Inspection Reports for
Antelope Valley Care Center

The facility was found deficient in multiple areas including medication administration errors, failure to monitor and document pain and antibiotic side effects, improper infection control practices, inadequate care planning, failure to ensure resident safety related to environmental hazards, and incomplete documentation. Several residents experienced risks related to these deficiencies, including potential for medication side effects, infections, falls, and delayed or inadequate care.

The complaint investigation found that Resident 1 refused buspirone multiple times from 12/5/2025 to 12/11/2025, but the facility did not notify the physician or document the refusal properly. The facility also failed to develop a care plan addressing the refusal, which could increase Resident 1's anxiety and delay care.

The facility failed to notify the physician of Resident 1's refusal of buspirone hydrochloride, which could delay necessary care and increase anxiety. Additionally, the facility did not develop a care plan to address the refusal, potentially impacting timely and appropriate care delivery.

The complaint investigation found substantiated deficiencies related to failure to monitor residents after changes of condition and failure to provide appropriate respiratory care, placing residents at risk for worsening medical conditions and respiratory infections.

The facility failed to ensure licensed nurses monitored three residents' respiratory and gastrointestinal status after changes of condition, and failed to provide proper respiratory care for one resident by not dating oxygen supplies and not providing an oxygen supplies bag. These deficiencies had the potential to cause harm or worsen residents' conditions.

The complaint investigation found that RNA 1 did not wear a gown while assisting Resident 2 with passive range of motion exercises despite the resident being on enhanced barrier precautions due to a chronic wound and indwelling catheter. Interviews with RNA 1, the Infection Preventionist, and the Director of Nursing confirmed the failure to follow PPE guidelines, which could potentially spread infection.

The facility failed to ensure that RNA 1 properly used PPE, specifically a gown, while assisting Resident 2 with passive range of motion exercises despite the resident being on enhanced barrier precautions due to a chronic wound and indwelling catheter. This failure had the potential to spread multi-drug resistant organisms among residents.

The facility failed to develop and implement comprehensive, person-centered care plans for multiple residents addressing various needs including use of medical devices, behavior management, antibiotic use, pain management, and fall prevention. Additionally, the facility failed to ensure a safe environment free from accident hazards, such as improper placement of furniture on fall mats, and did not conduct an interdisciplinary team review following a resident fall.

The complaint investigation was substantiated based on interviews and record reviews showing missed doses of Eliquis and Femara for Resident 3, missing documentation on the MAR, and concerns expressed by Resident 3 about medication availability and health risks.

The facility failed to ensure Resident 3 received prescribed medications Eliquis and Femara as ordered, and the Licensed Vocational Nurse did not sign off the Medication Administration Record after administering medications. These deficiencies posed potential harm to Resident 3, including risk of blood clots and exacerbation of medical conditions.

The facility was found deficient in ensuring proper pharmaceutical services, specifically leaving topical medication at a resident's bedside without proper assessment for self-administration, and failing to keep a call light within reach of a resident, both posing potential safety risks.

The facility failed to ensure Resident 6's pain medications were administered according to physician orders, resulting in unnecessary pain and potential decline in quality of life. Multiple instances of pain medication not being given or unavailable were documented, leading to increased discomfort and suffering.

The facility failed to develop and implement a comprehensive, person-centered care plan for Resident 1 that addressed the possession of a vaping device and failed to ensure accurate and complete documentation in Resident 1's medical records. These deficiencies placed Resident 1 at risk for inadequate care and potential worsening of respiratory conditions.

The complaint investigation found that the facility did not follow its grievance policy for Residents 2, 3, and 4 by failing to notify them of grievance resolutions verbally and in writing. The Social Services Director and Director of Nursing confirmed lack of follow-up communication. Resident 3 and Resident 4 both stated they were not updated or given copies of their grievances' resolutions.

The facility failed to provide timely and documented follow-up to residents regarding the resolution of their grievances for three sampled residents, violating their rights to be informed. Additionally, the facility failed to perform weekly skin assessments for one resident at risk for pressure ulcers, potentially worsening the resident's condition.

The facility failed to provide necessary respiratory care for Resident 4 by not dating oxygen tubings when changed, not storing oxygen tubings inside an oxygen supplies bag when not in use, and allowing oxygen tubings to touch unclean surfaces, which posed a risk of respiratory infections.

