Antelope Valley Care Center

In the surveyor’s words

From the most serious findings on record at Antelope Valley Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Mar 18, 2023

  Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), received immediate basic life-saving support, including cardiopulmonary resuscitation (CPR, any medical intervention used to restart a person's heartbeat and breathing after one or both have stopped), as per the resident ' s advance directives (a written instruction, such as a living will or durable power of attorney for health care, relating to the provision of health care when the individual is incapacitated). […]

• Immediate jeopardy, isolatedF689Apr 6, 2022

  Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1) received supervision and assistance to prevent accident, by failing to: 1. Monitor Resident 1 for safe swallowing since he was identified with swallowing difficulties on [DATE]. 2. Develop a plan of care with interventions addressing Resident 1's swallowing problem identified on [DATE]. 3. Notify Resident 1's physician on [DATE] about Resident 1's difficulty swallowing, pocketing food (holding food in the mouth for an extended amount of time without swallowing), lack of teeth or dentures while on a regular texture diet. 4. […]

• Actual harm, isolatedF600Jul 9, 2026

  Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) was free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm by one person towards another) when on 7/8/2026, at 8:30 a.m., while Resident 1 was seated in a wheelchair, Resident 1 used his (Resident 1) left palm and struck Resident 2's forehead while Resident 2 was also seated in a wheelchair in the hallway.As a result, on 7/8/2026, at 8:30 a.m., Resident 2 was subjected to physical abuse while under the care of the facility. […]

• Actual harm, isolatedF689Jan 14, 2025

  Based on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 1), who was assessed as high risk for falls was free from falls and injury in accordance with the resident's care plan by failing to: 1. Ensure Resident 1, who was identified as a high fall risk, was not left unattended by Physical Therapist (a health professional trained to evaluate and treat residents who have conditions or injuries that limit their ability to move and to physical activities) 1 (PT 1) during a physical therapy (is a medical treatment used to restore functional movements, such as standing, walking, and moving different body parts) session on 1/5/2025. 2. […]

• Actual harm, isolatedF689Aug 1, 2024

  Based on interview, and record review, the facility failed to prevent a fall (move downward, typically rapidly and freely without control, from a higher to a lower level) and injury for one of three sampled residents (Resident 1), who was identified as high fall risk by failing to: 1. Provide Resident 1 with bilateral (both sides of the body or two of something) bedside mats (Bedside mats, also known as a padded bedside fall mat or a bed mat, is a safety pad placed on the floor beside the bed to prevent injuries resulting from falls) as indicated in the resident ' s physician ' s orders. 2. […]