Health inspection·January 30, 2025

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain complete and accurate medical records for one of three residents (Resident 1) reviewed for assisted falls, when Resident 1 had a change in condition and an assisted fall which was not documented according to facility's policy. This failure had the potential for inaccurate communication between health care professionals, which can lead to delays in treatment, follow-up evaluations, and treatment plans for Resident 1. Findings: During the review of Resident 1's admission record (a document that gives a summary of resident's information), the document indicated Resident 1 was admitted to the facility on [DATE], with a diagnosis that included systemic lupus erythematosus (a chronic autoimmune disease that occurs when the body's immune system attacks healthy cells and tissues), and difficulty in walking. During an interview on January 30, 2025, at 11:28 AM, with the Case Manager (CM 1), the CM 1 stated Resident 1 claimed that she slid and fell in her room, but she was unable to locate the incident report for Resident 1 when she searched for it. She also looked for a Change of Condition (COC) report in Resident 1's record, but she could not find one. During a telephone interview on January 30, 2025, at 11:56 AM, with the Certified Nursing Assistant (CNA 1), the CNA 1 stated on December 25, 2024, Resident 1 wanted to get up to use the restroom. When Resident 1 tried to stand, she slipped off the bed and was helped to the floor. The daughter of Resident 1 was present at the time. CNA 1 subsequently sought assistance from another CNA, and they successfully helped Resident 1 to the restroom together. CNA 1 stated that she informed the Licensed Vocational Nurse (LVN 1) of the incident. CNA 1 claimed that the resident was not assessed by LVN 1. CNA further explained, because Resident 1 was unharmed, she did not submit a report. However, the Director of Staff Development (DSD) gave her instructions to do so, and on January 3, 2025, she completed it and turned it in to the DSD. During an interview on January 30, 2025, at 12:08 PM, with the Director of Nursing (DON 1), the DON 1 stated nurses must still complete a COC report and enter it in the chart for assisted fall incidents. During a concurrent telephone interview and record review, on February 3, 2025, at 4:53 PM, with the MDS (Minimum Data Set- a computerized assessment) Coordinator (MDSC 1), the facility's fall protocol policy and procedure (P&P) titled, Fall Prevention Program undated, was reviewed. The P&P (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 01/30/2025 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)