The facility failed to maintain infection control precautions when two Licensed Vocational Nurses changed a resident's gastrostomy tube feeding without wearing required personal protective equipment, posing a risk of infection spread. The Infection Preventionist and Director of Nursing confirmed staff must wear gowns and gloves during such care, and in-services will be provided to staff.

The complaint investigation found that the facility did not notify the attending physician timely about Resident 1's urinary catheter issues and significant change in condition. The physician was notified late, and follow-up communication was inadequate. The resident was eventually transferred to the hospital with acute urinary retention and UTI.

The facility failed to notify the attending Medical Doctor of Resident 1's significant change in condition related to urinary retention and urinary tract infection, resulting in a delay in transferring the resident to a hospital. The facility also failed to properly monitor and document Resident 1's urinary output, placing the resident at risk for complications.

The facility failed to ensure a licensed Administrator held a current and active license and was present at the facility for adequate hours. The Administrator in Training/Operations Manager performed administrative duties without a licensed ADM present, potentially affecting facility operations.

The facility was found deficient in multiple areas including improper pressure ulcer prevention care for Resident 1, failure to prevent a fall resulting in injury, and inadequate urinary catheter care leading to potential infection risks.

The facility failed to maintain accurate and complete medical records for one sampled resident by not documenting blood pressure before holding amlodipine as ordered by the physician. This deficiency had the potential to cause confusion in care and inaccurate medical records.

The facility failed to ensure proper care for one of four sampled residents with a urinary catheter by not following the physician's order for a timely treatment nurse check, resulting in potential for uncontrolled pain and delayed wound healing.

The facility was found deficient in ensuring proper use of hearing aids for a resident, appropriate pressure ulcer care including correct mattress settings, and administration of prescribed antibiotics, specifically Vancomycin, which was missed for 15 days, potentially risking worsening infections.

The complaint investigation found that Resident 2 physically abused Resident 1 on 2024-09-17. The allegation was reported late, 14 hours after the incident, violating the facility's abuse reporting policy. Residents affected were few, and the harm was minimal.

The facility failed to protect a resident from physical abuse by another resident and failed to timely report the abuse allegation to the appropriate authorities within the required two-hour timeframe. The abuse involved Resident 2 hitting Resident 1 with a closed fist, resulting in minimal harm. The facility's policy on abuse prevention and reporting was not followed.

The investigation was complaint-driven, focusing on respiratory care deficiencies for Residents 16, 32, and 34. The complaint was substantiated with findings that oxygen was administered without proper physician orders and monitoring, and oxygen flow rates exceeded physician orders, posing risks of respiratory distress and other complications.

The facility failed to ensure that residents requiring oxygen therapy were administered oxygen per physician's orders and that oxygen use was properly documented and monitored. Specifically, Resident 16 received oxygen without an active physician's order and without documented monitoring, and Residents 32 and 34 received oxygen at incorrect flow rates contrary to physician orders, potentially placing residents at risk for respiratory distress.

The facility had multiple deficiencies including failure to honor resident dignity during feeding, improper medication self-administration assessments, call light accessibility issues, failure to notify resident representatives of hospital transfers, missing consents and assessments for physical restraints, improper storage and administration of medications including insulin, lapses in infection control practices, and dietary service deficiencies including unsafe food storage temperatures, improper food preparation, and failure to follow recipes and portion sizes.

The facility failed to provide pharmaceutical services by not administering prescribed medications to a resident, failed to implement proper COVID-19 staff screening and testing procedures, and failed to properly document COVID-19 vaccination consent and status for residents and staff. These deficiencies posed potential risks for resident health and infection transmission.

The complaint involved Resident 2's grievance about Resident 3's television volume being too high, causing sleep disruption and distress. The facility failed to promptly and effectively resolve the grievance despite multiple staff interventions and offers of accommodations such as headphones and room changes, which were declined or ineffective.

The facility failed to ensure a comfortable and homelike environment by not adequately managing TV volume disturbances, failed to promptly resolve grievances related to the disturbance, did not assist Resident 3 in arranging a hearing test appointment, administered breathing treatment to Resident 5 without a physician's order, and lacked proper policies and control over video surveillance systems.

