Health inspection·January 22, 2026

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 3) was given pain medication as per physician's order.This failure had the potential to result in Resident 3's increased risk for drowsiness (sleepiness) and sedation (the use of medication to make a person calm, relaxed, or sleepy during a procedure).Findings:During a review of Resident 3‘s admission Record, the admission Record indicated the facility admitted Resident 3 on 12/13/2017, with diagnoses that included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), left knee pain and shortness of breath.During a review of Resident 3's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 7/30/2025, the H&P indicated Resident 3 had the capacity to understand and make decisions.During a review of Resident 3's Order Summary Report, dated 12/19/2025, the Order Summary Report indicated the following orders:Percocet (medication used to treat pain) oral tablet 5-325 milligram (mg-metric unit of measurement, used for medication dosage and/or amount) give one tablet by mouth every four hours as needed for moderate pain level of four to six out of ten pain level.Percocet oral tablet 10-325 mg give one tablet by mouth every four hours as needed for severe pain level of seven to ten out of ten pain level.During a review of Resident 3's Minimum Data Set (MDS-a resident assessment tool) dated 12/29/2025, the MDS indicated Resident 3's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact.During a review of Resident 1's Medication Administration Record (MAR- flowsheet that indicates medications given to a resident), dated 1/2026, the MAR indicated on 1/2/2026, at 8:16 p.m., Licensed Vocational Nurse 1 (LVN1) administered Percocet 10-325 mg to Resident 3 with a pain level of four.During a concurrent interview, and record review on 1/22/2026, at 9:22 a.m., with the Quality Assurance Nurse (QAN), Resident 3's Physician Order, dated 12/19/2025, and MAR dated 1/2/2026, were reviewed. The QAN stated on 1/2/2026, Resident 3's pain level was four out of ten and LVN 1 administered Percocet 10-325 mg instead of 5-325 mg as per physician order. The QAN stated LVN 1 should look at the physician order first and follow the physician order. The QAN stated Resident 3 could have increased risk for drowsiness because of administering 10 mg instead of 5 mg Percocet.During an interview on 1/22/2026, at 9:40 a.m., with the Director of Nursing (DON), the DON stated LVN 1 should look at the Physician Order first and follow the order. The DON stated if LVN 1 looked at the order, he (LVN 1) would have administered 5 mg of Percocet because Resident 3's pain level was four. The DON stated Percocet had slight sedative effects and Resident 3 could be drowsier because of receiving higher dose of pain medicine.During a review of facility's policy and procedure (P&P) titled, Pain Assessment and Management, dated 2001, and last reviewed on 5/2024, the P&P indicated, The purposes of this procedure are to help the staff identify pain in the resident, develop interventions consistent with the resident's goals and needs, and address the underlying causes of pain.Implementing Pain Management Strategies1. Establish a treatment regimen that is specific to the Residents Affected - Few Page 1 of 5 555456 555456 01/22/2026 Antelope Valley Care Center 44567 North 15th St. West Lancaster, CA 93534

F 0697 Level of Harm - Minimal harm or potential for actual harm residents based on consideration of the following: a. The residents' medical condition; b. Current medication regimen;.6. The medication regimen is implemented as ordered. Results of the interventions are documented and communicated directly to the provider when appropriate. Ongoing communication between the prescriber and the staff is necessary for the optimal and judicious use of pain medications. Residents Affected - Few 555456 Page 2 of 5 555456 01/22/2026 Antelope Valley Care Center 44567 North 15th St. West Lancaster, CA 93534

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for two of three sampled residents (Residents 1 and 2) by failing: To follow physician order to hold (temporarily stopping certain medications as instructed by a healthcare provider) metoprolol (medication used to treat hypertension [HTN-high blood pressure]) for systolic blood pressure (sbp- the top number in a blood pressure reading, indicating the pressure in your arteries when your heart beats) below 110/60 millimeters of mercury (mmHg-a standard unit of pressure). On 1/9/2026, at 9 a.m., Licensed Vocational Nurse 4 (LVN 4) administered metoprolol to Resident 1 who had a blood pressure of 104/76 mmHg.To ensure LVN 3 administer pantoprazole (medication used to treat too much acid in the stomach) and insulin lispro (medication used to lower blood sugar) to Resident 1 on 1/8/2026.To ensure LVN 3 administer famotidine (medication used to reduce acid in the stomach), gabapentin (medication used to treat nerve pain) and levothyroxine (medication used to treat underactive thyroid [releases hormones that control energy, heart rate, temperature, and weigh]) to Resident 2 on 1/8/2026.These failures had the potential to result in medication errors and could cause to Resident 1's hypotension (low blood pressure), hyperglycemia (elevated blood sugar) and could result in Resident 2's uncontrolled hypothyroid and pain.Findings:a. During a review of Resident 1‘s admission Record, the admission Record indicated the facility admitted Resident 1 on 11/11/2025, with diagnoses that included osteomyelitis (inflammation of bone or bone marrow, usually due to infection), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertensive heart disease (refers to heart conditions caused by long-term high blood pressure) with heart failure (heart cannot pump enough blood to meet the body's needs, often causing fatigue, fluid buildup, and shortness of breath).During a review of Resident 1's Order Summary Report, dated 11/11/2025, the Order Summary Report indicated metoprolol succinate extended release oral tablet 50 milligram (mg- metric unit of measurement, used for medication dosage and/or amount), give one tablet by mouth daily for HTN, hold for sbp less than 110 mmHg or hold for heart rate less than 60 beats per minute.During a review of Resident 1's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 11/13/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool) dated 11/18/2025, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact.During a review of Resident 1's Medication Administration Record (MAR- flowsheet that indicates medications given to a resident), dated 1/2026, the MAR indicated on 1/9/2026, at 9 a.m. LVN 4 administered metoprolol to Resident 1 who had a blood pressure of 104/76 mmHg.During a concurrent interview, and record review on 1/21/2026, at 10:03 a.m., with LVN 1, LVN 1 stated metoprolol should have been held on 1/9/2026, at 9 a.m., because Resident 1's sbp was below 110 mmHg. LVN 1 stated Resident 1's blood pressure could drop because LVN 4 administered metoprolol.During an interview on 1/21/2026, at 10:35 a.m., with the Director of Staff Development (DSD) stated Resident 1's blood pressure could further drop because LVN 4 administered metoprolol.During an interview on 1/21/2026, at 10:44 a.m., with the Director of Nursing (DON), the DON stated LVN 4 should have checked the physician order first before medication administration. The DON stated Resident 1 could experience hypotension because LVN 4 administered metoprolol.b. During a review of Resident 1's Order Summary Report, dated 11/11/2025, the Order Summary Report 555456 Page 3 of 5 555456 01/22/2026 Antelope Valley Care Center 44567 North 15th St. West Lancaster, CA 93534

