Antelope Valley Care Center
Inspection Findings
F-Tag F0684
F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
the facility's PnP titled, Charting and Documentation, last reviewed on 10/30/2025, the PnP indicated all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychological condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding
the resident's condition and response to care. The PnP indicated documentation in the medical record will be objective, complete, and accurate.
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
11/24/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Antelope Valley Care Center
44567 North 15th St. West Lancaster, CA 93534
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0695
F 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm or potential for actual harm
Based on observation, interview, and record review, the facility failed to provide necessary respiratory care and services for one of three sampled residents (Resident 3) by failing to: 1. Ensure Resident 3's oxygen tubing and oxygen humidifier (a device that adds moisture to the oxygen a person is breathing in during oxygen therapy) was dated when it was changed.2. Ensure Resident 3 had an oxygen supplies bag for the oxygen tubing to be kept inside when not in use. These deficient practices had the potential for Resident 3 to develop respiratory (organs and structures in the body that allow a person to breathe) diseases or infections.Findings: During a review of Resident 3's admission Record (undated), the admission Record indicated the facility admitted the resident on 11/19/2025 with diagnoses including pleural effusion (the buildup of excess fluid between the lungs and the wall lining inside the chest), asthma (a disease that affects the lungs), and chronic respiratory failure (a condition in which not enough oxygen passes from the lungs into the blood). During a review of Resident 3's Admission/readmission Evaluation/Assessment, dated 11/19/2025, the Admission/readmission Evaluation/Assessment indicated Resident 3's cognition was intact. The Admission/readmission Evaluation/Assessment indicated Resident 3 had shortness of breath (SOB) on exertion, at rest, and while laying flat. Resident 1 used oxygen at two liters per minute (Lpm - unit of measurement). During a review of Resident 3's Physician Order, dated 11/19/2025, the Physician Order indicated the use of oxygen at two Lpm via nasal cannula (a device used to deliver supplemental oxygen).
During a concurrent observation and interview on 11/24/2025 at 3 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 3 was observed with oxygen via nasal cannula connected to an oxygen concentrator (a device that provides extra oxygen). LVN 1 stated Resident 3's nasal cannula and oxygen humidifier were not dated. LVN 1 stated Resident 3's oxygen mask used for respiratory treatment was on top of the resident's bedside table. LVN 1 stated there were no oxygen supplies bags in Resident 3's room. LVN 1 stated Resident 3's oxygen therapy supplies should be inside a dated and labeled oxygen supplies bag when not in use. LVN 1 stated residents' oxygen therapy supplies should be dated and changed every 7 days. LVN 1 stated Resident 3's oxygen supplies could get dirty and had the potential to cause respiratory infections. During an interview on 11/24/2025 at 3:38 p.m. and concurrent record review of the facility's policy and procedure (PnP) titled Oxygen Administration, last facility-review on 10/30/2025, reviewed with
the Interim Director of Nursing (IDON), the IDON stated the PnP indicated .replace oxygen supplies / tubings typically every seven to 14 days or per manufacturer's guidelines. The IDON stated the resident oxygen supplies should indicate the date the supplies were last changed. The IDON stated the facility staff would be unaware how long Resident 3 had used the undated oxygen supplies. The IDON stated Resident 3's oxygen supplies should be in a dated oxygen supplies bag when not in use. The IDON stated not in use oxygen supplies outside the oxygen supplies bag and undated oxygen supplies had the potential to cause residents' respiratory infections. The IDON stated the facility failed to ensure the policy on oxygen administration was followed.
Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
ANTELOPE VALLEY CARE CENTER in LANCASTER, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in LANCASTER, CA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from ANTELOPE VALLEY CARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.