Health inspection·October 15, 2024

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement their policy and procedure (P&P) titled, Abuse Prevention and Prohibition Program, when two of three sampled residents (Resident 1 and Resident 3) medical doctor (MD) was not notified regarding the allegation of abuse and one of three sampled residents (Resident 1) responsible party (RP) was not notified of the allegation of abuse. These failures had the potential for Resident 1 and Resident 3 ' s MD and Resident 1 ' s RP not to be aware of Resident 1 and Resident 3 ' s allegation of abuse. Residents Affected - Few Findings: During an interview on 10/15/24 at 11:50 p.m. with the Director of Nursing (DON), the DON stated they (management) received an email from a former employee alleging abuse against Resident 1, Resident 2, and Resident 3. During a review of Resident 1's admission Record, (AR) the AR indicated, Resident 1 was admitted on [DATE], the AR indicated Resident 1 had a responsible party. During a review of Resident 3's AR, the AR indicated, Resident 3 was admitted on [DATE], the AR indicated Resident 3 was his own responsible party. During a concurrent interview and record review on 10/15/24 at 2:28 p.m. with DON, Resident 1 and Resident 3 ' s medical record was reviewed. DON confirmed there was no documentation Resident 1 ' s MD or RP were notified of the abuse allegation. DON confirmed there was no documentation Resident 3 ' s MD was notified of the allegation of abuse. DON stated If is not documented it's not done. During an interview on 10/15/24 at 3:03 p.m. with Administrator, Administrator confirmed the MD and RP notification was not documentation in Resident 1 and Resident 3's medical record. Administrator stated MD and RP notification should be documented in a progress note. During a review of the facility ' s policy and procedure (P&P) titled, Abuse Prevention and Prohibition Program, revised 1/31/20, the P&P indicated, To ensure the Facility establishes, operationalize, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements. The Facility will report allegations of abuse, neglect, exploitation, mistreatment . ii. The resident ' s attending physician and responsible party, if applicable, will also be notified of the of the [sic] allegations and outcome of the investigation. Page 1 of 2 555229 555229 10/15/2024 Valley Healthcare Center 1205 8th Street Bakersfield, CA 93304

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on interview and record review, the facility failed to consistently implement care plans for two of three sampled residents (Resident 1 and Resident 3).This failure had the potential for Resident 1 and Resident 3 to have unmet psychosocial and physical needs. Findings: During an interview on 10/15/24 at 11:50 p.m. with the Director of Nursing (DON), the DON stated they (management) received an email from a former employee alleging abuse against Resident 1, Resident 2, and Resident 3. During an interview on 10/15/24 at 2:11p.m. with Registered Nurse (RN) 1, RN 1 stated for allegations of abuse he would create a care plan for delayed injury and psychosocial outcome and monitor for 72 hours. During a review of Resident 1 ' s care plan with the focus on Alleged incident of physical abuse, initiated 10/9/24. The care plan indicated one of the intervention was to Monitor For Pyschosoical [sic] Well Being X (times) 72 Hours. During a review of Resident 3 ' s care plan with the focus on Alleged incident of neglect on unspecified date, initiated 10/9/24. The care plan indicated one of the intervention was to Monitor For Pyschosoical [sic] Well Being X 72 Hours. During a concurrent interview and record review on 10/15/24 at 2:28 p.m. with DON, Resident 1 and Resident 3 ' s medical record was reviewed. DON confirmed the psychosocial monitoring was not documented consistently over the 72 hour period for Resident 1 or Resident 3. During a review of the facility ' s policy and procedure (P&P) titled, Care Planning, revised 10/24/22, the P&P indicated, II. The care Plan serves as a course of action where the resident . to help the resident move toward resident specific goals that address the resident ' s medical, nursing, mental and psychosocial needs. III. A licensed Nurse will initiate the Care plan . and updated as indicated for change in condition, onset of new problems. 555229 Page 2 of 2