Inspection·March 13, 2025

F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow one of three sampled residents (Resident 1) care plan (personalized plan of care outlining a person's needs and how they will be addressed) to ensure Resident 1 who was high risk for falls (to move downward, typically rapidly and freely without control, from a higher to a lower level), had history of falls, and had Alzheimer's disease (progressive and fatal brain disorder that causes memory loss, cognitive decline [gradual decrease in mental abilities, such as memory, attention, reasoning, and judgment], and behavioral changes), had a floor mat (cushioned floor covering designed to reduce the impact of a fall, minimizing the risk of injury) to the right side of the bed and was wearing nonskid (designed to prevent sliding or skidding) socks when he got out of bed. These failures resulted in Resident 1 sustaining a fall and experiencing pain to the right hip. Resident 1 was transferred to the acute hospital requiring admission and operation for the acute (new) intertrochanteric (bony bumps on the upper part of the thigh bone) right femoral (relating to the thigh) fracture (broken bone). Findings: During a review of Resident 1's admission Record (AR), dated 3/13/25, the AR indicated, Resident 1 was admitted on [DATE]. The AR indicated, Diagnosis. Hemiplegia (paralysis on one side of the body) and Hemiparesis (weakness on one side of the body) Following Other Cerebrovascular Disease (condition that affects blood flow to the brain) Affecting Left Non-Dominant Side (side of the body that is not used as much as the other side for everyday tasks) . Muscle Weakness (Generalized). Other Abnormalities of Gait and Mobility (change in walking pattern) . Alzheimer's disease. During a review of Resident 1's Quarterly Minimum Data Set (MDS – an assessment tool), dated 2/3/25, the MDS indicated, under Section C (Cognitive Patterns – the ways people think, process information, and make judgments) Resident 1 had a BIMS (Brief Interview for Mental Status) score of 5 (score of 0 – 7 indicates severe cognitive impairment [decline in one or more mental abilities that affects a person's daily functioning]). The MDS indicated, under Section GG (Functional Abilities – a person's capacity to perform everyday activities) Resident 1's admission performance required substantial or maximal assistance (helper does more than half the effort) with putting on or taking off footwear. The MDS indicated walking was not attempted due to safety concerns (Resident 1 was not walking at the time of assessment). During a review of Resident 1's Fall Risk Evaluation (FRE – process used to identify factors that increase an individual's likelihood of falling), dated 2/1/25, the FRE indicated Resident 1 had a score of 15 (score of 10 or higher indicates high risk for falls). (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 055601 Printed: 05/15/2026 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 055601 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkview Julian Healthcare Center 1801 Julian Avenue Bakersfield, CA 93304 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)