Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Apple Valley Care Center during CMS and state inspections, most recent first.
A resident with multiple medical conditions, including a femur fracture, gout, COPD, and HTN, activated the call light for incontinence care but remained in a soiled brief for over 40 minutes while lunch was served. A CNA entered the room without knocking, turned off the call light, initially ignored the resident, and stated she could not provide peri-care because the roommate was eating. The CNA later claimed she had been told not to provide such care when someone in the room was eating, while the CN and DSD denied giving such instructions and referenced expectations for immediate response and use of privacy curtains. Review of the facility’s dignity policy and the DON’s statements confirmed that required practices for prompt toileting assistance, respect, and privacy were not followed.
A resident with diabetes, gait difficulty, and muscle weakness was admitted with documented discoloration on the lower back, but staff did not further assess, monitor, or care plan this finding, nor notify the physician or responsible party as required by the facility’s Changes in Residents Condition policy. The same resident had a PT order and repeatedly refused to ambulate on multiple occasions; the PT documented the refusals but did not notify nursing, and no change in condition process or care plan for treatment refusal was initiated, contrary to facility policy requiring action after two or more consecutive refusals.
The facility failed to follow infection control practices for respiratory equipment and COVID isolation PPE. Nebulizer tubing for several residents was found unlabeled and not stored in plastic bags, oxygen cannulas for multiple residents were unlabeled and undated, and an LPN entered a COVID isolation room without the required face shield or goggles. The DON and IIP acknowledged the policies were not followed.
Two residents with significant mobility limitations were found without accessible call lights, as one had the device placed out of reach above the pillow and another had it wrapped around a bedrail and hanging to the floor. Both residents were unaware of their call light locations, and staff failed to verify accessibility during routine checks, contrary to facility policy.
A resident with a history of pulling out a surgical drainage tube following cholecystectomy was admitted without the facility obtaining key surgical details or follow-up instructions. Despite repeated incidents of the resident attempting to remove the tube, there was no care plan addressing this behavior, and the physician was not notified. The resident ultimately removed the tube, requiring hospital transfer, and the facility did not follow its own policies for care planning and change of condition notification.
A resident with systemic lupus erythematosus and mobility issues experienced an assisted fall, which was not documented according to facility policy. The CNA reported the incident to the LVN, but no immediate assessment or documentation was completed. The facility's fall protocol requires such incidents to be documented and investigated, which was not followed in this case.
The facility failed to address grievances from residents regarding noise at night and staff not returning after responding to call lights. Despite a policy requiring prompt resolution of grievances, these issues persisted due to high staff turnover. The Activity Director did not consider concerns raised during resident council meetings as grievances, leading to ongoing unresolved issues documented from May to October 2024.
A facility failed to ensure the accuracy of a discharge MDS for a resident, incorrectly documenting the discharge location. The resident was discharged home, but the MDS indicated a discharge to a hospital. Interviews with the MDS Coordinator and DON confirmed the error, and the facility lacked a specific policy for MDS completion, relying on RAI guidelines.
The facility failed to notify physicians of pharmacy recommendations for two residents, leading to unaddressed medication issues. One resident had an incorrect morphine order that was not clarified, while another had inappropriate use of lorazepam and ABHR cream/gel for anxiety and agitation. The DON and Consultant Pharmacist had differing expectations for follow-up timeframes, but neither was met, resulting in a lack of documented physician response.
The facility exceeded the acceptable medication error rate, reaching 6.45% due to errors involving two residents. One resident received a multivitamin with minerals instead of the prescribed multivitamin without minerals, while another received a multivitamin without minerals instead of the prescribed multivitamin with minerals. The errors were acknowledged by the LVNs involved, and the importance of verifying medication labels against orders was emphasized by the DON and Administrator.
A resident was administered Haloperidol without proper informed consent from their representative. The facility's policy requires written consent for psychotropic drugs, but the consent form was incorrectly filled out, with the hospice nurse's name in the representative's space. The DON acknowledged the error, noting the lack of proper documentation of verbal consent from the resident's wife.
