F 0607
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review, the facility failed to follow their policy and procedure
(P&P) titled, Abuse Prevention and Prohibition Program, when the facility failed to:
Residents Affected - Few
1. Report and investigate misappropriation of property to the California Department of Public Health (CDPH
- local state agency) and local ombudsman for one of four sampled residents (Resident 1). This failure had
the potential for Resident 1 to experience further abuse.
2. Develop and implement a care plan to protect one of four sampled residents (Resident 1), when financial
abuse was discovered. This failure resulted in Resident 1 not to be protected from further abuse, and the
potential for Resident 1 ' s mental or psychosocial needs to go unmet.
Findings:
1. During an interview on 4/21/25 at 12:32 p.m. with Behavioral Health Worker (BHW), BHW stated
Resident 1 ' s reported that he gave his bank card to his brother and he gave his brother permission to use
$300 and his brother had not returned the card. BHW stated Resident 1 only get $316 monthly and he had
3 months on the card (approximately $900) on there. BHW stated there have been multiple charges on the
bank card Resident 1 did not approve. BHW stated this was like the third time Resident 1 ' s brother has
made unapproved charges. BHW stated she informed the Social Services Director (SSD) on 4/18/25 of the
unapproved charge to Resident 1 ' s bank card.
During a review of Resident 1's Minimum Data Set, (MDS - an assessment tool) dated 4/21/25, the MDS
indicated Resident 1's BIMS (Brief Interview for Mental Status) score was 15 (a score of 13 to 15 indicates
cognitive intactness).
During a concurrent observation and interview, on 4/24/25 at 2:17 p.m. with Resident 1, in Resident 1 ' s
room. Resident 1 stated he handles his own finances. Resident 1 stated he gave his bank card to his
brother and brother spent more money than he gave permission too. Resident 1 stated he told the Social
Services Director (SSD) about it. Resident 1 stated the plan to keep his bank card if the facility ' s safe.
Resident 1 ' s bank card was observed on the bedside table. Resident 1 stated he has his card because he
was supposed to go out of the facility yesterday but did not. Resident 1 stated they usually keep in the safe.
During a review of Resident 1 ' s Social Services Note, (SSN) dated 2/27/25, the SSN indicated, After
assisting (Resident 1) with calling the bank he was informed that someone else had been using his money
and ordering cards when it was in fact not him. SS and (Resident 1) informed (name of bank) bank where
exact [sic] he was at and it was not him. (name of bank) bank frozepatients [sic] acct [account].
(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
04/24/2025
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)
F 0607
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
During a review of Resident 1 ' s SSN, dated 3/4/25, the SSN indicated, (Resident 1) was visiting with his
brother in the facility. SS asked (Resident 1) if he informed his brother of what happened with his card, and
(Resident 1) stated no can you tell him. So [sic] (SSD) informed his brother . of the findings and at that point
he held up a debit card and stated its right here. So apparently, he was the one using and ordering new
cards. He was in the facility visiting (Resident 1) because it had declined twice. (SSD) informed him of the
reports to (local law enforcement) and he asked to stop them.
During a review of Resident 1 ' s SSN, dated 4/18/25, the SSN indicated, (Resident 1) is aware of his
brother using his card he allowed him to have $300. He stated he does not want anything done to his
brother. Risk and benefits explained.
During an interview on 4/24/25 at 4:15 p.m. with SSD, SSD stated Resident 1 informed his BHW his brother
had his bank card. SSD stated the BHW took it upon herself to go get the card, the BHW brought SSD the
bank card and informed her of the situation (unapproved charges to Resident 1 ' s bank card). SSD stated
Resident 1 had charges he did not approve or make on his bank card. SSD stated she asked Resident 1
what he wanted us to do. SSD stated she discussed the risk and benefits with Resident 1 because every
time this (financial abuse) has happened before, Resident 1 never wanted to press charges against his
brother.
