Apple Valley Post-Acute Rehab

In the surveyor’s words

From the most serious findings on record at Apple Valley Post-Acute Rehab, in the surveyor’s own words.

• Actual harm, isolatedF684Nov 18, 2022

  Based 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. […]

• Actual harm, isolatedF726Nov 18, 2022

  Based 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. […]

• Actual harm, isolatedF689Jul 26, 2021

  Based on interview and record review, the facility failed to ensure that one of three sampled residents (Resident 1), who was at high risk for falls, had revisions and implementation of Resident 1's nursing care plan to prevent further falls to keep Resident 1 safe. The facility also failed to follow its policy on fall prevention for residents with recurrent falls. As a result, Resident 1 suffered a fall with major injury which consisted of a fracture to the right tibia(The larger of the two bones in the lower leg) and a fracture to the right fibula (A small bone located on the outside of the lower leg), which required hospitalization and surgery. […]

• No harm, potential for more than minimal, widespreadF755Aug 21, 2026

  Based on interview and record review, the facility failed to ensure Licensed Nurses (LNs):1. Administered medication per the physician's order and resident's plan of care to one resident (Resident 60) of six sampled residents; and,2. Followed the facility's policy and procedure for the receipt of pharmaceuticals when medications, including narcotics, were not reconciled for 19 residents (Residents 6,50,73,60,81,77,79,8,103,95,7,22,1,48,115,44,84,24,43) upon delivery. These failures decreased the facilities potential to safely administer medications to residents and prevent drug diversion (when healthcare providers obtain or use prescription medications illegally). 1. […]

• No harm, potential for more than minimal, widespreadF761Aug 21, 2026

  Based on observation, interview, and record review, the licensed nursing staff failed to ensure pharmaceutical products were properly handled and stored for a census of 86 residents when inspection of three medication carts revealed:1. Pill cutters had powdery residue in the crevices and brown matter in the hinges;2. An expired medicated inhaler;3. Two unlabeled vials of insulin;4. The bottom of the medication drawers had visible dirt and sticky residue; and,5. Loose pills of unknown identity.These failures decreased the facility's potential to maintain clean and organized medication carts and ensure residents received medications with their expected potency.FindingsDuring a concurrent observation and interview on 8/18/26 at 10:37 a.m., Licensed Nurse 7 (LN 7) opened Medication Cart 3 for… […]