The facility failed to maintain a clean and homelike environment in Resident 1's room, as evidenced by red stains on the ceiling above the resident's bed. Staff interviews revealed awareness of the issue but lack of timely action to clean the ceiling, posing a potential infection risk and negatively impacting the resident's psychosocial wellbeing.

The facility failed to ensure that Certified Nursing Assistant 1 wore a gown while providing perineal care to Resident 2, who was on Enhanced Barrier Precautions, potentially increasing the risk of multidrug-resistant organism transmission. Observations, interviews, and record reviews confirmed non-compliance with infection control protocols.

The complaint investigation substantiated that the facility failed to prevent a fall and injury for Resident 1, who was identified as high fall risk. Resident 1 suffered a left hip fracture after falling on 7/22/2024 due to lack of bilateral bedside mats and inadequate care plan updates.

The facility failed to provide Resident 1 with bilateral bedside mats as ordered by the physician and failed to update the care plan accordingly. Resident 1 fell on 7/22/2024, resulting in a left intertrochanteric hip fracture requiring surgical repair. Interviews and record reviews confirmed the lack of implementation of the fall prevention interventions.

The complaint investigation was triggered by an incident on 6/26/2024 where Resident 7 punched Resident 6. The facility failed to protect Resident 6 from abuse and failed to properly investigate the incident, including not interviewing key witnesses and not documenting attempts to interview the roommate (Resident 8). The allegation was ultimately unsubstantiated by the facility despite evidence to the contrary.

The facility failed to protect Resident 6 from physical abuse by Resident 7, witnessed by staff. The facility also failed to thoroughly investigate the abuse allegation, including not interviewing key witnesses. Additional deficiencies included failure to provide pharmaceutical services according to physician orders for three residents and failure to implement infection control measures during a COVID-19 outbreak.

The complaint investigation focused on dignity issues related to urinary catheter care, unsafe discharge of a resident with intellectual and mental health disabilities to an unlicensed board and care without proper notification to conservator or receiving facility, inadequate pressure ulcer prevention practices, and incomplete medical record documentation including failure to document oxygen therapy and late entries.

The facility failed to maintain dignity for a resident by not covering a urinary catheter bag, discharged a resident unsafely to an unlicensed board and care without proper notification or care coordination, did not follow manufacturer guidelines for linens on air mattresses risking pressure ulcers, and failed to document oxygen intervention and late entry notes properly in medical records.

The complaint investigation focused on the failure to notify the attending physician and transfer Resident 1 in a timely manner after signs of infection were observed, leading to severe infection and septic shock. Interviews revealed staff delays and lack of persistence in contacting physicians. The complaint also included failure to update care plans for Resident 5 with behavioral issues.

The facility failed to promptly notify the attending physician and transfer Resident 1 to the hospital despite signs of infection and pus drainage at the dialysis port, resulting in the resident developing septic shock and bloodstream infection. Additionally, the facility failed to review and revise the care plan for Resident 5, who exhibited verbally abusive behavior and other behavioral issues.

The complaint investigation was substantiated. Resident 2 fell from a Hoyer lift on 4/16/2024 due to staff transferring him alone despite care plans requiring two-person assistance. Resident 2 sustained head and back injuries, was hospitalized for five days, and reported severe pain. Staff interviews confirmed the incident and failure to follow protocols.

The facility failed to ensure Resident 2, who required two-person assistance for transfers due to high fall risk and physical impairments, was transferred safely. Resident 2 fell from the Hoyer lift when transferred alone by CNA 1, resulting in head and back injuries requiring hospital admission. Staff interviews and record reviews confirmed the failure to follow safe transfer protocols.

The facility failed to ensure competency evaluation for one Certified Nursing Assistant, potentially impacting resident care. Additionally, infection control procedures were not followed for a resident on contact isolation, risking cross-contamination.

The facility failed to ensure that post-dialysis assessments were completed and documented for three sampled residents receiving dialysis, posing potential risks for unidentified complications such as swelling, pain, bleeding, and bruising. Missing pre- and post-dialysis communication forms were noted for Residents 1, 2, and 3 during the review period.