During an interview on 4/24/25 at 4:29 p.m. the Administrator, the Administrator stated he was aware of the
unapproved charges for Resident 1 ' s bank card. The Administrator stated when he spoke to Resident 1,
Resident 1 stated he knew his brother was using his bank card, how was it stealing if Resident 1 was giving
it to his brother. The Administrator stated Resident 1 has a history of financial abuse by his brother and
does not want to press charges against his brother. The Administrator stated it was not reported or
investigated because Resident 1 himself had made no allegation and stated he was aware his brother was
using the card. The Administrator stated if resident ' s funds were being mismanaged or were not approved
by the resident, he would report it and investigate.
During a review of the facility ' s P&P titled, Abuse Prevention and Prohibition Program, revised 1/31/20, the
P&P indicated, To ensure the Facility establishes, operationalizes, and maintains an Abuse Prevention and
Prohibition Program designed . protect residents, and to ensure a standardized methodology for the
prevention, identification, investigation, and reporting of abuse . misappropriation of property, and crime in
accordance with federal and state requirements Policy I. Each resident has the right to be free from .
misappropriation of property. The Facility has zero-tolerance for abuse, . misappropriation of resident
property. Staff must not permit anyone to engage in . misappropriation of resident property. IV. Prevention .
B. Supervisors shall immediately intervene, correct, and report identified situations where abuse .
misappropriation of resident property is at risk for occurring. G. The Facility conducts an ongoing review and
analysis of abuse incidents and implements corrective actions to prevent future occurrences of abuse. H.
Resident Assessments and Care Planning are performed to monitor resident needs and address behaviors
that may lead to conflict. VI. Investigation A. The Facility promptly and thoroughly investigates reports of
resident abuse, . or criminal acts. IX. Reporting/Response A. Facility Staff are Mandatory Reporters i.
Facility . employees, managers, agents, . are obligated by the Elder Justice Act and the California Elder
Abuse and Dependent Adult Civil Protection Act to report known or suspected instances of abuse of elder
or dependent adults. iv. Failure to report suspected or known abuse may result in legal action against the
individual(s) withholding such information. B. Administrator, or his/her designee, as Abuse Coordinator i. In
order to facilitate reporting, ensure confidentiality, and promote order at the Facility, the Administrator, or
his/her designee, of the Facility shall be the individual who reports known or
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055601
If continuation sheet
Page 2 of 3
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
04/24/2025
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)
F 0607
Level of Harm - Minimal harm
or potential for actual harm
suspected instances of abuse of residents at the Facility to the proper authorities. C. All mandated reporters
will report reasonable suspicion of a crime against a resident when it is objectively reasonable for a person
to entertain a suspicion of conduct that appears to be financial abuse . D. The Facility will report allegations
of abuse, . misappropriation of resident property, or other incidents that qualify as a crime. ii. No later than
24 hours . to the state survey agency, law enforcement, and the Ombudsman.
Residents Affected - Few
2. During a concurrent interview and record review, on 4/24/25 at 4:29 p.m. with Director of Nursing (DON),
Resident 1's care plans were reviewed. DON stated there were no care plans developed or implemented to
protect Resident 1 from financial abuse by brother and no care plan developed or implemented for Resident
1 ' s refusal to be protected from abuse by brother.
During a review of the facility ' s P&P titled, Care Planning, revised 11/1/2017, the P&P indicated, To ensure
that a comprehensive person-centered Care Plan is developed for each resident based on their individual
assessed needs. II. Each resident ' s Care Plan will describe the following: A. Services that are to be
furnished to attain or maintain the resident ' s highest practicable physical, mental and psychosocial
well-being; . V. The IDT will revise the Care Plan as needed at the following intervals: . B. As dictated by
changes in the resident's condition; . D. To address changes in behavior and care; and E. Other times as
appropriate or necessary.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055601
If continuation sheet
Page 3 of 3