Health inspection·February 2, 2026

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident was discharged in a safe and orderly manner for one of three sampled residents (Resident 1), by failing to: 1. Ensure Resident 1's post-discharge destination could meet Resident 1's needs prior to the discharge on [DATE].2. Involve Resident 1's Representative in the development of the discharge plan and informed of the final discharge plan. These deficient practices had the potential for Resident 1 not to receive necessary care and services and negatively affecting Resident 1's well-being.Findings:During a review of Resident 1's admission Record, the admission record indicated the facility admitted Resident 1 on 5/14/2025 with diagnoses including heart failure (a progressive condition where the heart muscle is too weak or stiff to pump enough oxygen-rich blood to meet the body's needs), encounter for palliative care (specialized medical care for people with serious illnesses, focusing on relieving symptoms, pain, and stress to improve quality of life), unspecified dementia (a progressive state of decline in mental abilities), and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 5/15/2025, the MDS indicated Resident 1's cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks) was severely impaired. The MDS indicated Resident 1 required moderate assistance (helper does less than half the effort) from the facility staff with oral hygiene, toileting hygiene, upper and lower body dressing, and personal hygiene. During a review of Resident 1's Order Summary Report, the report indicated the following physician's order:-5/15/2025 at 6:49 p.m.: Transfer resident to Board and Care 1 (a small residential home providing 24-hour non-nursing care, meals, and supervision to residents). During an interview on 2/2/2026 at 1 p.m. with the Director of Nursing (DON), the DON stated there was no documented evidence to indicate the facility staff had evaluated Board the Board and Care Facility and communicated with them (Board and Care 1) prior to Resident 1's discharge on [DATE]. The DON stated the facility staff failed to verify and ensure Resident 1 was discharged to a facility that met the required standards and would be able to ensure provision of care to Resident 1. The DON stated the facility staff relied on the information provided by the palliative care provider and did not complete proper assessment and evaluation. The DON stated Resident 1 was inappropriately discharged . The DON stated Resident 1 was placed at risk of not receiving necessary care to have his (Resident 1) needs met. The DON stated there was a potential for Resident 1 not to receive correct medications, pain assessment and management, negatively affecting Resident 1's well-being. During an interview on 2/2/2026 at 1:17 p.m. with Resident 1's Power of Attorney (POA-legally authorized person to make financial, legal, or medical decisions on behalf of the resident), POA stated that on 5/15/2026, the facility's previous Administrator (Administrator 1) had contacted him (POA) to inform that Resident 1 would be transferred back to the previous Skilled Nursing Facility (SNF) 1.The POA stated that the (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 02/02/2026 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)