Health inspection·March 27, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on interview and record review, the facility failed to ensure a Responsible Party (RP) 1 was notified when a change in diet texture was ordered for one of four sampled residents (Resident 35). This failure resulted in RP 1 not being aware of changes in Resident 35's status. Findings: During an interview on 3/24/25 at 3:01 p.m. with RP 1, RP 1 stated Resident 35 was placed on a pureed (pudding-like consistency) diet and the facility did not inform her. RP 1 stated she was speaking on the phone with Resident 35 and Resident 35 told her the facility was feeding her baby food. RP 1 stated Resident 35 can eat a regular diet if she is sitting up. During a concurrent interview and record review on 3/25/25 at 3:03 p.m. with Director of Nursing (DON), DON stated Resident 35 saw another resident in the dining room eating a pureed diet and requested one. DON stated nurses can change a resident's diet order, without informing the physician, if the diet consistency is being downgraded. The Physician Order dated 7/15/24 indicated Resident 35's diet order was Regular with a thin consistency [diet with no restrictions on food textures or liquid thickness, allowing for all types of foods, including those that are thin liquids like water, juice, and milk]. DON stated there were no nurse's notes indicating RP 1 was informed of Resident 35's change in diet consistency. The Progress Notes dated 3/7/25 indicated Resident 35's diet consistency was changed to pureed. DON stated RP 1 should have been notified of the change in Resident 35's diet consistency. During a review of the facility's policy and procedure (P&P) titled, Change of Condition Notification dated 11/1/17, the P&P indicated, To ensure residents, family, legal representatives, and physicians are informed of changes in the resident's condition in a timely manner. Page 1 of 14 555229 555229 03/27/2025 Valley Healthcare Center 1205 8th Street Bakersfield, CA 93304

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to ensure resident assessments were completed for two of two sampled dialysis (medical procedure that filters waste products and excess fluids from the blood when the kidneys no longer function adequately) residents (Resident 8 and Resident 59). This failure resulted in an incomplete assessment of Resident 8 after dialysis, and an incomplete assessment of Resident 59 before and after dialysis. Residents Affected - Few Findings: During a concurrent interview and record review on 3/26/25 at 7:40 a.m. with Registered Nurse (RN) 1, Resident 8's Nursing Dialysis Communication Record (NDCR), dated 3/5/25 was reviewed. The NDCR indicated no pain assessment was done after dialysis for Resident 8. RN 1 stated Resident 8's pain should have been assessed. RN 1 stated a nursing assessment of Resident 8 was very important after dialysis for the early identification of complications. During a concurrent interview and record review on 3/26/25 at 7:50 a.m. with RN 2, Resident 59's NDCR, dated 2/12/25 was reviewed. The NDCR indicated Resident 59 did not have her respirations (breathing rate) assessed before dialysis. During a concurrent interview and record review on 3/26/25 at 7:52 a.m. with RN 2, Resident 59's NDCR, dated 2/26/25 was reviewed. The NDCR indicated Resident 59 did not have her pain assessed after dialysis. RN 2 stated Resident 59's after dialysis care should have included a pain assessment. During a concurrent interview and record review on 3/26/25 at 8:44 a.m. with Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Dialysis Care, dated 11/1/17 was reviewed. The P&P indicated, Policy I. The Facility will be responsible for the overall care delivered to the resident, monitoring of the resident prior to and after the completion of each dialysis treatment. V. Documentation A. All documentation concerning dialysis services and care of the dialysis resident will be maintained in the resident's medical record. DON stated the P&P was not followed and should have been. 555229 Page 2 of 14 555229 03/27/2025 Valley Healthcare Center 1205 8th Street Bakersfield, CA 93304

