Health inspection·December 17, 2024

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility failed to follow their policy by not following physician ' s order to provide physical therapy five times a week for one of three sampled residents (Resident 1). This failure had the potential to cause contractures (a condition of shortening and hardening of muscles, tendons, or other tissues, often leading to deformity and rigidity of joints) and decreased mobility to Resident 1, by negatively affecting his physical health, mental and psychosocial well-being. Findings: During a review of Resident 1 ' s admission Record (general demographics), the document indicated Resident 1 was last admitted to the facility on [DATE], with diagnoses that included, wedge compression fracture of first lumbar vertebra (fracture occurs when the actually collapses to the front part of the vertebra and form a wedge shape), polyneuropathy( damage to multiple nerves outside of the brain and affects several nerve in different parts of the body at the same time), hypertension ( High blood pressure), acute on chronic systolic congestive heart failure (Is a type of heart failure that occurs when a patient has active symptoms of heart failure that develops on top of a long term condition), hyperlipidemia (high levels of fat particles in the blood), cardiomegaly (enlarge heart), chronic pulmonary edema ( a condition where fluid builds up in the lungs over time and making it difficult to breath), myocardial infarction, type 2 ( a heart attack caused by imbalance between the heart muscle oxygen supply and demand without the presence of a ruptured atherosclerotic plaque), major depressive disorder ( loss of interest in activities, causing significant impairment in daily life). During a concurrent record review of service matrix log and interview on December 18, 2024, at 12:45 PM with the Physical Therapy Director (PT 1), when asked about Resident 1 ' s frequency of physical therapy services, PT 1 stated, Physical therapy was ordered five times a week and according to our service matrix log, we are doing it only 3 times per week and some are 4 times per week . It is primarily due to staff calling in sick. When HFEN asked PT1 if that was an acceptable practice, PT 1 stated it is not acceptable. During a record review of physician ' s phone order dated August 15, 2024, at 6:18PM on December 18,2024 at 1:20PM, it stated Physical Therapy Clarification Order: PT Eval and Tx. See patient QD 5x/wk. X 4 wks. Tx. Approaches may include: TherEX, Ther/Acts, NMRE, Gait training, Manual PT. Orthotic training, Group TherActs, Wheelchair mobility training and modalities as needed. During a phone interview on December 22, 2024, at 2:35 PM with the Administrator (ADM), ADM stated (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 12/17/2024 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)