The facility failed to follow the comprehensive care plan for Resident 1, resulting in a fall due to insufficient staff assistance during ambulation with a family member. Additionally, the facility failed to provide timely wound care treatments and weekly wound assessments as ordered, potentially placing the resident at risk for wound worsening and infection.

The facility was found deficient in providing appropriate rehabilitative care and range of motion exercises for a resident with declining mobility, failing to follow physician's orders for holding blood pressure medications based on parameters for two residents, and maintaining accurate medication administration documentation for two residents. These deficiencies posed potential risks for resident decline, hypotension, and delayed care.

The complaint investigation found that Resident 5 used a racial slur against Resident 4, who responded by punching Resident 5. Both residents experienced verbal and physical abuse. The Director of Nursing confirmed the incident as abuse, with Resident 5's racial slur constituting verbal abuse and Resident 4's physical strike constituting physical abuse.

The facility failed to protect two residents from verbal and physical abuse when Resident 5 used a racial slur against Resident 4, who then physically struck Resident 5. The investigation included interviews, record reviews, and care plan evaluations confirming the incident and the facility's deficient practices.

The facility was found deficient in providing a comfortable, sanitary, and odor-free environment during resident care, failed to protect residents from physical abuse and timely report suspected abuse, and did not administer prescribed morphine medication on time, potentially causing pain and distress to residents.

The facility was found deficient in multiple areas including failure to develop a baseline care plan addressing COVID-19 for a resident, inadequate environmental safety measures such as low beds not being in the lowest position and water spills on floors, and failure to implement infection prevention and control protocols including improper mask use, social distancing violations, unlabeled oxygen tubing, and improper PPE education and use by visitors. These deficiencies posed risks for falls, infection transmission, and delayed care.

The facility was found deficient in multiple areas including failure to develop a baseline care plan for COVID-19 for a resident, inadequate environmental safety measures leading to fall risks, and failure to properly implement infection prevention and control protocols during a COVID-19 outbreak. Specific issues included unlabeled oxygen tubing, residents not wearing masks properly, overcrowding and lack of social distancing in the activity room, improper handling of ice and ice scoopers, and inadequate visitor education on PPE use and hand hygiene.

The facility was found deficient in protecting residents' personal and medical record confidentiality, timely reporting of resident-to-resident abuse investigations to the State Survey Agency, and ensuring medication carts were locked and medications were not left unattended. These deficiencies posed potential risks of privacy violations, unidentified abuse, and unauthorized access to medications.

The investigation was complaint-related, focusing on medication documentation discrepancies. The complaint was substantiated as multiple doses of Norco were documented on the CDR but not on the MAR, confirmed by interviews with nursing staff and review of records.

The facility failed to ensure that the Controlled Drug Record (CDR) form matched the Medication Administration Record (MAR) for Resident 1, resulting in multiple doses of Norco documented on the CDR but not on the MAR. This discrepancy posed a risk of medication errors, including potential under- or overdosing.

The facility failed to develop and implement a comprehensive, person-centered care plan addressing Resident 1's food dislikes, resulting in the resident being served disliked food. Additionally, the facility failed to ensure Resident 1's food preferences were followed, and failed to follow infection control procedures for Resident 2, including hand hygiene and glove use during medication administration.

The complaint investigation focused on allegations that the facility failed to develop and implement appropriate care plans for Resident 4 and failed to provide timely laboratory services and appropriate care for Resident 1's suspected urinary tract infection, which resulted in Resident 1's hospitalization and death.

The facility failed to develop and implement a comprehensive person-centered care plan for Resident 4 addressing pain management and transportation needs, resulting in missed appointments and potential delays in care. Additionally, the facility failed to ensure timely and accurate laboratory testing for Resident 1's suspected urinary tract infection, including mislabeled urine samples, failure to collect samples, lack of documentation, and failure to notify the physician and family, which contributed to Resident 1's hospitalization and subsequent death.

The facility was found deficient in responding to resident call lights, posting nurse staffing information daily, and implementing infection prevention and control measures including proper handling of oxygen tubing, linen carts, and ice scoop storage. These deficiencies posed minimal harm or potential for actual harm to residents.

The facility failed to provide timely administration and proper documentation of Norco medication for one resident, which had the potential to increase the resident's pain and risk inaccurate medication reconciliation and drug diversion.

