Health inspection·June 9, 2025

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few patent and draining dark green fluid effectively. Education provided to patient on importance of keeping drainage tube patent . : 4. Nurse Note April 06, 2025 @2226: New admit, recent cholecystectomy for removal of drainage tube to surgical site. At 1626 resident attempted to remove drainage tube. Resident also been seen getting up out and wandering in the hallways . 5. Nurse Note May 04, 2025, 2143: At 2000 family members notified the Registered nurse (RN) and this License Vocational Nurse (LVN) they noticed the site around the residents Jackson Pratt (JP) (surgical drainage tube) drain was red, noticed pitting edema on both feet. Upon assessment, it was noted the (JP) drain was pulled out. Redness around the site .resident was transferred out by 2124. 6. Careplan: (No Notes for .At risk/attempts for pulling on JP drainage tube noted). During an interview on May 07, 2025, at 11:45AM, with the Certified Nursing Assistant (CNA), the CNA stated, Resident 1 was always messing with the (JP) tube, she would have it on her pant leg, hanging. I would stick in her pants and part hanging out. I was not here when she pulled it out. The nurse when I first started taking care of her told me to keep an eye out because she pulls the JP tube. She had an abdominal binder; she would take it off. During an interview on May 07, 2025, at 12:40PM, with the Director of Nursing (DON), the DON stated, Resident 1 Initial admission was April 04, 2025, for status post cholecystectomy she has acute pancreatitis, there was orders to monitor and drainage. She was taken to Emergency Department 4/4/25 because she pulled out tube cholecystectomy done JP to stay in place 6 weeks she has Dementia. I don't know when her actual surgery was done. When first admitted , we have a to check if there is any follow up appointments, if any procedures. We don't have that one for this resident. There is no documentation in system, us asking the family about the procedure, the JP tube incident of pulled out prior to admission. I can admit, she had episodes of her trying to pull out drainage tube but no documentation is noted of this. There was supposed to have an SBAR. I can agree this was already an issue of her pulling her JP tube before this resident got here. There is no follow through from us on this issue. We do SBAR first and inform the doctor and family and continue at least 72 hours monitoring and if still persist continue monitoring, we update the Careplan. I can agree there was no interventions set for her pulling the JP tube, she was sent out May 04. 2025, for pulling out her JP tube. We failed in not having Change Of Condition (COC) for her pulling on JP tube and no follow up regarding procedure (JT) tube from emergency Department or family. During a review of the facility's policy and procedure titled, Change in a Resident's Condition or Status revised June 2020, the policy and procedure indicated, Our facility shall promptly notify the resident, his or her Attending Physician and representative of changes in the residents medical/mental condition and or status .1a. accident or incident involving the resident .3.Prior to notifying the Physician, the nurse will make detailed observations and gather relevant and pertinent information for the provider.7 the nurse will record in the residents medical record information relative to changes in the residents medical/mental condition or status. During a review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered revised March 2024, the policy and procedure indicated, A comprehensive, person-centered care plan the includes measurable objectives and timetables to meet the resident's, physical, psychological and functional needs is developed and implemented for each resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555476 If continuation sheet Page 2 of 3 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 06/09/2025 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)

F 0684 Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure titled, Safety and Supervision of Residents revised July 2024, the policy and procedure indicated, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide-priorities. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555476 If continuation sheet Page 3 of 3