Antelope Valley Care Center in Lancaster: Inspection Record Review, Complaints and Abuse Reports (Updated October 30, 2026)

According to the 2567 report from a September 2026 complaint survey, inspectors found the facility failed to prevent a fall and injury for Resident 1. The report describes Resident 1 as having severely impaired cognition, a high risk for falls, and a daily order for aspirin (a blood thinner that can increase the risk of bleeding). His care plan and records listed him as fully dependent on staff for bed mobility and toileting hygiene, with one- to two-person assistance for morning and evening care.

Inspectors found that on 8/27/2026 at around 4:04 a.m., Resident 1 rolled off the bed onto the floor while CNA 1 was providing incontinent care (hygiene help for a resident who cannot control bladder or bowel) with no help from another staff member. The 2567 report states he landed on his left side, hit his head and knee, and had abrasions (scrapes) to the left eyebrow and left knee. He was sent through 911 to an acute care hospital at 4:50 a.m. with a diagnosis of fall and head injury.

The 2567 report states the facility was cited under F689, Free of Accident Hazards/Supervision/Devices, at severity G. Inspectors found the resident had a prior fall recorded on 4/2/2025, when he was found sitting on the floor mat next to his bed, and that his fall care plan called for the facility's fall prevention program and safety devices such as a fall mat.

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According to the citation, CDPH made an unannounced visit on 7/9/2026 to investigate a resident-to-resident abuse allegation. CDPH found the facility failed to protect Resident 2's right to be free from physical abuse. On 7/8/2026 at 8:30 a.m., while both residents sat in wheelchairs in the hallway, Resident 1 struck Resident 2's forehead with his palm. The citation states Resident 2 had a reddened forehead with a bump about one inch long and one inch wide, grimaced, yelled and covered her forehead because of pain. She was sent to an acute care hospital at 8:55 a.m. with a head injury and a forehead hematoma (blood collected under the skin).

Inspectors found Resident 1's records showed earlier aggression. On 4/26/2026 he punched a staff member's jaw and was sent to a hospital for evaluation. Records from May 2026 described more aggression toward staff, including striking a staff member's face, and a physician's order dated 5/20/2026 to monitor him every shift for striking out at staff. His July 2026 medication record listed four episodes of striking staff on 7/3/2026. His assessment showed severely impaired cognitive skills. After the 7/8/2026 incident, the physician ordered injected medications for agitation, and he was sent to a hospital for a behavioral evaluation.

According to the citation, CDPH issued a Class A citation with a $15,000 penalty. The 2567 report states the same visit resulted in F600, Free from Abuse and Neglect, at severity G.

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According to the citation, CDPH made an unannounced visit on 1/14/2025 to investigate a quality-of-care complaint. CDPH found the facility failed to keep Resident 1, a 73-year-old resident assessed as high risk for falls, free from falls and injury as his care plan required. He had weakness on his left side after a stroke, and his care plan called for a bed alarm, keeping him within supervised view, and raised safety floor mats on both sides of the bed.

Inspectors found three failures on 1/5/2025. Physical Therapist 1 left Resident 1 unattended during a therapy session, did not put the fall mat back on the floor before leaving the room, and the bed alarm was not placed between the resident and the mattress. At about 1:20 p.m., after PT 1 placed a knee brace on his right leg and stepped out, LVN 2 heard Resident 1 screaming and found him on the floor bleeding from the head. A hospital diagnosed a scalp hematoma (pooled blood under the skin) and a scalp laceration (cut), and imaging showed a large hematoma and contusion (bruise) on the left forehead extending around the left eye. During the 1/14/2025 visit, inspectors observed the bed alarm lying on the floor under his bed.

According to the citation, CDPH issued a Class A citation with a $25,000 penalty that was trebled to $75,000. The 2567 report states the facility was cited under F689, Free of Accident Hazards/Supervision/Devices, at severity G.

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According to the citation, CDPH made an unannounced visit on 8/1/2024 to investigate a resident fall. CDPH found the facility failed to prevent a fall and injury for Resident 1, a 78-year-old man admitted on 7/1/2024 with a history of traumatic subdural hemorrhage (bleeding under the outer covering of the brain), prior falls and difficulty walking. His fall risk assessment rated him high risk, and a physician's order dated 7/1/2024 called for bedside mats on both sides of the bed and a low bed.

Inspectors found the facility did not provide the bedside mats the physician ordered and did not add them to his care plan, either in the plan written on 7/2/2024 or in the version revised after the fall on 7/23/2024. The citation states the facility also failed to implement its own policies on falls and care planning. On 7/22/2024 at 8:01 p.m., a CNA reported Resident 1 on the floor. He showed left hip pain by grimacing and was sent to an acute care hospital, where he was diagnosed with a left intertrochanteric fracture (a break in the upper thigh bone near the hip). He had surgery to realign the bone and fix it with hardware (open reduction and internal fixation).

According to the citation, CDPH issued a Class A citation with a $25,000 penalty. The 2567 report states the same complaint survey resulted in F689, Free of Accident Hazards/Supervision/Devices, at severity G.