Failure to Provide Timely Incontinence Care and Maintain Resident Dignity
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and to honor a resident’s dignity and comfort. Resident 1, who had diagnoses including a left femur fracture, gout, COPD, hypertension, and a history of falling, reported that she activated her call light at 11:00 AM because she needed a diaper change. She stated that a CNA brought her lunch at 11:30 AM but refused to assist with the diaper change. At 11:41 AM, the resident was observed in bed stating she had been waiting since 11:00 AM for incontinence care. At 11:43 AM, while the surveyor was present, the resident again activated her call light. CNA 1 entered the room in less than a minute without knocking or announcing her presence, turned off the call light, ignored the resident, checked only on the roommate, and was about to leave the room until the visibly distressed resident requested assistance, stating she would not eat while soiled. CNA 1 told the resident she could not change the diaper because the roommate was eating. In a subsequent interview, CNA 1 stated she had been on lunch break from 10:40 AM to 11:20 AM, believed another staff member had answered the earlier call light, and claimed she had been instructed by the DSD not to provide peri-care if someone in the room was eating, and that the charge nurse had told her she could not do it. The charge nurse denied instructing CNA 1 not to change the resident and stated she had told CNA 1 to pull the privacy curtain and assist with the diaper change. The DSD denied ever instructing staff to delay care due to a roommate eating and stated staff were expected to attend to residents’ needs immediately and use privacy curtains during personal care. Review of the facility’s “Dignity” policy showed requirements that residents be treated with dignity and respect, that staff knock and request permission before entering rooms, promote and protect privacy, and promptly respond to toileting requests. The DON acknowledged that the policy was not followed when staff did not provide necessary personal care and left the resident in a soiled diaper for more than 40 minutes, in violation of facility standards and CMS regulations.
Failure to Address Skin Discoloration and Repeated Therapy Refusals as Changes in Condition
Penalty
Summary
The facility failed to implement its policy on Changes in Residents Condition or Status for a resident admitted with multiple diagnoses, including type 2 diabetes mellitus, difficulty in walking, and muscle weakness. On the admission skin assessment, the Wound Care Nurse documented discolorations on the resident’s lower back. However, there was no documentation in the clinical record that this discoloration was further assessed, monitored, or addressed. The Wound Care Nurse acknowledged that no change of condition monitoring was done, no care plan was initiated, and the skin condition was not assessed or documented prior to the resident’s transfer out of the facility. The DON stated that the discoloration should have triggered a change of condition notification to the primary physician and responsible party on admission, and that it should have been monitored and documented according to facility policy. The facility also did not follow its policy regarding refusals of treatment. The resident had a physician’s order for Physical Therapy evaluation and treatment, and Physical Therapy notes showed that the resident refused to ambulate on four documented occasions. There was no evidence in the clinical record that these repeated refusals were addressed by the facility. The Physical Therapist stated that the resident often refused to get out of bed and walk with a walker on more than two occasions and that these refusals were only documented in therapy notes without notifying the licensed nurse. The DON stated that the resident’s refusal to get out of bed should have been communicated to the licensed nurse and that a care plan should have been initiated after more than two refusals, consistent with the facility’s policy requiring physician notification and care plan review or revision for significant changes in condition and repeated refusals of treatment.
Respiratory Equipment and Isolation PPE Not Managed per Policy
Penalty
Summary
The facility failed to follow its infection prevention and control policies for respiratory equipment and isolation precautions. During observations and interviews, nebulizer tubing for Residents 41, 54, and 139 was found unlabeled and not stored in plastic bags when not in use. Resident 41 had diagnoses including chronic respiratory failure with hypoxia, COPD, and asthma, and the physician order directed that the handheld nebulizer and bag be changed weekly and initialed and dated every Thursday. Resident 54 had COPD, lobar pneumonia, and syncope and collapse, and Resident 139 had chronic respiratory failure with hypoxia, COPD, and dependence on supplemental oxygen. The facility’s Respiratory Therapy-Prevention of Infection policy required nebulizer tubing and plastic bags to be labeled with the date and replaced every 7 days or sooner if needed, but staff and the DON acknowledged the policy was not followed. Resident 139’s portable oxygen tank nasal cannula tubing was also observed without a date in the resident’s room. The physician order required oxygen by nasal cannula at 3 liters per minute and directed that oxygen cannula and mask tubing be changed every 7 days or as needed for soilage. The facility’s Respiratory Therapy-Prevention of Infection policy required oxygen cannula, tubing, and plastic bags to be labeled every 7 days and kept in a plastic bag when not in use. The IIP confirmed the tubing was not dated, and the DON stated the policy was not followed. The facility also failed to ensure staff used required eye protection when entering a room under novel respiratory precautions. LVN 3 was observed donning a mask, gown, and gloves before entering the COVID-positive room of Residents 51 and 151, but did not wear the required face shield or goggles. Both residents had physician orders for novel respiratory isolation for COVID-19 infection. The DON reviewed the COVID-19 Prevention and Control policy, which required eye protection when caring for residents in the COVID care cohort or COVID isolation areas, and stated the policy was not followed. In addition, nasal cannulas for Residents 51, 95, and 160 were observed unlabeled and undated while they were receiving oxygen therapy, and LVN 1 and the IIP acknowledged the tubing should have been labeled and dated but was not.