The complaint was substantiated as the facility delayed administering Methotrexate to Resident 1 for one week. Resident 1 reported not receiving the medication as ordered, and staff interviews confirmed the delay and lack of proper documentation and communication.

The facility failed to administer Methotrexate to Resident 1 as ordered, resulting in a delay of one week in treatment. Interviews with Resident 1, the Director of Nursing, and the Administrator confirmed the delay and identified procedural shortcomings in medication administration and documentation.

The complaint investigation focused on Resident 3's non-compliance with hemodialysis and related clinical care failures. The Director of Nursing confirmed lack of RN assessment and documentation after critical lab results and medication administration, and noted that RN assessments could have helped identify more problems and potentially prevented harm.

The facility failed to assess and document a Change of Condition for Resident 3 after a high potassium lab result, did not re-evaluate potassium levels after medication administration, failed to repeat a lab test after a hemolyzed sample, and did not assess for fluid overload. These deficiencies had the potential to adversely affect Resident 3's health.

The complaint investigation focused on Resident 3's non-compliance with hemodialysis and the facility's failure to properly assess and monitor potassium levels and fluid status. The Director of Nursing confirmed the lack of RN assessment and documentation following abnormal lab results and missed dialysis treatments.

The facility failed to assess and document a Change of Condition for Resident 3 after a high potassium lab result, did not re-evaluate potassium levels after medication administration, failed to repeat a lab test after a hemolyzed sample, and did not assess for fluid overload. These deficiencies had the potential to adversely affect Resident 3's health.

The complaint investigation was triggered by allegations that the facility failed to provide immediate CPR and emergency response to Resident 1, who was found unresponsive with no pulse or breathing. The investigation found delays in calling for help, initiating CPR, and calling paramedics. Staff competency and training deficiencies were also identified. The complaint was substantiated with an Immediate Jeopardy situation declared and later removed after corrective actions.

The facility failed to ensure timely CPR and emergency response for Resident 1, resulting in immediate jeopardy to resident health. Deficiencies included delayed CPR initiation, failure to call paramedics immediately, inadequate staff training and orientation, and failure to administer medications to Resident 5 as ordered. Additionally, incomplete and inaccurate medical records were maintained for Residents 1 and 5.

The complaint investigation was triggered by allegations that the facility failed to provide immediate CPR and emergency response to Resident 1, who was found unresponsive with no pulse or breathing. The facility also failed to ensure staff competency in emergency response and failed to administer medications as ordered to Resident 5. Immediate jeopardy was identified and later removed after the facility implemented corrective actions.

The facility failed to ensure timely CPR and emergency response for Resident 1, resulting in immediate jeopardy to resident health. Staff lacked proper hands-on CPR training and delayed calling for help and paramedics. Additionally, the facility failed to provide medications as ordered to Resident 5 and maintain accurate medical records for Residents 1 and 5.

The complaint investigation found that the facility's policy did not reflect the current regulation requiring abuse allegations to be reported within two hours, potentially endangering resident safety.

The facility's policy on abuse prevention did not include the required timeframe for reporting abuse allegations within two hours, which could potentially place residents at risk for further abuse. The Administrator confirmed the policy was outdated and did not reflect current regulations.

The facility failed to ensure that one of five sampled staff, an Occupational Therapist, wore a surgical mask while seated inside the rehabilitation room, despite the presence of COVID-19 positive residents and facility policies requiring masking at all times indoors. This deficiency had the potential to spread infection.

The facility failed to ensure that one of five sampled staff, an Occupational Therapist, wore a surgical mask while seated inside the rehabilitation room, despite the presence of COVID-19 positive residents and facility policies requiring mask use at all times indoors. This deficiency had the potential to result in the spread of infection.

The facility was found deficient in protecting resident privacy by leaving electronic clinical records unattended, maintaining safe and comfortable room temperatures, and ensuring proper disinfection of equipment used by residents, which placed residents and staff at risk.

The facility was found deficient in multiple areas including failure to feed residents at eye-level, incomplete and outdated care plans, improper pressure ulcer care, incorrect enteral feeding practices, unsafe oxygen administration, inadequate pain management, medication administration errors, lack of specific indications for psychotropic medications, and lapses in infection control practices such as unlabeled nasal cannulas and improper hand hygiene.