Apple Valley Post-Acute Rehab

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure a dignified existence and the right to receive services promptly for one of three sampled residents (Resident 1), when staff did not respond in a timely manner to Resident 1's repeated calls for assistance while experiencing a life-threatening medical emergency. This failure delayed access to emergency care and made Resident 1 feel frightened and ignored, and had the potential to result in severe harm including death. A review of Resident 1's admission record (facility demographic) indicated she was admitted to the facility on [DATE] with diagnoses of left ankle fracture, diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor healing), and congestive heart failure (a disorder which causes the heart to not pump efficiently). [...]

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse within the mandated timeframe for one resident (Resident 2) of two sampled residents when the facility submitted notification to the California Department of Public Health (CDPH) on 8/25/25 when the allegation of abuse was reported to a nurse on 8/24/25. This failure decreased the facility's potential to protect residents.

Inspectors wroteBased on interview and record review, the facility failed to honor a resident's desire to go outdoors when one of two sampled residents, Resident 1, was asked repeatedly by multiple staff members to go inside to his room where he was in isolation for COVID-19. This failure potentially resulted in an escalation of Resident 1's anxiety prompting a call to the police and Resident 1's subsequent arrest.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to issue a written notice of bed hold when a resident transferred to a local hospital for 1 (Resident # 78) of 2 sampled residents reviewed for hospitalization. This failure resulted in a bed not being available upon discharge of the resident from the acute care hospital.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to resubmit a Level I screening for 1 (Resident #6) of 4 sampled residents reviewed for preadmission screening and resident review (PASARR, a tool to ensure residents are not inappropriately placed in nursing homes for long term care). This failure had the potential to affect the care the resident received.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure staff performed hand hygiene when soiled gloves were removed and before a new pair of gloves were put on during the provision of wound care for 1 (Resident #4) 1 sampled resident reviewed for pressure ulcer/injury. This failure had the potential to cause the spread of infection between residents.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure that one of two sampled residents, Resident 1, received an accurate reconciliation of medications (A process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of both prescription and over the counter medications that included the drug name, dosage, frequency, route, and indication for use for the purpose of preventing unintended changes or omissions at transition points in care) during her discharge, when Resident 1 received three (3) over the counter medications that were ordered for another resident, Resident 2. This failure had the potential to result in a medication error and could affect the safety and well-being of Resident 1, if she accidentally took the medications that were not ordered for her.

Inspectors wroteBased on interview and record review, the facility failed to keep one of three sampled residents (Resident 1) safe from elopement (Leaving the facility without notice), when he had a history of attempting to elope from the facility and was able to walk without a wheelchair. The facility's intervention to prevent him from elopement included a wander guard (Bracelets that trigger alarms at exit monitored doors to prevent the resident from leaving unattended) placed on his wheelchair. As a result, Resident 1 eloped from the facility by foot, left the wheelchair at the facility, which did not trigger the wander guard system, fell during the process, and hitchhiked to a neighboring town 8.5 miles away. This failure had the potential to result in serious harm, including death, to Resident 1.

Inspectors wroteBased on observation, interview and record review, the facility failed to manage two of three resident's (Resident 1 and Resident 2) pain according to professional standards of practice and resident's preferences when residents were not properly educated about their pain medication management. This failure resulted in increased pain levels and had the potential to cause a delay in recovery, impair mobility, impair mood, disturb sleep, and diminish quality of life and wellbeing.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to provide safety reminders, guidance, and assistance to one of four residents (Resident 1) before he tripped on a transition strip on the floor and fell while walking at the lobby of the facility. This failure resulted in Resident 1 sustaining a closed or incomplete fracture of the neck of the right thigh bone, pain, and hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to ensure quality healthcare services for one of 18 sampled residents (Resident 76), when facility staff did not: 1. Utilize an accurate medication administration record (MAR, a clinical record indicating medications used by an individual, including the medication names, dosages, and administration times) that reflected the resident's current opioid regimen. Resident 76 received opioid medication orally and by intrathecal pump (e.g., continuous delivery of medication directly into the spinal cord) for pain management. 2. Administer the opioid-reversal agent Narcan, as ordered, when the resident appeared pale and sleepy on [DATE]. 3. Provide coordinated, safe physician services for pain management involving more than one physician-prescriber. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sufficient licensed nurses competent to manage one resident's (Resident 76) opioid-overdoses and intrathecal (e.g., continuous delivery of medication directly into the spinal cord via a pump system) opioid-delivery system, and manage another resident's (Resident 78) chest pain, when the facility's licensed nurses: 1. Could not consistently demonstrate the process for accessing and administering the opioid-reversal agent Narcan; 2. Were not trained how to safely care for residents using an intrathecal pump to deliver medication for pain management; 3. Did not appropriately respond to Resident 78's complaints of chest pain. Resident 76 required use of oral opioid medication as well as opioid medication administered via an intrathecal pump. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the bathrooms used by residents in 34 of 34 resident rooms had a call light system accessible to residents lying on the floor. This failure placed all the 74 facility residents at risk of being unable to alert staff via the facility's communication system if they fell in the bathroom and were unable to get up. One of 18 sampled residents fell twice in the bathroom in 2022 and had to verbally call for staff assistance (cross-reference to tag F-689).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a comfortable environment for eight of 74 residents (Residents 19, 23, 31, 43, 47, 55, 60 and 182) when the ambient temperature at the facility was too cold for these residents. This failure resulted in Residents 19, 23, 31, 43, 47, 55, 60 and 182 reporting feeling cold and uncomfortable in their rooms.