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on interview and record review that facility failed to ensure one of five sampled residents (Resident 13) psychotropic medication (medication that alters mood, behavior, and mentation), Oxcarbazepine (medication prescribed for bipolar-mood disorder) was reviewed quarterly (every 3 months) by the interdisciplinary team (IDT- healthcare professionals including physician, pharmacist, social services, activities, and nursing). This failure resulted in Resident 13 not having an IDT medication review for Oxcarbazepine and had the potential for unnecessary medications. Findings: During a concurrent interview and record review on 3/26/25 at 11:29 a.m. with Social Service Director (SSD), Resident 13's Physician Order (PO) dated 2/21/25 was reviewed. The PO indicated Resident 13 was prescribed Oxcarbazepine 600 mg by mouth once daily for bipolar disorder. SSD stated Resident 13 had been taking Oxcarbazepine as prescribed daily. During a concurrent interview and record review on 3/26/25 at 11:57 a.m. with SSD, Resident 13's Gradual Dose Reduction Binder (GDRB- attempts made to lower strength or frequency of medication), dated February 2024 to March 2025 was reviewed. The GDRB indicated Resident 13 did not have his prescribed medication Oxcarbazepine reviewed during the facility IDT meetings. SSD stated there was no documentation that Resident 13 had an IDT medication review for Oxcarbazepine. SSD stated psychotropic medications were supposed to be reviewed quarterly by the IDT team. SSD stated, We didn't address the medication Oxcarbazepine in any of the IDT meetings. During a concurrent interview and record review on 3/26/25 at 2:45 p.m. with SSD, the facility's policy and procedure (P&P) titled, Psychotherapeutic Drug Management, dated 11/30/20 was reviewed. The P&P indicated, Purpose. To help promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being, promote resident safety and security, and to enhance the resident's ability to interact positively with his/her environment. VII. Interdisciplinary Team (IDT) Responsibility F. The IDT. will discuss the psychotherapeutic medications at least quarterly, or as needed. i. The IDT note will include: reasons for the drug, manifestations for the drug, and analysis of the resident's response to the drug. SSD stated the facility's P&P was not followed and should have been. 555229 Page 3 of 14 555229 03/27/2025 Valley Healthcare Center 1205 8th Street Bakersfield, CA 93304

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) titled, Med Pass for two of three sampled medication carts (Medication Cart 1 and Medication Cart 2). This failure had the potential for residents, staff, and visitors to unsafely access medications. Findings: During a concurrent observation and interview on 3/26/25 at 6:02 a.m. with Director of Nursing (DON) in the South Main Hallway, Medication Cart 2 was unaccompanied in the corner of the hallway in front of the nurse's station. All of Medication Cart 2's drawers, except for the controlled medication (drug or substance regulated by the government due to its potential for abuse and addiction) drawer, were unlocked and able to be opened. There was no nurse in the proximity of Medication Cart 2. DON was in the hallway; she was able to open the unlocked drawers. DON attempted to lock the cart but was unable to secure the locking mechanism. DON stated the unlocked medication cart had the potential for residents to open the cart and take medications. During an observation on 3/26/25 at 6:45 a.m. in the North Hallway outside of room [ROOM NUMBER], Registered Nurse (RN) 3 prepared to give Resident 41 medications including Lactulose (used to treat constipation and reduce ammonia levels in alcoholics). RN 3 poured the prescribed amount of Lactulose into a medication cup from a large jar of the medication. RN 3 placed the jar of Lactulose on top of Medication Cart 1 and went into Resident 41's room to administer the medications. During a concurrent observation and interview on 3/26/25 at 6:48 a.m. with RN 3, in the North Hallway by Medication Cart 1, RN 3 picked up the bottle of Lactulose and stated she usually does not leave medications on carts unattended. During a review of the facility's P&P titled, Med Pass, (undated), the P&P indicated, MEDICATION STORAGE IN THE FACILITY STORAGE OF MEDICATIONS Policy: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. 555229 Page 4 of 14 555229 03/27/2025 Valley Healthcare Center 1205 8th Street Bakersfield, CA 93304

