Health inspection·August 5, 2025

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Eliquis oral tablet 5 mg give one (1) tablet by mouth every 12 hours for a-fib indicated 9- 8/5/2025 (for the scheduled time of 9a.m.) Eliquis oral tablet 5 mg give one (1) tablet by mouth every 12 hours for a-fib indicated it was not signed off.During a review of Resident 3's Progress Notes, dated 8/1/2025 at 7:45 a.m., the Progress Notes indicated Femara tablet 2.5 mg medication was not available at this time, faxed refill request to pharmacy and awaiting arrival.During a review of Resident 3's Progress Notes, dated 8/4/2025 at 10:32 p.m., the Progress Notes indicated Eliquis oral tablet 5 mg was found after contacting Pharmacy.During an interview on 8/5/2025 at 10 a.m. with Resident 3, Resident 3 stated has been out of Eliquis. Resident 3 stated has also had issues with missing her Famara which is her (Resident 3) cancer medication. Resident 3 stated she (Resident 3) is concerned because she (Resident 3) has had two blood clots, is trying to get better and wants to go home.During a concurrent interview and record review on 8/5/2025 at 10:17 a.m. of Resident 3's MAR with LVN 1, LVN 1 stated Resident 3 does not have Eliquis, not sure when Resident 3 received the last dose of Eliquis. LVN 1 reviewed Resident 3's MAR and stated Resident 3 received Eliquis on 8/4/2025 at 11:26 a.m. Resident 3 did not get her (Resident 3) evening dose. LVN 1 reviewed the medication cart and stated there is no Eliquis in the medication cart for the morning dose for Resident 3 there are doses for the evening dose. LVN 1 stated nurses are the ones in charge of ordering medication, should be ordering medications when there are 4 doses left. LVN 1 stated if Resident 3 is not getting her (Resident 3) Eliquis as prescribed can be a potential for Resident 3 to develop deep vein thrombosis (DVT-a blood clot that forms in a deep vein, usually in the leg or thigh) and blood clots. LVN 1 stated Resident 3 has now missed two doses with the morning dose.During a concurrent interview and record review on 8/5/2025 at 11:19 a.m. of Resident 3's Medication Bubble Pack (a pharmacy organized card that packages doses of medication within small, clear, or light-resistant, amber-colored plastic bubbles [or blisters]), with the Assistant Director of Nursing (ADON), the ADON stated the facility has the morning Eliquis for Resident 3. The ADON stated the number five (5) bubble was punched out because it was administered to Resident 3 today. During an interview on 8/5/2025 at 12 p.m. with Resident 3, Resident 3 stated she did get her Eliquis this morning, staff were able to find the Eliquis.During a concurrent interview and record review on 8/5/2025 at 1:30 p.m. of Resident 3's MAR with the Director of Nursing (DON), the DON reviewed Resident 3's MAR and stated Eliquis for 8/4/2025 for the p.m. dose was not given. The DON stated for the 8/5/2025 dose it was given this morning it was punched out on the bubble pack. The DON reviewed Resident 3's MAR and stated the MAR is not signed off indicating the Eliquis was given this morning (8/5/2025). The DON stated when administering medication should pour, pass, chart, should be signed the MAR right after resident takes medication. The DON stated the nurse should be giving the medications as scheduled and documenting them right away because it can cause Resident 3 to have side effects for not receiving medications as prescribed and it is inaccurate documentation. The DON reviewed Resident 3's MAR for Femara dated 8/1/2025 and stated Resident 1 did not get the medication that day. The DON stated the rule of thumb, and our policy is there needs to be three (3) days of supplies, nurses must reorder prior to the medication running out. The DON stated potential for not getting medication as prescribed can exacerbate the residents' condition, resident needs to be stable and not have complications, because for Eliquis there is a potential for clotting, and can be a potential for a-fib and risk to have clots. During a review of the facility's policy and procedure (P&P) titled, Medication and Treatment Orders, last reviewed on 5/30/2025, the P&P indicated drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than three (3) days prior to the last dosage being administered to ensure that refills are readily available. During a review of the facility's P&P titled, Administering (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555456 If continuation sheet Page 2 of 3 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 555456 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Antelope Valley Care Center 44567 North 15th St. West Lancaster, CA 93534 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)

F 0760 Level of Harm - Minimal harm or potential for actual harm Medications, last reviewed on 5/30/2025, the P&P indicated medications are administered in a safe and timely manner, and as prescribed.4. Medications are administered in accordance with prescriber orders, including any required time frames.22. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next one. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555456 If continuation sheet Page 3 of 3