Inspectors wroteBased on observation, interview, and record review, the facility failed to minimize accident hazards for three of 24 sampled residents (Residents 41, 279, and 2), when facility staff did not: 1. For Resident 41, accurately indicate the resident's fall history, past medical history, and medication history when assessing the resident's risk of falling. 2. For Resident 279, plan the resident's bowel and blader care to include interventions to mitigate falls associated with the resident's toileting pattern. 3. For Resident 2, implement fall prevention interventions to mitigate the resident's fall risk. The failure associated with Resident 41 resulted in the facility not collecting sufficient data to plan for the resident's fall risk and safety, and had the potential to not prevent future falls. [...]

Inspectors wroteBased on interview and record review, the facility failed to keep record of visits from the attending physician for one of three sampled residents, Resident 76. This failure resulted in Resident 76's caregivers and practitioners having no written record of his physician's examination, plan of care, or clinical decision-making for a six-month period of time.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient staff to maintain the highest practicable physical, mental, and psychosocial well-being for 3 of 18 sampled residents (Residents 44, 66, and 8), when nursing staff did not: 1. Timely respond to residents who triggered a call light 2. Follow the Facility Assessment's recommendation for nurse staffing. The call-light-response failure resulted in nurses taking between 12 and 38 minutes to respond to call lights, and caused Residents 44 and 66 to feel humiliated, as well as angry, helpless, and frustrated due to being left wet for an extended time. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dignity and respect for one resident (Resident 8), when the resident regularly requested his fingernails be neatly trimmed but facility staff did not schedule time to provide the requested service. This failure resulted in Resident 8's fingernails growing long, sharp, and dirty, which caused Resident 8 to feel bothered by the long nails and caused accidental injuries to the resident's skin, and had the potential to cause an infection.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow its policy and procedure on disclosure and release of information, when a request for records of one resident (Resident 1) by her legal representative on 9/6/22, was not processed and released within two days. This failure did not ensure resident rights and had the potential to adversely affect Resident 1's health, safety, and best interests.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1) Ensure of one of one resident (Resident 280) was protected from potential abuse, when it discharged Resident 280 home with the suspected abuser on 10/22/22 without notifying Adult Protective Services (APS, a state-funded program that promote safety, independence, and quality-of-life of vulnerable adults). 2) Report the result of its abuse investigation for two of two residents (Residents 280 and 38) to the State Survey Agency (SSA), within 5 working days of the incident. These failures did not ensure residents' right to be protected from abuse, and did not comply with facility policy and procedure.

Inspectors wroteBased on observation, interview and record review, the facility failed to meet the activities' interests of one of 18 sampled residents (Resident 183) when Resident 183 enjoyed watching TV but was provided the remote control of another resident's TV. This failure did not support the well-being of Resident 183, which required the resident to watch TV looking sideways and caused the resident discomfort and neck pain.

Inspectors wroteBased on observation and interviews, the facility failed to follow its policy and procedure in safe storage of food in the dry storage area when one expired item (seasoning sauce) was stored with other food items. The dietary staff wrote on the seasoning sauce container that it was opened on 10/26/21, and a used by date of 10/26/2022. The sauce container had a manufacturer's recommendation indicating it was best to use date by 7/31/2022. This failure had the potential to result in food borne illnesses to the residents of the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff demonstrated the appropriate use of PPE, when one direct care staff demonstrated inappropriate PPE re-use and santizing practices. These failure did not minimize the risk of spreading infection in the facility and did not comply with facility policy and procedure.

Inspectors wroteBased on record review, interview, and review of facility policy, the facility failed to ensure one resident, (Resident (R)19), of three sampled residents whose clinical records were reviewed for participation in care planning, were invited to their care plan meetings. Eighty-one residents resided in the facility.