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure its food preparation sink in the kitchen had an air gap (a backflow prevention device consisting of vertical space between the water outlet and flood level of a sink designed to ensure contaminated water does not flow back into the clean water supply). This failure had the potential to contaminate residents' food supply and exposure to infectious diseases. Findings: During an observation on 3/26/25 at 6:33 a.m., in the kitchen, there was no air gap in the two compartment sink. During an interview on 3/26/25 at 6:50 a.m., in the kitchen, with the Consultant Dietary Services Manager (CDSM), the CDSM stated the two compartment sink in the kitchen was used to wash produce and food for residents. The CDSM stated the two compartment sink in the kitchen had no air gap. During an observation on 3/26/25 at 7:25 a.m., in the kitchen, dietary staff washed fresh strawberries in the two compartment sink. During a concurrent observation and interview on 3/26/25 at 10:54 a.m., with the Director of Maintenance (DM), in the kitchen, the DM stated the two compartment sink in the kitchen had no air gap. The DM stated it was not possible to create an air gap in the two compartment sink in the kitchen. The DM stated the facility did not have a policy and procedure on air gaps. During a review of the U. S. Food and Drug Administration 2022 Food Code (FDA Food Code), version 1/18/23, the FDA Food Code indicated: 5-202.13 Backflow Prevention, Air Gap. During periods of extraordinary demand, drinking water systems may develop negative pressure in portions of the system. If a connection exists between the system and a source of contaminated water during times of negative pressure, contaminated water may be drawn into and foul the entire system. Standing water in sinks, dipper wells, steam kettles, and other equipment may become contaminated with cleaning chemicals or food residue. To prevent the introduction of this liquid into the water supply through back siphonage, various means may be used. The water outlet of a drinking water system must not be installed so that it contacts water in sinks, equipment, or other fixtures that use water. Providing an air gap between the water supply outlet and the flood level rim of a plumbing fixture or equipment prevents contamination that may be caused by backflow. 5-202.13 Backflow Prevention, Air Gap. An air gap between the water supply inlet and the flood level rim of the PLUMBING FIXTURE, EQUIPMENT, or non-FOOD EQUIPMENT shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch). 5-203.14 Backflow Prevention Device, When Required. A PLUMBING SYSTEM shall be installed to preclude backflow of a solid, liquid, or gas contaminant into the water supply system at each point of use at the FOOD ESTABLISHMENT, including on a hose [NAME] if a hose is attached or on a hose [NAME] if a hose is not attached and backflow prevention is required by LAW, by: (A) Providing an air gap as 555229 Page 5 of 14 555229 03/27/2025 Valley Healthcare Center 1205 8th Street Bakersfield, CA 93304

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few specified under § 5-202.13; or (B) Installing an APPROVED backflow prevention device as specified under § 5-202.14. During a review of the facility's policy and procedure (P&P) titled Maintenance Services, dated 11/1/17, the P&P indicated, The Maintenance Department is responsible for. Maintaining the building in compliance with current federal, state, and local laws, regulations and guidelines. 555229 Page 6 of 14 555229 03/27/2025 Valley Healthcare Center 1205 8th Street Bakersfield, CA 93304

F 0865 Have a plan that describes the process for conducting QAPI and QAA activities. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility Quality Assurance and Performance Improvement (QAPI-systematic process for ensuring that products and services ensure quality care) committee failed to maintain, identify, and correct a physical environment deficient practice identified by the survey team (reference tag F-919). This failure resulted in a non-functional resident restroom call light system and an unsafe physical environment of care for all 85 facility residents. Residents Affected - Many Findings: During a concurrent interview and record review on 3/27/25 at 2:03 p.m. with Medical Director (MD), the facility document titled, Facility Assessment Tool, dated 11/25/24 was reviewed. MD stated he reviewed the completed facility assessment as part of the QA committee. MD stated the facility assessment tool included the facility's call light system. MD stated there was no resident restroom call light deficits the QA committee was aware of. MD stated the residents' nonfunctional restroom call lights were a safety concern and needed to alarm staff of an emergency. During a concurrent interview and record review on 3/27/25 at 2:26 p.m. with Administrator, the facility's QAPI binder, dated 2/12/25 was reviewed. The QAPI binder indicated no physical environment deficits. Administrator stated there was no documentation that the residents' restroom call lights were not working. Administrator stated the resident restroom call lights should work to ensure safety and meet the communication needs of residents. During an interview on 3/27/25 at 2:47 p.m. with Maintenance Supervisor (MS). MS stated there was no documentation to provide that the resident restroom call lights were checked. MS stated he did not know the residents' restroom call lights did not work. During a review of the facility's document titled, Facility Assessment Tool, dated 11/25/24, the Facility Assessment Tool indicated, Requirement Nursing facilities will conduct, document, and review a facility-wide assessment, which includes. the resources the facility needs to care for their residents. 3. Facility resources needed to provide competent care for residents. physical environment and building needs. Part 3: Facility Resources Needed to Provide Competent Support and Care for our Resident Population During Day-to-Day Operations and During Emergencies. 3. Technology and Communication Systems. b. Call light and alert system for resident safety. During a review of facility's policy and procedure (P&P) titled, Quality Assessment & Assurance Program, dated 11/1/17, the P&P indicated, Purpose To ensure that all services provided by the Facility to residents meet the level of quality as required. Implementation. F. Individual departments or services develop quality indicators for programs and services in which they are involved and which affect their function. VI. Focus The following areas are monitored for quality and appropriateness of resident care, and any trends in performance and outcomes. G. Physical Environment. 555229 Page 7 of 14 555229 03/27/2025 Valley Healthcare Center 1205 8th Street Bakersfield, CA 93304

