Health inspection·January 21, 2026

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 observation, interview, and record review, the facility failed to ensure their policy and procedure for Changes in Residents Condition (COC) or Status was implemented for one of three sampled residents (Resident 1) when: 1. Resident 1 was assessed with discoloration on his lower back. 2. Resident 1 refused to receive Physical Therapy (a healthcare service that helps people restore movement, manage pain, and improve physical function after injury, surgery or treatments due to a condition. This failure had the potential for Resident 1's overall medical condition to decline and go undetected by the facility. Findings: 1.During a review of Residents 1's admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included type 2 diabetes mellitus (a disease in which there is too much sugar in the blood and the body is not able to control the sugar ), difficulty in walking ( unusual change in the normal walking pattern often due to problems with the brain nerves, leading to unsteadiness, limping, or other abnormal movements that affect mobility and coordination), muscle weakness ( reduction in muscle strength).During a review of Resident 1's admission Skin Assessment, dated October 29, 2025, at 7:30 AM, documented by the Wound Care Nurse (WCN), it indicated Resident had Discolorations on Lower Back.During a review of Resident 1's clinical records, there was no documented evidence to indicate the discolorations on Client 1's lower back were addressed by the facility.During a concurrent interview and review of Resident 1's clinical records with the WCN, on December 29, 2025, at 11:25 AM, the WCN stated that a monitoring of change of condition was not done for the discolorations of his lower back on admission skin. The WCN stated, I did not initiate the care plan as well. The WCN further stated that without the care plan they were not able to monitor the discoloration, nor assess or document the skin condition prior to Resident 1 transferring out of the facility. During an interview with the Director of Nursing (DON) on December 29, 2025, at 1:00 PM, the DON stated, The wound care nurse documented on the admission skin assessment that there is a discoloration on lower back. There should have been a change of condition notification to the primary physician and responsible party on admission. A care plan should have been initiated to monitor the discoloration for 14 days. The DON stated it should have been monitored and documented. 2. During a review of Residents 1's admission Record, the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included type 2 diabetes mellitus, difficulty in walking, and muscle weakness.During a review of Resident 1's admission Physician Orders, dated October 28, 2025, it indicated Resident 1 had an order for Physical Therapy Evaluation and Treatment.During a review of Resident 1's Physical Therapy Treatment Encounter notes from November 11, 2025, through November 16, 2025, it indicated Resident 1 refused to ambulate on four occasions, November 11, 2025, November 12, 2025, November 13, 2025, and November 16, 2025.During a review of Resident 1's clinical records, there was no documented evidence to indicate Resident 1's refusals to ambulate were addressed by the facility.During a concurrent interview and review of Resident Residents Affected - Few (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 01/21/2026 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)