Apple Valley Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of the three sampled residents (Resident 1) received timely incontinence care to maintain dignity and comfort when on February 17, 2026, Resident 1 was left in a soiled brief for more than 40 minutes while being served lunch. This failure resulted in Resident 1's dignity and comfort being diminished. Furthermore, Resident 1 experienced a reduction in her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that call light was accessible for two of the three sampled residents (Resident 2 and 3), when Resident 2's call light was observed to be placed on the side of the bed, above the pillow, and beyond Resident 2's reach, while Resident 3's call light was found to be wrapped around the right bedrail, which was also out of Resident 3's reach. This failure had the potential to hinder Residents 2 and 3 from seeking help, when necessary, thereby elevating the risk of unaddressed care requirements and potential harm. During a review of Resident 2's face sheet (contains demographic and medical information) indicated Resident 2 was admitted to the facility on [DATE], with diagnoses that included fracture of unspecified part of neck of right femur (thigh bone), difficulty in walking. [...]

Inspectors wroteBased 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: 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.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records for one of three residents (Resident 1) reviewed for assisted falls, when Resident 1 had a change in condition and an assisted fall which was not documented according to facility's policy. This failure had the potential for inaccurate communication between health care professionals, which can lead to delays in treatment, follow-up evaluations, and treatment plans for Resident 1.

Inspectors wroteBased on interview, document review, and facility policy review, the facility failed to resolve grievances voiced by 5 (Residents #20, #36, #66, #195, and #200) of 5 residents who attended the resident council meeting.

Inspectors wroteBased on record review, document review, and interview, the facility failed to ensure the discharge Minimum Data Set (MDS) was accurate for the location of disposition at the time of discharge for 1 (Resident #91) of 18 sampled residents.

Inspectors wroteBased on interview, record review, document review, and facility policy review, the facility failed to notify the physician of pharmacy recommendations and failed to ensure the facility policy indicated a time frame for the physician response to pharmacy recommendations for 2 (Resident #40 and Resident #85) of 5 sampled residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure the medication error rate was not greater than 5 percent (%). The facility had 2 medication errors out of 31 total opportunities, which resulted in a medication error rate of 6.45% (percent) for 2 (Resident #23 and Resident #66) of 7 residents observed for medication administration.

Inspectors wroteBased on interview and record review the facility failed to follow their policy for one of three sampled residents (Resident 1) when informed consent was not provided by resident or representative prior to psychotropic medication was administered (medications that affects mind, emotion and behavior). This failure resulted in Residents 1's representative rights to be violated and risks, benefits, adverse reactions and right to refuse the administration of the medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain resident room temperatures between 71- and 81-degrees Fahrenheit (°F) in 39 of 41 rooms when temperatures dropped below 71 °F in the resident bedrooms during the time in which the facility's heating system became inoperable on (January 10, 2024) and needed to be replaced. Furthermore, resident room temperatures continued to intermittently be below 71 °F nearly one month later while the facility's heating system was still undergoing assessment and maintenance. This failure had the potential for all 95 of 95 residents living within the facility to experience physical discomfort, and emotional distress associated with exposure to cold temperatures throughout the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe environment for all 95 residents living within the facility when portable space heaters were in use in multiple resident rooms during the time the facility's heating system was being repaired. This failure had the potential for all 95 residents to be at risk of physical injury due to the increased risk of fire hazards associated with the use of space heaters.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure call light (a device that triggers a visual and/or auditory queue when a resident needs assistance) was accessible for one of three sampled Residents (Resident 1) when Resident 1 ' s call light was not plugged into the wall and not accessible to Resident 1. This failure had the potential to place Resident 1, at risk of harm, as Resident 1 may have experienced an emergency or needed assistance and would not have been able to call for help.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper sanitation and food safety practices to prevent food-borne illnesses as evidenced by: 1. Six pie crusts were inside the freezer in an unsealed packaging, with no label nor dates which can result in food contamination and quality deterioration. 2. Food debris, black grime, and trash, were observed under the kitchen stove, tilting skillet, and center island that had the potential to contaminate food. 3. Food crumbs and debris were observed at the base of the cabinet attached to the kitchen stove that had the potential to contaminate food. 4. Wet pans and trays were stacked together which could promote bacterial growth. 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the garbage storage area in a sanitary condition when one of two garbage dumpsters was overflowing with the lid open, and trash and leaves were accumulating around the garbage dumpster. This failure had the potential for harborage and feeding of pests within and around the facility.