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According to the citation, CDPH received a complaint on 5/29/2024 and made an unannounced visit on 5/30/2024. CDPH found the facility did not follow its own change-of-condition policy, which required staff to notify the attending physician of a significant change in a resident's condition. Resident 1 was a 29-year-old man on hemodialysis (a machine treatment that filters the blood when the kidneys fail) through a catheter in his right upper chest.

Inspectors found that on 5/27/2024 at 9 a.m., a licensed vocational nurse documented yellow exudate (fluid that can signal infection) draining from the dialysis site, and the citation states the physician was not notified. A registered nurse saw the drainage again that evening, cleaned the area and placed a small dressing. A physician ordered a non-emergency transfer to a hospital emergency room on 5/28/2024 at 3 p.m. The resident left the facility at 5:48 p.m., which the citation describes as 32 hours after the change was first observed. At the hospital he was diagnosed with septic shock (a drop to very low blood pressure after an infection), bacteremia (bacteria in the blood) and a bloodstream infection related to his central venous catheter.

According to the citation, CDPH issued a Class A citation with a $25,000 penalty. The 2567 report states the facility was also cited under F580, Notify of Changes (Injury/Decline/Room, etc.), at severity G.

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According to the citation, CDPH received a complaint about falls on 5/9/2024 and made an unannounced visit on 5/15/2024. Resident 2 was a 42-year-old man with a cervical spinal cord injury and quadriplegia (paralysis of all four limbs). His assessment showed he was fully dependent on staff for bed-to-chair transfers, and his care plan called for two people for morning and evening care and transfers with a Hoyer lift (a mechanical sling lift).

CDPH found that on 4/16/2024 at about 4:45 p.m., CNA 1 moved Resident 2 alone from the bed to a wheelchair with the Hoyer lift, without the help of another staff member. The citation states he fell from the Hoyer lift to the floor. He told inspectors that two CNAs then lifted him with the sling's bottom straps uncrossed, and he swung and hit his head on the metal sling bar. He reported head and back pain of 10 out of 10 and was given oxycodone (a strong pain medication). He went to an acute care hospital and stayed five days, and was discharged with diagnoses of headache and body aches. The assistant director of nursing told inspectors CNA 1 had moved him alone.

According to the citation, CDPH issued a Class A citation with a $25,000 penalty. The 2567 report states the facility was cited under F689, Free of Accident Hazards/Supervision/Devices, at severity G, for not providing the two-person assistance he needed.

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According to the citation, CDPH made an unannounced visit on 7/19/2023 to investigate complaints about quality of care and a death. Resident 1 was a 76-year-old woman on hemodialysis with diabetes, dementia and urinary incontinence. Her physician ordered a urine test on 5/23/2023 to rule out a urinary tract infection (UTI).

CDPH found that staff mislabeled the urine sample cup, so the laboratory did not run the test. Nurses later documented a sample as collected on 5/24/2023 when none was sent, did not follow up with the laboratory, and did not promptly tell the physician they could not get a sample. After a new order on 5/30/2023, nurses could not collect urine with a straight catheter (a thin tube that drains the bladder) and did not inform the physician or keep trying in the following days. Inspectors found the facility also did not create a care plan for the suspected UTI and did not identify her pain when urinating before her representative raised it on 6/9/2023. On 6/13/2023 her representative told nurses she was not acting like herself. She was lethargic (very sluggish) with abnormal vital signs, and paramedics took her to an acute care hospital. She was diagnosed with a UTI, emphysematous cystitis (a severe bladder infection with gas in the bladder wall), hydronephrosis (a kidney swollen with backed-up urine) and sepsis. The citation states she died at the hospital on 7/4/2023.

According to the citation, CDPH issued a Class AA citation with a $120,000 penalty. State records list an appeal and a final penalty of $90,000. The 2567 report states the facility was cited under F690, Bowel/Bladder Incontinence, Catheter, UTI, at severity G.

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According to the citation, CDPH made an unannounced visit on 3/8/2023 to investigate three complaints. Resident 1 was an 82-year-old woman with COPD (a chronic lung disease), shortness of breath and COVID-19. Her physician's order called for full resuscitation, which meant staff were to perform CPR if her heart or breathing stopped.

CDPH found that on 3/5/2023 at 3:34 p.m., Occupational Therapist 1 found Resident 1 in bed, not responding, with no blood pressure, oxygen or heart rate reading. He did not call for help until 3:39 p.m. Staff, including a physical therapist and a registered nurse, did not start CPR until 3:43 p.m., nine minutes later, because they were checking her records for her code status (her instructions about resuscitation). Inspectors found staff also did not call paramedics right away, as the facility's policy required. A licensed vocational nurse called them at 3:44 p.m. They arrived at 3:51 p.m. and took over CPR. The citation states paramedics pronounced Resident 1 dead at the facility at 4:19 p.m.

According to the citation, CDPH issued a Class AA citation with a $120,000 penalty. The 2567 report states the facility was cited under F678, Cardio-Pulmonary Resuscitation (CPR), at severity J. In interviews with inspectors, the occupational therapist and the physical therapist said they started CPR after the registered nurse arrived and told them she was a full code.

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