Apple Valley Village Health Care Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF684Aug 13, 2021

  Based on interview and document review, the facility failed to identify and report a significant change of condition to the resident's medical provider, and the resident's representative in a timely manner for 1 of 3 residents (R1) reviewed for a change in condition. This resulted in an immediate jeopardy (IJ). The IJ began on [DATE], at 7:45 a.m. when nursing assistant (NA)-A found R1 unresponsive. NA-A reported this to registered nurse (RN)-A, who stated it could be a stroke. RN-A did not conduct a thorough assessment of R1, and did not contact R1's nurse practitioner (NP)-A to report R1 was unresponsive until 10:14 a.m., and at that time did not give full report that R1 was not responding. In addition, RN-A failed to notify R1's family on the change in condition. […]

• Immediate jeopardy, isolatedF689Jan 19, 2021

  Based on interview and document review, the facility failed to ensure the sling was properly applied to the full body mechanical lift for 1 of 3 residents (R1) who used a mechanical lift. R1 suffered a fractured knee and subdural hemorrhage requiring hospitalization when the loop of the sling come out of the mechanical lift causing R1 to fall to the ground. The facility immediately implemented interventions and corrected the deficient practice on 1/5/21. As a result of the immediate interventions this is being issued as past noncompliance at Immediate Jeopardy (IJ). The immediate jeopardy began on 1/4/21, when R1 fell out of the sling during a transfer from bed to wheelchair was corrected on 1/5/21, when the facility implemented interventions to prevent reoccurrence. […]

• No harm, potential for more than minimal, patternF684Aug 10, 2023

  Based on observation, interview, and document review, the facility failed to ensure symptoms of respiratory impairment and potential infection were assessed and acted upon for 1 of 1 residents (R44); failed to ensure combative behaviors with personal, intimate care (i.e., pericare) were assessed and, if able, interventions developed to provide comfort during such care for 1 of 1 resident (R77); and failed to ensure interventions to reduce or control developed edema were implemented or re-evaluated for 2 of 2 residents (R44, R31) observed with lower extremity edema. […]

• No harm, potential for more than minimal, patternF755Aug 10, 2023

  Based on observation, interview, and document review, the facility failed to ensure resident medications were ordered in a timely manner to avoid underdosing for 3 of 3 residents (R1, R89, R101) reviewed for medication administration. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had intact cognition, independent with eating and required extensive assistance for all other activities of daily living (ADLs). R1's diagnoses included diabetes, schizoaffective disorder/bipolar, chronic obstructive pulmonary disease (COPD-causing inflammation and narrowing of the airway and difficulty breathing), obstructive sleep apnea (OSA-causing intermittent periods of non-breathing during sleep), and unspecified allergies. […]

• No harm, potential for more than minimal, patternF684Mar 31, 2022

  Based on observation, interview, and document review, the facility failed to comprehensively assess and develop interventions to promote comfort with poor wheelchair posture and worsening hemorrhoids for 1 of 2 residents (R39) reviewed for positioning and quality of care. In addition, the facility failed to ensure 1 of 1 resident (R472) had weights monitored in accordance with physician parameters to prevent complication of associated medical conditions. In addition, the facility failed to coordinate with an outside orthopedic clinic to adequately monitor a surgical wound to ensure healing and reduce the risk of complications for 1 of 1 residents (R375) who admitted after surgery. […]