.C.'s wheelchair into a hallway and let go, allowing the wheelchair to roll into an isolation cart and causing Patient Y.C. to hit her knee. WHEREFORE, Complainant requests that a hearing be held on the matters herein alleged, and that following the hearing, the Board of Vocational Nursing and Psychiatric Technicians issue a decision: 1. Revoking or suspending Vocational Nurse License Number ., issued to [LVN 1]; 2. Ordering [LVN 1] to pay the Board of Vocational Nursing and Psychiatric Technicians the reasonable costs of the investigation and enforcement of this case, pursuant to Business and Professions Code section 125.3; and, 3. Taking such other and further action as deemed necessary and proper. In a continued interview with the DSD, the DSD stated she had not been involved with the hiring of (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 09/12/2024 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)