Health inspection·November 24, 2025

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some facility admitted the resident on 11/19/2025 with diagnoses including pleural effusion (the buildup of excess fluid between the lungs and the wall lining inside the chest), asthma (a disease that affects the lungs), and chronic respiratory failure (a condition in which not enough oxygen passes from the lungs into the blood). During a review of Resident 3's Admission/readmission Evaluation/Assessment, dated 11/19/2025, the Admission/readmission Evaluation/Assessment indicated Resident 3's cognition was intact. During a review of Resident 3's Change in Condition Evaluation, dated 11/20/2025, the Change in Condition Evaluation indicated the resident had shortness of breath. During an interview on 11/24/2025 at 1:55 p.m. and concurrent record review of Resident 3's Progress Notes, dated 11/19/2025 to 11/24/2025, reviewed with RN 1, RN 1 stated on 11/20/2025 at 9:30 a.m., Resident 3 had a COC for shortness of breath. RN 1 stated residents should be monitored for 72 hours after a COC. RN 1 stated Resident 3's Progress Notes indicated there was no documented evidence that monitoring was done on the following days and shifts: a. 11/20/2025 (11 p.m. to 7 a.m. shift),b. 11/22/2025 (11 p.m. to 7 a.m. shift), and c. 11/23/2025 (7 a.m. to 3 p.m. shift).RN 1 stated Resident 3 was not monitored every shift after the resident had a COC on 11/20/2025. RN 1 stated Resident 3's respiratory condition had the potential to be missed and worsen. During an interview on 11/24/2025 at 3:38 p.m. and a concurrent record review of Resident 3's Progress Notes, dated 11/19/2025 to 11/24/2025, reviewed with the IDON, the IDON stated Resident 3 was not monitored every shift after the resident's COC on 11/20/2025. The IDON stated resident monitoring after a COC should be done to ensure and assess if the interventions were effective or not. The IDON stated Resident 3's respiratory condition had the potential to worsen. The IDON stated the facility failed to ensure Resident 3 was monitored every shift for 72 hours after the resident's COC. During a review of Resident 2's admission Record (undated), the admission Record indicated the facility admitted the resident on 7/11/2023 with diagnoses including acquired absence of left foot, type 2 diabetes mellitus with foot ulcer (wound), and gastro-esophageal reflux disease (a condition in which the stomach contents leak backward from the stomach into the esophagus [food pipe]). During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decision making was intact. During a review of Resident 2's Change in Condition Evaluation, dated 11/21/2025, the Change in Condition Evaluation indicated the resident had nausea (feeling an urge to vomit), seven episodes of vomiting, and abdominal pain. During an interview on 11/24/2025 at 1:55 p.m. and concurrent record review of Resident 2's Progress Notes, dated 11/20/2025 to 11/24/2025, reviewed with RN 1, RN 1 stated on 11/21/2025 at 7:33 p.m., Resident 2 had a COC for nausea, vomiting and abdominal pain. RN 1 stated residents should be monitored for 72 hours after a COC. RN 1 stated Resident 2's Progress Notes indicated there was no documented evidence that monitoring was done on 11/23/2025 during the 3 p.m. to 11 p.m. shift. RN 1 stated Resident 1 was not monitored every shift after the resident had a COC on 11/21/2025. RN 1 stated Resident 2's condition had the potential to worsen. During an interview on 11/24/2025 at 3:38 p.m. and a concurrent record review of Resident 2's Progress Notes, dated 11/20/202/ to 11/24/2025, reviewed with the IDON, the IDON stated Resident 2 was not monitored on 11/23/2025, 3 p.m. to 11 p.m. shift, after the resident's COC on 11/21/2025. The IDON stated resident monitoring after a COC should be done to ensure and assess if the interventions were effective or not. The IDON stated Resident 2's symptoms had the potential to be missed and worsen. The IDON stated the facility failed to ensure Resident 2 was monitored every shift for 72 hours after the resident's COC. During a review of the facility's policy and procedure (PnP) titled, Acute Condition Changes - Clinical Protocol, last reviewed on 10/30/2025, the PnP indicated the staff will monitor and document the resident/patient's progress and responses to treatment, and the physician will adjust treatment accordingly. During a review of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555456 If continuation sheet Page 2 of 4 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 11/24/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete the facility's PnP titled, Charting and Documentation, last reviewed on 10/30/2025, the PnP indicated all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychological condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. The PnP indicated documentation in the medical record will be objective, complete, and accurate. Event ID: Facility ID: 555456 If continuation sheet Page 3 of 4 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 11/24/2025 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide necessary respiratory care and services for one of three sampled residents (Resident 3) by failing to: 1. Ensure Resident 3's oxygen tubing and oxygen humidifier (a device that adds moisture to the oxygen a person is breathing in during oxygen therapy) was dated when it was changed.2. Ensure Resident 3 had an oxygen supplies bag for the oxygen tubing to be kept inside when not in use. These deficient practices had the potential for Resident 3 to develop respiratory (organs and structures in the body that allow a person to breathe) diseases or infections.Findings: During a review of Resident 3's admission Record (undated), the admission Record indicated the facility admitted the resident on 11/19/2025 with diagnoses including pleural effusion (the buildup of excess fluid between the lungs and the wall lining inside the chest), asthma (a disease that affects the lungs), and chronic respiratory failure (a condition in which not enough oxygen passes from the lungs into the blood). During a review of Resident 3's Admission/readmission Evaluation/Assessment, dated 11/19/2025, the Admission/readmission Evaluation/Assessment indicated Resident 3's cognition was intact. The Admission/readmission Evaluation/Assessment indicated Resident 3 had shortness of breath (SOB) on exertion, at rest, and while laying flat. Resident 1 used oxygen at two liters per minute (Lpm - unit of measurement). During a review of Resident 3's Physician Order, dated 11/19/2025, the Physician Order indicated the use of oxygen at two Lpm via nasal cannula (a device used to deliver supplemental oxygen). During a concurrent observation and interview on 11/24/2025 at 3 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 3 was observed with oxygen via nasal cannula connected to an oxygen concentrator (a device that provides extra oxygen). LVN 1 stated Resident 3's nasal cannula and oxygen humidifier were not dated. LVN 1 stated Resident 3's oxygen mask used for respiratory treatment was on top of the resident's bedside table. LVN 1 stated there were no oxygen supplies bags in Resident 3's room. LVN 1 stated Resident 3's oxygen therapy supplies should be inside a dated and labeled oxygen supplies bag when not in use. LVN 1 stated residents' oxygen therapy supplies should be dated and changed every 7 days. LVN 1 stated Resident 3's oxygen supplies could get dirty and had the potential to cause respiratory infections. During an interview on 11/24/2025 at 3:38 p.m. and concurrent record review of the facility's policy and procedure (PnP) titled Oxygen Administration, last facility-review on 10/30/2025, reviewed with the Interim Director of Nursing (IDON), the IDON stated the PnP indicated .replace oxygen supplies / tubings typically every seven to 14 days or per manufacturer's guidelines. The IDON stated the resident oxygen supplies should indicate the date the supplies were last changed. The IDON stated the facility staff would be unaware how long Resident 3 had used the undated oxygen supplies. The IDON stated Resident 3's oxygen supplies should be in a dated oxygen supplies bag when not in use. The IDON stated not in use oxygen supplies outside the oxygen supplies bag and undated oxygen supplies had the potential to cause residents' respiratory infections. The IDON stated the facility failed to ensure the policy on oxygen administration was followed. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555456 If continuation sheet Page 4 of 4