Health inspection·June 28, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow their policy for one of three sampled residents (Resident 1) when informed consent was not provided by resident or representative prior to psychotropic medication was administered (medications that affects mind, emotion and behavior). Residents Affected - Few This failure resulted in Residents 1's representative rights to be violated and risks, benefits, adverse reactions and right to refuse the administration of the medication. Findings: During review of Residents 1's admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include: senile degeneration of brain (mental deterioration, loss of intellectual ability), palliative care (specialized care for people with serious illness), unspecified dementia (impaired ability to remember, think or make decisions), anxiety (feeling of fear, feeling tense and restless), delirium (mental state of confusion, disoriented, and lack of awareness). During a concurrent interview and record review of Resident 1's with the Director of Nursing (DON), reviewed are as follows: 1. Physician Telephone Order (Hospice) Dated July 27, 2023, Medication Order: Haloperidol (antipsychotic medication used to treat certain types on mental disorders) LAC 5 mg/mL vial inject 1 mL IM every 6 hours as needed .Signed July 28, 2023. 2. Documents: Apple Valley Care Center, Facility Verification of Residents Informed Consent Psychotherapeutic Drugs of Prolonged Use of Device Dated July 27, 2023: Resident Representative as Charter Hospice [Name] Registered Nurse, Relationship: [Name] Registered .Nurse receiving Order [Name] Registered Nurse .doctor signature dated July 28, 2023. (No resident or Resident Representative (spouse) signature of consent noted). 3. Medication Administration Record (MAR) July 2023: Haldol injection 5mg/mL, inject 1 mL intramuscularly every 6 hours as needed for r/t agitation, Administered July 28, 2023, at 11:12 and 1754. During an interview with the Director of Nursing DON (DON), the DON stated, The hospice nurse told me she called the wife for Haldol consent. I will not give medication if there is not a verbal or a signed consent. The hospice nurse told me she was the one who called the wife to get the consent, but I see the document, she [the hospice nurse] signed on the wrong space, it has her name in the resident representative. When asked, based on this document reviewed does it state the wife was called (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: 555476 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 555476 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Apple Valley Care Center 11959 Apple Valley Rd Apple Valley, CA 92308 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)