Failure to Ensure Call Light Accessibility for Residents with Mobility Impairments
Penalty
Summary
The facility failed to ensure that call lights were accessible to two residents, both of whom had significant mobility impairments. For one resident with a right femur fracture and difficulty walking, the call light was observed placed above the pillow and out of reach. The resident was unaware of the call light's location. A Licensed Vocational Nurse confirmed the call light was not accessible and subsequently placed it in the resident's hand. The Certified Nursing Assistant (CNA) responsible for this resident admitted she had not checked the call light's accessibility during her last round, despite facility policy requiring her to do so each time she entered the room. For another resident with hemiplegia and hemiparesis following a stroke affecting the right side, the call light was found wrapped around the right bedrail, hanging down and touching the floor, making it unreachable. This resident also did not know where the call light was. The CNA responsible for this resident stated she had not checked the call light's location during her last check, mistakenly believing it had been removed by maintenance. Maintenance staff clarified that call lights should not be wrapped around bedrails and should be accessible, and the Minimum Data Set Nurse confirmed that facility policy requires call lights to be within reach, especially for residents with weakness on one side.
Failure to Address Resident's Repeated Tampering with Surgical Drainage Tube
Penalty
Summary
The facility failed to provide appropriate care and services for a resident admitted after a cholecystectomy with a surgical drainage tube in place. The facility was unaware of the date of the resident's surgery and did not have information regarding necessary follow-up visits or treatments from the resident's surgeon. There was no documentation of the facility seeking this information from the hospital, family, or other sources, and the care plan did not address the resident's previously identified behavior of attempting to pull out the drainage tube. Multiple nursing notes documented that the resident had a history of pulling on the drainage tube, including specific incidents where the resident was observed attempting to remove it. Despite this, there were no interventions or care plan updates to address this behavior, and the physician was not notified of these incidents. Staff interviews confirmed that the resident frequently tampered with the tube and that this was a known issue upon admission, but no formal documentation or care planning was completed to mitigate the risk. Ultimately, the resident pulled out the drainage tube, resulting in redness and edema at the site, and was transferred to the hospital. The facility's own policies required prompt notification of changes in condition, comprehensive care planning, and measures to ensure resident safety and supervision, but these were not followed in this case. The lack of care planning, physician notification, and follow-up on the surgical procedure directly contributed to the deficient practice.
Failure to Document Assisted Fall Incident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who experienced an assisted fall. The resident, diagnosed with systemic lupus erythematosus and difficulty in walking, was admitted to the facility and later reported a fall incident. The Case Manager was unable to locate the incident report or a Change of Condition (COC) report in the resident's records, indicating a lapse in documentation according to the facility's policy. The Certified Nursing Assistant (CNA) involved in the incident stated that the resident slipped while attempting to stand and was assisted to the floor. Although the CNA informed the Licensed Vocational Nurse (LVN) of the incident, no assessment was conducted, and the incident was not documented immediately. The Director of Nursing confirmed that a COC report should have been completed for the assisted fall. The facility's fall protocol requires documentation and investigation of such incidents, which was not adhered to in this case.
Failure to Resolve Resident Grievances
Penalty
Summary
The facility failed to resolve grievances voiced by five residents who attended a resident council meeting. The facility's grievance policy, revised in April 2017, states that residents and their representatives have the right to file grievances, and the facility staff must make prompt efforts to resolve them. However, during a resident council meeting, residents reported that the facility did not always follow up on their grievances. They expressed concerns about noise at night in the hallways and staff responding to call lights but not returning to provide services. These issues were reportedly communicated to the facility, but due to high staff turnover, the problems persisted. The Activity Director (AD) stated that concerns raised during the resident council meetings were not considered grievances and were only discussed in subsequent meetings if not addressed. The Resident Council Minutes from May 2024 to October 2024 documented ongoing concerns about unanswered call lights and staff not returning to provide services.
