Health inspection·October 3, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure that an allegation of physical abuse for one of three sampled residents (Resident 1) was reported to the local, state, and federal agencies immediately in accordance with their facility's policy. This failure had the potential for the alleged abuse to go uninvestigated and unreported thereby increasing the chances of health, safety, and psychosocial harm to Resident 1. Findings: During an interview with Administrator on September 5, 2024, at 2:30 PM, he stated that he did not feel there was enough evidence based on interviews with witnesses and resident to report it to the state. Stated the son came to him highly upset and he said he felt LVN 1 ( Licensed Vocational Nurse) threw resident on the ground, states what LVN 1 said to him resident was threatening to leave the building and I redirected him and told him to go back to his room He stated I don ' t know why she started to stop him at the nurses station, I usually wait until they get to the main door and then I redirect, when talked to LVN 1, I said you should have let him get to the door, because then he could have told you he was not trying to leave the building I just wanted to get away from you he stated the resident ' s claims was LVN 1 failed to give him pain medicine. He stated the son gets very upset when his father does not get his pain medications, and they are planning to move him closer to the daughter. He stated the son also told him he did not believe LVN 1 did that, and the son called the nursing board where they told him she was under investigation, so he felt LVN 1 did do this. States the son did not witness it but there were 2 other witnesses that say same thing LVN 1 says. States resident went to hospital and there were no finding and was cleared to return to facility. Since then, resident was moved to another side of the building so LVN 1 has nothing to do with resident. He stated he did report it to the licensing board. Stated he did not report it to CDPH because when he had the son and LVN 1 in his office the son stated I agree with what you ' re saying maybe my dad was just confused so that is why I did not report it. I let him know that in his policy it states he must report any allegation or suspicion of abuse and he stated ok, I will report it today. During an interview with LVN 1 on September 5, 2024, at 3:00PM, She stated that resident 1 was always fighting with roommate, so Doctor added more meds, Ativan (is used in adults and children at least [AGE] years old to treat anxiety disorders. Ativan is also used to treat insomnia caused by anxiety) and Norco (is used to relieve moderate to severe pain) for pain. States son and resident told the doctor he wanted to go home. She states the resident was dependent on Ativan and that particular night he kept asking for Norco and she gave it to him. States she was on the phone with the resident ' s daughter and noted the resident wheeled himself out the door stating he was going home, they ae (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 10/03/2024 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)