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility: Residents Affected - Some 1. Failed to ensure three of three dietary staff (DS 1, DS 2 and DS 3) washed their hands according to the Centers for Disease Control and Prevention (CDC) guidelines on hand washing and failed to ensure its policy and procedure (P&P) on Hand Hygiene conformed to the CDC guidelines on hand washing. This failure had the potential for the spread of infectious diseases in the facility. 2. Failed to ensure it kept an inventory of Personal Protective Equipment (PPE - gowns, gloves, masks, goggles and faceshields). This failure had the potential for the facility to run out of PPE and placing residents at risk of infectious diseases. Findings: 1. During an observation on 3/26/25 at 6:10 a.m., in the kitchen, with DS 1, DS 1 washed her hands in the handwashing sink as follows: DS 1 first applied soap to her hands and rubbed them together, wet her hands under running water, rubbed her hands, rinsed and dried them. During an observation on 3/26/25 at 6:12 a.m., in the kitchen, with DS 2, DS 2 washed her hands in the handwashing sink as follows: DS 2 first applied soap to her hands and rubbed them together, wet her hands under running water, rubbed her hands, rinsed and dried them. During an observation on 3/26/25 at 6:15 a.m., in the kitchen, with DS 3, DS 3 washed her hands in the handwashing sink as follows: DS 3 first applied soap to her hands and rubbed them together, wet her hands under running water, rubbed her hands, rinsed and dried them. During an observation on 3/26/25 at 6:30 a.m., there was a sign on the top of the kitchen handwashing sink which indicated the following: Handwashing Procedure . Wet hands and forearms first . Add soap and rub hands . for at least 20 seconds .rinse hands .dry hands . During an interview on 3/26/25 at 9:16 a.m., with the Infection Preventionist Nurse (IPN), the IPN stated facility staff should wash their hands observing the following steps in the following order: wet hands, apply soap, rubs hands for 20 seconds, rinse and dry hands. During a review of the CDC document titled About Handwashing, dated 2/16/24, the CDC guidelines indicated the following steps: 1. Wet your hands with clean, running water (warm or cold), turn off the tap, and apply soap. 2. Lather your hands by rubbing them together with the soap. Lather the backs of your hands, between your fingers, and under your nails. 3. Scrub your hands for at least 20 seconds. Need a timer? Hum the Happy Birthday song from beginning to end twice. 4. Rinse your hands well under clean, running water. 555229 Page 8 of 14 555229 03/27/2025 Valley Healthcare Center 1205 8th Street Bakersfield, CA 93304

