Health inspection·November 26, 2024

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure licensed vocational nurse (LVN 1) perform medications administration according to the facility's policies and procedures (P&P) for one of four sample residents (Resident 1) when during resident 1's medication pass, the surveyor noticed that the LVN pre-signed the medication before administering it, failed to check the medication's expiration date, and failed to record on Resident 1's MAR the reason why Amlodipine (a medication used to treat high blood pressure) not available, believing that she could have borrowed Amlodipine from another resident for Resident 1. This deficient practice had the potential to adversely affect the health and safety of Resident 1 who is clinically compromised. Findings: During the review of Resident 1's admission record (a document that gives a summary of resident's information), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnosis that included Atherosclerotic heart disease (hardening of the blood vessels that supplies blood to the heart), acute myocardial infarction (heart attach), hypertension (high blood pressure). During a concurrent observation and interview with LVN 1, on [DATE], at 8:45 AM, LVN 1 administered medication to Resident 1. LVN 1 marked her initials on the MAR prior to administering the medication. LVN 1 stated that Resident 1's amlodipine is not available, and she will circle her initials in the MAR to show medication was not administered. She also stated that she doesn't have to provide a reason for medication not being given in the MAR. She further added that she could potentially borrow Amlodipine from another resident's medicine if needed. LVN 1 explained that although she does not always think to check the expiration date, she is aware that it is required by policy before giving the medication. During an interview with the Assistant Director of Nursing (ADON 1) on [DATE], at 11:02 AM. The ADON 1 stated she expects LVNs to do the 7 rights check when administering medication and ensuring the medication is not expired. She added that the squares on the MAR should be initial after medication is administered. Stated LVNs are not supposed to initial before administering the medication. She stated that LVNs should not borrow medication from another resident. A review of the facility policy and procedure titled Policy and Procedure on Medication and Treatment Administration indicated, .14. Licensed nurse should use the method of Pour, Pass & Chart when administering medications . 16. Before administering medication or treatment, check every (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 11/26/2024 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)