Inaccurate Discharge MDS for Resident
Penalty
Summary
The facility failed to ensure the accuracy of the discharge Minimum Data Set (MDS) for a resident, specifically regarding the location of disposition at the time of discharge. The resident was admitted to the facility and later discharged home, as indicated by the admission record and physician orders. However, the discharge MDS inaccurately recorded the resident as being discharged to a short-term general hospital. Interviews with the MDS Coordinator and the Director of Nursing (DON) confirmed the error, with the DON stating that the facility did not have a specific policy for MDS completion but followed the Resident Assessment Instrument (RAI) guidelines. The Administrator also expressed the expectation that the MDS should be accurate.
Failure to Notify Physician of Pharmacy Recommendations
Penalty
Summary
The facility failed to notify the physician of pharmacy recommendations and did not ensure a specified time frame for physician response to these recommendations for two residents. Resident #40, who was admitted with severe cognitive impairment and chronic pain syndrome, had an incorrect morphine sulfate order that was not clarified despite a pharmacy recommendation to do so. The Director of Nursing (DON) acknowledged forgetting to follow up on the recommendation, which was initially discussed with an unidentified charge nurse. The DON expected the physician to be notified within 48 hours, but this did not occur, leaving the morphine order unclarified. Resident #85, also with severe cognitive impairment and on hospice care, had orders for lorazepam and ABHR cream/gel for anxiety and agitation. The pharmacy recommended limiting lorazepam use to 14 days and discontinuing the ABHR cream/gel, as the reasons for their use were deemed insufficient. The DON stated that the hospice nurse was informed of the recommendations, who then spoke to the hospice physician, but there was no documentation of physician notification. The Consultant Pharmacist expected follow-up within two weeks, while the DON expected it within one week, but neither timeframe was met, resulting in a lack of documented physician response.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 6.45% during a survey. This deficiency was identified through observations, record reviews, and interviews. Two residents were involved in the medication errors. Resident #66, who was admitted with a diagnosis of generalized muscle weakness, was prescribed a multivitamin without minerals. However, during medication administration, LVN #6 administered a multivitamin with minerals instead. The nurse acknowledged the mistake during an interview, and the Director of Nursing confirmed that the nurse should have verified the medication label against the physician's order. Similarly, Resident #23, with a history of chronic obstructive pulmonary disease, was prescribed a multivitamin with minerals. LVN #7 administered a multivitamin without minerals, contrary to the physician's order. The nurse admitted to the error during an interview, and the Director of Nursing reiterated the importance of comparing the medication label with the medication administration record. The facility's Administrator also emphasized that the nurses should have verified the medication orders and sought clarification if there were any doubts.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent from a resident's representative before administering a psychotropic medication, Haloperidol, to the resident. The resident, who was admitted with diagnoses including senile degeneration of the brain, unspecified dementia, anxiety, and delirium, was given the medication without the proper consent documentation. The Physician Telephone Order for Haloperidol was signed, but the consent form was incorrectly filled out, with the hospice nurse's name appearing in the space designated for the resident's representative. During an interview, the Director of Nursing (DON) acknowledged that the hospice nurse claimed to have obtained verbal consent from the resident's wife, but the documentation did not reflect this. The facility's policy requires written informed consent for psychotherapeutic drugs, and the consent form should have included the name of the person who gave consent and the date. The failure to follow this policy resulted in a violation of the resident's representative rights, as the necessary consent was not properly documented in the resident's medical record.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 117 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Apple Valley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Knolls West Post Acute Llc | 3.6 mi | ★★★★★ | 2 | 0 |
| Spring Valley Post Acute Llc | 5.1 mi | ★★★★★ | 8 | 1 |
| Desert Ridge Transitional Care Center, Lp | 5.3 mi | — | 7 | 0 |
| Mountains Community Hosp Dp/snf | 14.5 mi | ★★★★★ | 0 | 0 |
| Hillcrest Nursing Home | 20.7 mi | ★★★★★ | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Apple Valley Care Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.