Health inspection·October 17, 2024

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, document review, and interview, the facility failed to ensure the discharge Minimum Data Set (MDS) was accurate for the location of disposition at the time of discharge for 1 (Resident #91) of 18 sampled residents. Residents Affected - Few Findings included: The Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual, dated 10/2024, revealed The RAI process has multiple regulatory requirements. Federal regulation at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that (1) the assessment accurately reflects the resident's status. The User's Manual specified, Knowing the setting to which the individual was discharged helps to inform discharge planning. An admission Record revealed the facility admitted Resident #91 on 07/16/2024. According to the admission Record, Resident #91 discharged home on [DATE]. A discharge MDS, with an Assessment Reference Date (ARD) of 07/30/2024 indicated Resident #91 discharged to a short-term general hospital. Resident #91's care plan, included a focus area initiated 06/21/2024, that indicated the resident wished to discharge to home when their therapy goals were met. Resident #91's physician orders revealed an order with a revision date of 07/29/2024, that indicated the resident would discharge home with family on 07/3/2024. In an interview on 10/17/2024 at 8:51 AM, the MDS Coordinator stated the information on Resident #91's discharge MDS was incorrect. In an interview on 10/17/2024 at 11:29 AM, the Director of Nursing (DON) stated her expectation was that the MDS should be completed timely and correctly. The DON stated the facility did not have a policy for MDS completion but followed the RAI guidelines. In an interview on 10/17/2024 at 11:39 AM, the Administrator stated she expected the MDS to be correct. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555476 If continuation sheet Page 2 of 6 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 10/17/2024 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)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on interview, record review, document review, and facility policy review, the facility failed to notify the physician of pharmacy recommendations and failed to ensure the facility policy indicated a time frame for the physician response to pharmacy recommendations for 2 (Resident #40 and Resident #85) of 5 sampled residents reviewed for unnecessary medications. Findings included: A facility policy titled, Medication Regimen Reviews, revised 05/2019, indicated, Policy Statement The consultant pharmacist reviews the medication regimen of each resident at least monthly. The policy specified, 4. The goal of the MRR [medication regimen review] is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medications. The policy indicated, 11. If the physician does not provide a timely or adequate response, or the consultant pharmacist identified that no action has been taken, he/she contacts the medical director or (if the medical director is the physician of record) the administrator. 12. The attending physician documents in the medical record that the irregularity has been reviewed and what (if any) action was taken to address it. The policy did not indicate a time frame for the physician response. 1. A significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/01/2024, revealed the facility admitted Resident #40 on 09/07/2023. The MDS revealed the resident had active diagnoses to include arthritis, cervical disc degeneration, disorders of bone density and structure, and chronic pain syndrome. Per the MDS, the resident had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #40 took an opioid medication. Resident #40's Order Summary Report, that contained active orders as of 10/16/2024, revealed an order dated 08/20/2024, for Morphine Sulfate (concentrate) solution 20 milligrams per milliliter (mg/ml), give 0.5 ml by mouth every four hours for pain management. The facility medication regimen review report dated 10/04/2024, revealed a recommendation that directed the staff to call the physician now and write an order to clarify the dose of morphine sulfate that should be administered to the resident. In an interview on 10/17/2024 at 11:29 AM, the Director of Nursing (DON) stated the morphine order was still incorrect and had not been clarified. The DON stated she forgot to follow up because the pharmacist discussed the recommendation with the charge nurse, but the DON did not know which charge nurse it was. The DON stated she expected the physician to be notified within 48 hours of a pharmacy recommendation. The DON stated if the recommendation was not followed up on, there could be an adverse reaction. 2. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/15/2024, revealed the facility admitted Resident #85 on 08/09/2024. The MDS revealed the resident had active diagnoses to include Alzheimer's disease, non-Alzheimer's dementia, anxiety disorder, and encounter for palliative care. Per the MDS, the resident had a Brief Interview for Mental Status (BIMS) score of 2, which indicated the resident had severe cognitive impairment. Resident #85's Order Summary Report, that contained active orders as of 10/16/2024, revealed an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555476 If continuation sheet Page 3 of 6 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 10/17/2024 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)

