Health inspection·December 18, 2025

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure proper and safe infection control practices were followed when:1. Resident 41, Resident 54, and Resident 139's nebulizer (a small machine that turns liquid medicine into a mist that can be easily inhaled) tubing (a thin plastic hose that delivers pressurized air from the nebulizer's air compressor machine to the medicine cup) was found unlabeled and not stored in plastic bags in accordance with the facility's policy and procedure (P&P).2. Resident 139's portable oxygen tank (a lightweight, mobile container that stores oxygen) nasal canula tubing (a small flexible plastic tube that connects to an oxygen source) was found unlabeled in Resident 139's room. 3. Licensed Vocational Nurse 3 (LVN 3) was observed entering Resident 51 and Resident 151's room on novel respiratory precaution without the required face shield or goggles in accordance with facility's policy and procedure (P&P).4. Resident 51, Resident 95, and Resident 160's nasal cannula (a lightweight, clear tube with two prongs that fit into the nostrils to deliver supplemental oxygen or increased airflow for respiratory support) was found undated and unlabeled in accordance with facility's policy and procedure (P&P). These failures had the potential to spread infectious disease (disease caused by bacteria, viruses, fungi or parasite) to 87 medically compromised residents and staff in the facility.Findings: Residents Affected - Some 1.a. During a review of Resident 41's admission Record (contains medical and demographic information), the admission Record indicated Resident 41 was admitted to the facility on [DATE] with the diagnoses which included chronic respiratory failure with hypoxia ( The lungs have a long-term problem keeping enough oxygen in your blood, leading to low oxygen levels), Chronic Obstructive Pulmonary Disease(COPD- a progressive lung disease that blocks airflow, making it hard to breathe) and Asthma (a chronic lung condition where airways become inflamed, swollen, and narrow, making it hard to breathe). During a review of Resident 41's Physician Order dated February 26, 2025, the Physician Order indicated, . Change handheld nebulizer and put in new bag weekly. Initial and date HHN (handheld nebulizer) and bag every day shift every Thursday. During a concurrent observation and interview, with Licensed Vocational Nurse 2 (LVN 2) on February 15, 2025, at 10:50 AM, in Resident 41's room, LVN 2 confirmed Resident 41's nebulizer tubing was not in use and not stored in a plastic bag, she further confirmed the nebulizer tubing was not labeled per policy. 1b. During a review of Resident 54's admission Record, the admission Record indicated Resident 54 was admitted to the facility on [DATE] with the diagnoses which included, Chronic Obstructive Pulmonary Disease (COPD- a progressive lung disease that blocks airflow, making it hard to breathe) and Lobar Pneumonia (a lung infection that inflames the air sacs causing them to fill with fluid or pus (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 5 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 12/18/2025 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)