Health inspection·January 21, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on interview and record review, the facility failed to ensure care plans were developed and implemented for two of three sampled residents (Resident 1 and Resident 2). This failure had the potential for Resident 1 and Resident 2 to experience accidents and injuries. Findings: During a review of Resident 1's Fall Risk Assessment, (FRA) dated 11/28/24, the FRA indicated Resident 1 scored a 45 (High risk 45 and higher, moderated risk 25-44 and low risk 0-24) Resident 1 was at high risk for falls. During a concurrent interview and record review, on 12/10/24 at 4:24 p.m. with Director of Nursing (DON), Resident 1's FRA, dated 11/28/24 was reviewed. There was no fall risk care plan noted in the clinical record. DON confirmed there was no fall risk care plan developed for Resident 1. During a review of Resident 2's FRA, dated 4/3/24, the FRA indicated Resident 2 scored a 60, Resident 2 was at high risk for falls. During a review of Resident ' 2 s SBAR (situation, background, assessment, recommendation- form used to communicate information) Summary for Providers, (SBAR) dated 6/21/24, the SBAR indicated Resident 2 sustained a fall and suffered abrasion on mid back and bruising to left thumb. During a review of Resident 2's SBAR, dated 7/12/24, the SBAR indicated Resident 2 sustained a fall and suffered a skin tear to right lower arm. During a concurrent interview and record review, on 1/13/25 at 12:36 p.m. with DON (DON), Resident 2's FRA, dated 4/3/24 was reviewed. Resident 2's SBAR, dated 6/21/24 and 7/12/24 were reviewed. DON confirmed Resident 2 was high risk for falls and Resident 2 had two fall incidents (6/21/24 and 7/12/24) in the facility. Resident 2's care plans were reviewed. DON confirmed fall risk care plan was initiated on 7/15/24. DON stated fall risk care plans were not developed prior to falls on 6/21/24 and 7/12/24 and stated the fall risk care plans should be created and implemented to prevent falls. During a review of the facility's policy and procedure (P&P) titled, Fall Risk Assessment, revised November 1, 2017, the P&P indicated, The Facility will ensure that the resident's environment remains as free of accident hazards as is possible, and that each resident receives adequate supervision and assistance to prevent accidents. I. The Facility assesses all resident upon admission and periodically for their risk of falling. The facility uses this information to develop both individualized plans of care and Facility-wide fall prevention measures. A. The licensed Nurse will use the Fall (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 2 Event ID: 555229 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 555229 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Healthcare Center 1205 8th Street 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)