Health inspection·December 30, 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to follow their policy and procedure on medication administration when a Licensed Vocational Nurse failed to administer Nifedipine (medication use to lower blood pressure) ordered by physician to one of three sampled Residents (Resident 1). Residents Affected - Few This failure has a potential to place a clinically compromised Resident 1 ' s health and safety at risk. 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, cerebral infarction ( damage to tissues in the brain due to a loss of oxygen to the area), hypertension ( High blood pressure), gastroesophageal reflux ( involuntary back flow of stomach contents back into the esophagus or food pipe ), rheumatoid arthritis (chronic autoimmune disease that causes inflammation and damage to the joints), malignant neoplasm of female breast ( a cancerous tumor that develops in the breast tissue ), polyneuropathy (affects nerves that control movement, feeling, or both), depressive disorder ( loss of pleasure or interest in activities for long periods of time), anxiety disorder ( feelings of worry, anxiety, or fear that strong enough to interfere with one ' s daily activities). During an interview with a Licensed Vocational Nurse 2 (LVN2), on December 17, 2024, at 12:30 PM, LVN2, stated on December 3, 2024, at 10:40 AM, LVN2 notified Resident 1 ' s Primary Physician (PMD) regarding a PRN (as situation demands or as needed) order for Hydralazine 60 mg PO (By mouth) every 6 hours PRN for Blood Pressure above 160 systolic. LVN 2 stated Hydralazine 60 mg po was administered on December 3, 2024, at 11:00 AM for a high blood pressure above 160 systolic. LVN 2 stated that Resident 1 verbalized she did not receive her blood pressure medication on December 2, 2024, at 9:00 pm. During a concurrent MEDICATION ADMINISTRATION RECORD (MAR) review and interview with Nursing Office Assistant (NOA), on December 17,2024, at 1:20 PM. NOA stated there is no documentation or signature on MAR, that Nifedipine ER 60 mg po Q HS was administered on November 28, 2024, and November 29, 2024, at 9:00 PM During an interview with Administrator (ADM) on December 22,2024 at 2:35 PM, ADM stated that he did a grievance following a complaint from Resident 1 ' s daughter regarding the missed medication dose on Resident 1 on December 2, 2024, at 9:00 PM. ADM interviewed LVN 1, and he stated that Nifedipine ER 60 mg was not given on December 2, 2024, at 9:00 pm due to blood pressure below110 systolic. ADM stated, upon reviewing the MAR, there is no documentation/Signature that a dose was administered on (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 12/30/2024 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)