Inspectors wroteBased on interview and record review, the facility failed to have all the required members (Director of Nursing, Medical Director, Administrator, and Infection Preventionist) at the monthly and quarterly Quality Assurance Performance Improvement (QAPI - meeting to identify opportunities for improvement, implement improvement plans and monitors effectiveness of interventions to improve the quality of life, care, and services to residents) meetings per facility policy and procedure, per regulatory requirements, when monthly and quarterly meetings did not have the required members documented as being present at these meetings. This failure had the potential to leave important issues unidentified for residents impacting their quality of life, care, and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all equipment within the facility was maintained in safe operating condition when: 1. Two refrigerators within the facility's kitchen were in a non-operational state. This failure had the potential for staff to access the refrigerators and store items inside non-functional units that were no longer capable of properly cooling or holding food at safe temperature, and also attract pests. 2. There was no documented evidence the facility's industrial clothes dryer had the lint trap (a filter used to catch the lint as the air goes out when drying clothes) cleaned as specified in the facility's policy and procedure when the log used to document periodic lint trap removal, was not completed from April 22, 2021 through January 5, 2022. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their infection control program to help prevent the spread of COVID-19 (A highly infectious disease caused by the SARS-CoV-2 virus) and other communicable diseases when: 1. One staff member (Certified Nursing Assistant-CNA 1) was observed to be improperly wearing her N95 respirator mask (a filtering facemask used to protect the wearer from fine particles including viruses) when the N95 mask was located around her neck and was not covering her nose and mouth on January 4, 2022. 2. One staff member (Licensed Vocational Nurse-LVN 1) did not accurately complete the COVID-19 screening log (a log used to screen staff and visitors for COVID-19 symptoms and exposure prior to entering the facility) regarding her signs and symptoms of the COVID-19 illness, on January 4, 2022. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a comfortable and homelike environment for one of three residents (Resident 67), when his room was found to be less than the regulatory required temperature range of 71 degrees Fahrenheit (a unit of measure) to 81 degrees Fahrenheit on two occasions. This failure negatively impacted Resident 67's sense of well-being and comfort.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one resident (Resident 88) received interventions to help manage pain on January 1, 2022, when Resident 88 experienced severe pain (scaled 7 out of 10 where 0 = no pain and 10 = excruciating pain) and the Licensed Vocational Nurse 2 (LVN 2) did not provide non-pharmacological interventions (non-medicinal techniques to help alleviate pain) and did not provide the resident with pain medication as was ordered by the physician. These findings had the potential for Resident 88 to experience undue stress, physical discomfort and pain.

Inspectors wroteBased on observation, interview, and facility record review, the facility failed to ensure a medication error rate of less than 5% when the medication error rate was 18.5%, with five errors in 27 opportunities, when for one of 12 residents (Resident 82) a Licensed Vocational Nurse (LVN 5) put four crushable medications, and opened one capsule adding the contents to these medications and then administered all five medications together via gastrostomy tube (GTube - a tube that enters through the abdomen to deliver nutrition and medication), instead of separately as per facility policy and procedure. This failure had the potential to affect the compatibility and absorption of the medications reducing their efficacy and impacting Resident 82's health.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure licensed nurses reviewed resident food trays prior to distributing the meals, to ensure that prescribed diets to include therapeutic diets, were provided to the residents as ordered by their physician when: 1. Two staff members (Certified Nursing Assistant-CNA 1 and CNA 3) were observed distributing meal trays to residents who resided in the 100 hall without the trays being checked by licensed staff according to the facility's policy and procedure on January 3, 2022. 2. Multiple CNA's were observed to be distributing meal trays to residents who resided in the 400 hall prior to the meal trays being checked by nursing staff, on January 3, 2022. This failure had the potential for residents to receive meal trays with foods that were not in accordance with their prescribed diet.