F 0880 5. Dry your hands using a clean towel or an air dryer. Level of Harm - Minimal harm or potential for actual harm During a review of facility's P&P titled, Hand Hygiene, dated 11/1/17, the P&P indicated the following hand hygiene technique: Vigorously lather hands with soap and rub them together, creating friction to all surfaces, for at least twenty (20) seconds under a moderate stream of running water . rinse hands thoroughly under running water . dry hands thoroughly . Residents Affected - Some 2. During a concurrent observation and interview on 3/26/25 at 10:23 a.m., with the IPN and the Supplies Supervisor (SS), at the supplies room, where the facility kept its stock of PPE, the IPN and the SS, stated the facility maintained a stock of PPE but did not keep a written inventory or record of how many masks, gowns, face shields and gloves were in kept in stock. The SS stated she monitored the PPE inventory by eyeing the supplies in the supply room and if she thought the facility was running low she ordered more PPE supplies. During a review of facility policy and policy (P&P) titled Personal Protective Equipment - Infection Control Manual, dated 4/28/20, the P&P indicated: Personal protective equipment appropriate to specific task requirements is available at all times. 555229 Page 9 of 14 555229 03/27/2025 Valley Healthcare Center 1205 8th Street Bakersfield, CA 93304

F 0912 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure 23 of 34 resident rooms measured at least 80 square feet per resident in multiple resident rooms. This failure had the potential for residents to experience negative outcomes due to having insufficient personal space in their rooms. Findings: During a review of facility document titled Client Accommodations Analysis (CAA) (a facility document indicating the size of resident rooms), dated 3/12/18, the CAA indicated the following room measurements: room [ROOM NUMBER]: 153 square feet room [ROOM NUMBER]: 154 square feet room [ROOM NUMBER]: 132 square feet room [ROOM NUMBER]: 210 square feet room [ROOM NUMBER]: 210 square feet room [ROOM NUMBER]: 210 square feet room [ROOM NUMBER]: 225 square feet room [ROOM NUMBER]: 210 square feet room [ROOM NUMBER]: 156 square feet room [ROOM NUMBER]: 220 square feet room [ROOM NUMBER]: 220 square feet room [ROOM NUMBER]: 220 square feet room [ROOM NUMBER]: 220 square feet room [ROOM NUMBER]: 220 square feet room [ROOM NUMBER]: 220 square feet room [ROOM NUMBER]: 220 square feet room [ROOM NUMBER]: 220 square feet room [ROOM NUMBER]: 220 square feet 555229 Page 10 of 14 555229 03/27/2025 Valley Healthcare Center 1205 8th Street Bakersfield, CA 93304

F 0912 room [ROOM NUMBER]: 220 square feet Level of Harm - Minimal harm or potential for actual harm room [ROOM NUMBER]: 220 square feet room [ROOM NUMBER]: 220 square feet Residents Affected - Some room [ROOM NUMBER]: 220 square feet room [ROOM NUMBER]: 220 square feet During a review of the Resident List Report (RLR) (a document indicating the number of residents in the facility and their respective rooms), dated 3/24/25, the RLR indicated the following number of residents in each room: room [ROOM NUMBER]: two residents (resulting in 76.5 square feet of space per resident) room [ROOM NUMBER]: two residents (resulting in 77 square feet of space per resident) room [ROOM NUMBER]: two residents (resulting in 66 square feet of space per resident) room [ROOM NUMBER]: three residents (resulting in 70 square feet of space per resident) room [ROOM NUMBER]: three residents (resulting in 70 square feet of space per resident) room [ROOM NUMBER]: three residents (resulting in 70 square feet of space per resident) room [ROOM NUMBER]: three residents (resulting in square feet of space per resident) room [ROOM NUMBER]: three residents (resulting in 70 square feet of space per resident) room [ROOM NUMBER]: two residents (resulting in 75 square feet of space per resident) room [ROOM NUMBER]: three residents (resulting in 73 square feet of space per resident) room [ROOM NUMBER]: three residents (resulting in 73 square feet of space per resident) room [ROOM NUMBER]: three residents (resulting in 73 square feet of space per resident) room [ROOM NUMBER]: three residents (resulting in 73 square feet of space per resident) room [ROOM NUMBER]: three residents (resulting in 73 square feet of space per resident) room [ROOM NUMBER]: three residents (resulting in 73 square feet of space per resident) room [ROOM NUMBER]: three residents (resulting in 73 square feet of space per resident) room [ROOM NUMBER]: three residents (resulting in 73 square feet of space per resident) room [ROOM NUMBER]: three residents (resulting in 73 square feet of space per resident) 555229 Page 11 of 14 555229 03/27/2025 Valley Healthcare Center 1205 8th Street Bakersfield, CA 93304