F 0756 Level of Harm - Minimal harm or potential for actual harm order dated 09/12/2024, for lorazepam intensol oral concentrate 2 milligram (mg) per milliliter (ml), give 0.5 ml by mouth every six hours as needed for anxiety manifested by agitation /restlessness and an order dated 09/19/2024, for ABHR (a topical gel that contained four drugs: lorazepam, diphenhydramine, haloperidol, and metoclopramide that was used to treat nausea and vomiting and to subdue agitated residents) cream/gel apply 1 ml to inner wrist every six hours as needed for anxiety/agitation. Residents Affected - Few The facility medication regimen review report dated 08/12/2024, revealed a recommendation for Resident #85 that indicated agitation, unspecified, or restlessness were not sufficient reasons for the use an antipsychotic medication and to limit the as needed Ativan (lorazepam) to 14 days. The facility medication regimen review report dated 10/04/2024, revealed a recommendation for Resident #85 that indicated agitation, unspecified, or restlessness were not sufficient reasons for the use an antipsychotic medication and to discontinue the as needed ABHR today because as needed antipsychotics were not appropriate in this setting. In an interview on 10/17/2024 at 9:36 AM, the Director of Nursing (DON) stated Resident #85 was on the PRN medications because the resident was on hospice services. The DON stated she spoke to the hospice nurse about the pharmacist's recommendations, who then spoke to the hospice physician; however, there was no documentation of the physician notification. In an interview on 10/17/2024 at 10:31 AM, the Consultant Pharmacist stated his expectation was that his recommendations would be followed up on within two weeks. In a follow-up interview on 10/17/2024 at 11:29 AM, the DON stated her expectation was that the medication regimen review recommendations should be followed up on within one week. The DON stated if the physician was not notified there could be an adverse reaction. In an interview on 10/17/2024 at 11:39 AM, the Administrator stated she expected the physician to be notified of any pharmacy recommendations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555476 If continuation sheet Page 4 of 6 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 10/17/2024 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)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, interview, and facility policy review, the facility failed to ensure the medication error rate was not greater than 5 percent (%). The facility had 2 medication errors out of 31 total opportunities, which resulted in a medication error rate of 6.45% (percent) for 2 (Resident #23 and Resident #66) of 7 residents observed for medication administration. Residents Affected - Few Findings included: A facility policy titled, Administering Medications, revised 04/2019, specified, Medications are administered in a safe and timely manner, and as prescribed. The policy specified, 10. The individual administering the medication checks the label to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. 1.An admission Record indicated the facility admitted Resident #66 on 07/01//2024. According to the admission Record, the resident had a medical history that included a diagnosis of generalized muscle weakness. Resident #66's Order Summary Report revealed a physician's order dated 07/02/2024, for a multiple vitamin tablet to be given one time per day as a supplement. During an observation of medication administration on 10/15/2024 at 9:17 AM, Licensed Vocational Nurse (LVN) #6 administered one multivitamin with minerals tablet to Resident #66. During an interview on 10/15/2024 at 11:20 AM, LVN #6 stated she gave a multivitamin with minerals to Resident # 66, but she gave the wrong one because the physician's order was for a multivitamin with no minerals. During an interview on 10/15/2024 at 11:34 AM, the Director of Nursing stated the nurse should have read the label on the medication, followed the order, and gave the correct medication to Resident #66. 2. An admission Record indicated the facility admitted Resident #23 on 11/13/2020. According to the admission Record, the resident had a medical history that included a diagnosis of chronic obstructive pulmonary disease. Resident #23's Order Summary Report revealed a physician's order dated 01/19/2022, for a multiple vitamin with minerals tablet to be given one time per day as a supplement. During an observation of medication administration on 10/15/2024 at 9:53 AM, Licensed Vocational Nurse (LVN) #7 administered one multivitamin tablet to Resident #23. During an interview on 10/15/2024 at 11:16 AM, LVN #7 stated she did not give Resident #23 the multivitamin with minerals, but gave the resident the multivitamin. LVN #7 stated she gave the multivitamin without minerals, which was not ordered. During an interview on 10/15/2024 at 11:36 AM, the Director of Nursing stated the nurse should have followed the order and compared the medication label to the medication administration record before she administered the medication. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555476 If continuation sheet Page 5 of 6 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 10/17/2024 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)

F 0759 Level of Harm - Minimal harm or potential for actual harm During an interview on 10/17/2024 at 11:18 AM, the Administrator stated the nurses should have read the label for both residents and compared it to what was ordered and gave the right medication as ordered. The Administrator stated if there was a question about the medication, the nurses should have stopped and called to double check the order with the doctor or asked the DON for direction. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555476 If continuation sheet Page 6 of 6