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some indicated the following orders:1. Pantoprazole sodium oral tablet delayed release 40 mg, give one tablet by mouth in the morning for gastroesophageal reflux disease (GERD- condition caused by the frequent backflow of stomach acid into the esophagus, leading to irritation) on an empty stomach.2. Insulin lispro injection (the delivery of medication or fluids directly into the body's tissues or bloodstream using a needle and syringe) solution 100 units per milliliter, inject as per sliding scale (a chart or formula that tells a person how much insulin to take based on their current blood sugar level) subcutaneously (beneath the skin) before meals for diabetes.During a review of Resident 1's MAR dated 1/2026, the MAR indicated on 1/8/2026, at 6:30 a.m., pantoprazole and insulin lispro were blank.During an interview on 1/21/2026, at 10:44 a.m. with the DON, the DON stated Resident 1 could experience hyperglycemia (elevated blood sugar) and GERD because LVN 3 did not administer the pantoprazole and insulin.During a concurrent interview, and record review on 1/22/2026, at 9:22 a.m. with the Quality Assurance nurse (QAN), Resident 1's Order Summary Report, dated 11/11/2025, and MAR dated 1/2026 were reviewed. The QAN stated pantoprazole and insulin lispro were left blank. The QAN stated there was no record blood sugar on 1/8/2026, at 6:30 a.m., when the insulin lispro was due and at 8:10 a.m., Resident 1's blood sugar was high at 221 mg/dl. The QAN stated Resident 1 could experience GERD and hyperglycemia.c. During a review of Resident 2‘s admission Record, the admission Record indicated the facility admitted Resident 2 on 5/9/2024, with diagnoses that included metabolic encephalopathy (a change in how your brain works due to an underlying condition), unspecific (unconfirmed) hereditary (the passing of genetic information from parent to child) and idiopathic (unknown cause) neuropathy (nerve damage) and unspecific hypothyroid.During a review of Resident 2's Physician Order, dated 8/22/2025, the Physician Order indicated the following orders:Famotidine oral tablet 20 mg, give one tablet by mouth in the morning for GERD before meals.Gabapentin oral capsule 300 mg, give one capsule by mouth in the morning for neuropathy.Levothyroxine sodium oral tablet 50 micrograms (mcg- one-millionth of a gram), give one tablet by mouth in the morning for hypothyroidism given before breakfast.During a review of Resident 2's H&P, dated 11/28/2025, the H&P indicated Resident 2 had the capacity to understand and make decisions.During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decisions were moderately impaired.During a review of Resident 2's MAR dated 1/2026, the MAR indicated on 1/8/2026 at 6 a.m. a.m., gabapentin and levothyroxine were blank.During a review of Resident 2's MAR dated 1/2026, the MAR indicated on 1/8/2026 at 6:30 a.m., famotidine was blank.During a concurrent interview. and record review on 1/22/2026. at 9:22 a.m. with the QAN, Resident 2's Physician Order, dated 8/22/2025, and MAR, dated 1/8/2026, were reviewed. The QAN stated on 1/8/2026, Resident 2's famotidine, gabapentin and levothyroxine were left blank. The QAN stated blank in MAR indicated medication was not administered. The QAN stated Resident 2 could experience GERD, increase in neuropathic pain and uncontrolled hypothyroid.During an interview on 1/22/2026, at 9:40 a.m., with the DON, the DON stated blank in MAR indicated medication not administered. The DON stated Resident 2 could experience acid reflux because LVN 3 did not administer famotidine. The DON stated Resident 2 could experience pain because LVN 3 did not administer gabapentin. The DON stated Resident 2 could experience uncontrolled hypothyroidism and affect Resident 2's metabolism because LVN 3 did not administer levothyroxine.During a review of facility's policy and procedure (P&P), titled, Administering Medications, dated 5/2024, was reviewed. 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 frame.7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders) .11. The following information is checked/verified for 555456 Page 4 of 5 555456 01/22/2026 Antelope Valley Care Center 44567 North 15th St. West Lancaster, CA 93534

F 0755 each resident prior to administering medications: a. Allergies to medications; and b. Vital signs, if necessary. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 555456 Page 5 of 5