Health inspection·June 9, 2025

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 provide the appropriate care and services to meet the needs of one of three sampled residents (Resident 1) when: Residents Affected - Few Resident 1 was admitted to the facility for cholecystectomy (surgical removal of the gallbladder) and removal of drainage tube to surgical site, but the facility was unaware of when the surgery took place and follow up visits and treatments from Resident 1's surgeon. The facility did not have a care plan to address Resident1's previously identified behavior of pulling out the drainage tube. The facility did not notify Resident 1's physician regarding the incidents of Resident 1 pulling out the drainage tube. These deficient practices compromised the delivery of care and services and led for Resident 1 to be transferred to the hospital for pulling out the drainage tube attached to the surgical site. 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: cholecystectomy (surgical removal of the gallbladder), atrial fibrillation (irregular heart rhythm), biliary pancreatitis (gallstones blocking pancreatic duct), hypertension (high blood pressure). During a concurrent interview and record review of Resident 1's Medical Record, on May 07, 2025, at 11:10AM, with the Director of Nursing (DON) the following were reviewed and verified: 1. [Acute Hospital Name] History and Physical dated April 04, 2025: A 92-yr old patient History of cholecystectomy presents to Emergency Department for removal of draining tube to surgical site. Per Emergency Medical Services (EMS) had cholecystectomy done and accidentally removed the draining tube, tube was meant to stay in place for approx. 6 weeks. (Facility does not know date or surgery or follow up on plan of care). 2. Order dated April 05, 2025: Right upper abdomen drain tube every shift monitor output. Right upper Abd drain tube site everyday shift cleanse with NS pat dry cover with dry dressing. (No ranges for output noted and when to notify physician). 3. Nurse Note April 06, 2025 @ 02:19: Patient observed pulling on drainage tube. Tubing remains Page 1 of 3 555476 555476 06/09/2025 Apple Valley Care Center 11959 Apple Valley Rd Apple Valley, CA 92308

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. 555476 Page 2 of 3 555476 06/09/2025 Apple Valley Care Center 11959 Apple Valley Rd Apple Valley, CA 92308

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 555476 Page 3 of 3