Health inspection·January 23, 2025

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 ensure proper care was provided to prevent a pressure ulcer/injury (injury to skin/tissue from prolonged pressure on the skin) for one of three sampled residents (Resident 1). Residents Affected - Few This failure resulted on resident 1 acquired pressure ulcer to coccyx left and right buttocks (lower back/spine) developed while in the facility. Findings: During review of Residents 1 ' s admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included metabolic encephalopathy (problem in brain caused by chemical imbalance in blood), down syndrome ( a genetic disorder causing developmental and intellectual delays), sepsis ( a life threatening complication of an infection), osteomyelitis of right hand (bone infection) and cellulitis of right finger (bacterial skin infection). During a concurrent interview and record review of Resident 1 ' s clinical records with Treatment Nurse 1 on January 6, 2025, at 2:30 PM, the Treatment Nurse 1 reviewed and verified the following: 1. Comprehensive admission Skin Assessment dated September 18, 2024, at 7:20 PM, the assessment indicated, Body parts: Coccyx area Clear. 2. Braden Scale (a tool use for predicting pressure sore risk) dated September 18, 2024, at 11:15 PM, it indicated Resident 1 ' score was 18 - Low Risk (Score of 15-18 Low Risk). 3. Nursing Notes dated November 8, 2024, at 3:00 PM stated Resident 1 placed on COC (Change of Condition) for redness on left and right buttocks. Doctor notified. New treatment orders noted and carried out. 4. Physician Wound Progress Notes, dated November 11, 2024, indicated, Site 1: Right Buttock – Stage 2 Pressure Ulcer. Size: 1.7cm X 1.2 cm X 0.1cm. Site 2: Left Buttock- Stage 2 Pressure Ulcer. Size: 1.0 cm X 0.7 cm X 0.1 cm. 5. Physician Wound Progress Notes, dated November 18, 2024, indicated, Site 1: Right ButtockRESOLVED. Site 2: Left Buttock Pressure Ulcer, Size: 1.2cm X 1.5cm X 0.1 cm. 6. Physician Wound Progress Notes, dated November 25, 2024, indicated, Site 1: RESOLVED. Site 2: (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 01/23/2025 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)