Health inspection·September 17, 2025

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to ensure Restorative Nurse Assistant (RNA) 1 implemented proper use of personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) for one of three sampled residents (Resident 2) placed on enhanced barrier precautions (EBP-an infection control strategy that uses gloves and gowns during high-contact resident care to reduce the spread of multidrug resistant organisms {MRDOs}). This deficient practice had potential to result in the spread of MRDOs among residents.Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility originally admitted Resident 2 on 9/13/2023, and readmitted on [DATE] with diagnoses including quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), stage four pressure ulcer (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone). During a review of Resident 2's Order Summary Report, the report indicated the following physician's order: -6/27/2024: RNA for passive range of motion (PROM-movement of joint through the range of motion {ROM-full movement potential of a joint, where two bones meet} with no effort from the person) exercise bilateral lower extremities as tolerated every week during day shift on Monday, Tuesday, Wednesday, Thursday, and Friday. -4/11/2025: EBP to be utilized every shift during high contact resident care activities secondary to chronic wound (a long-lasting, non-healing injury that fails to proceed through the normal stages of healing in a timely manner) and indwelling catheter (a tube left in the bladder to drain urine for an extended period). During a review of Resident 2's Minimum Data Set (MDS-a resident assessment tool), dated 8/1/2025, the MDS indicated Resident 2 had intact cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks). The MDS indicated Resident 2 required maximal assistance (helper does more than half the effort) from facility staff with upper and lower body dressing. The MDS indicated Resident 2 was dependent (helper does all the effort) with toileting hygiene and transferring from chair to bed. During a review of Resident 2's Care Plan, last revised on 8/12/2025, the Care Plan indicated Resident 2 required enhanced barrier precautions during high-contact resident care activities due to the presence of chronic pressure wound (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) and indwelling catheter. During an observation on 9/17/2025 at 8:46 a.m. in Room A (Resident 2's room), RNA 1, who was not wearing an isolation gown, was observed assisting Resident 2 with ROM exercise of bilateral legs. During an interview on 9/17/2025 at 9:05 a.m. with RNA 1, RNA 1 stated Resident 2 was placed on EBP because of the presence of a wound and an indwelling catheter. RNA 1 stated he (RNA 1) did not wear a gown Residents Affected - Few (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: 555456 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 09/17/2025 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)