F 0912 room [ROOM NUMBER]: three residents (resulting in 73 square feet of space per resident) Level of Harm - Minimal harm or potential for actual harm room [ROOM NUMBER]: three residents (resulting in 73 square feet of space per resident) room [ROOM NUMBER]: three residents (resulting in 73 square feet of space per resident) Residents Affected - Some room [ROOM NUMBER]: three residents (resulting in 73 square feet of space per resident) room [ROOM NUMBER]: three residents (resulting in 73 square feet of space per resident) During an interview on 3/27/25 at 3:25 p.m., with the Administrator, the Administrator stated the above rooms did not measure at least 80 square feet per resident. During the survey, no residents in the above rooms identified with providing fewer than 80 square feet per resident were negatively affected by the size of their rooms. During a review of the facility's policy and procedure (P&P) titled Maintenance Services, dated 11/1/17, the P&P indicated: The Maintenance Department is responsible for . Maintaining the building in compliance with current federal, state, and local laws, regulations and guidelines. 555229 Page 12 of 14 555229 03/27/2025 Valley Healthcare Center 1205 8th Street Bakersfield, CA 93304

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure 18 of 18 resident bathrooms and three of three resident shower rooms had operational call lights within reach of residents. This failure had the potential for all 85 residents not to be able to call for help if they required assistance while using the bathrooms and shower rooms. Residents Affected - Many Findings: During a concurrent observation and interview on 3/27/25 at 9:10 a.m., with the Maintenance Supervisor (MS), the call light systems located in resident bathrooms and shower rooms were checked for proper functioning and placement. The MS stated resident bathrooms and shower rooms were equipped with a call light system that when activated alerted staff at the nurse's station. The call light in the bathroom shared by residents in Rooms #1 and #3 was activated but there was no corresponding visual or auditory alarm outside the rooms or in the nurse's station. The call light in the bathroom used by residents in room [ROOM NUMBER] was activated but there was no corresponding visual or auditory alarm outside the room or in the nurse's station. The call light in the bathroom shared by residents in Rooms #4 and #6 was activated but there was no corresponding visual or auditory alarm outside the rooms or in the nurse's station. The call light in the bathroom shared by residents in Rooms #5 and #7 was activated but there was no corresponding visual or auditory alarm outside the rooms or in the nurse's station. The call light in the bathroom used by residents in room [ROOM NUMBER] was activated but there was no corresponding visual or auditory alarm outside the room or in the nurse's station. The call light in the bathroom shared by residents in Rooms #11 and #12 was activated but there was no corresponding visual or auditory alarm outside the rooms or in the nurse's station. The call light in the bathroom shared by residents in Rooms #14 and #15 was activated but there was no corresponding visual or auditory alarm outside the rooms or in the nurse's station. The call light in the bathroom used by residents in room [ROOM NUMBER] was activated but there was no corresponding visual or auditory alarm outside the room or in the nurse's station. The call light was next to the sink and not accessible to residents using the toilet. This bathroom was also a shower room and there was no call light accessible to residents in the shower stall. The call light in the bathroom shared by residents in Rooms #17 and #18 was activated but there was no corresponding visual or auditory alarm outside the rooms or in the nurse's station. The call light in the bathroom used by residents in room [ROOM NUMBER] was activated but there was no corresponding visual or auditory alarm outside the room or in the nurse's station. This bathroom was also a shower room and there was no call light accessible to residents in the shower stall. The call light in the bathroom shared by residents in Rooms #21 and #22 was activated but there was 555229 Page 13 of 14 555229 03/27/2025 Valley Healthcare Center 1205 8th Street Bakersfield, CA 93304

F 0919 no corresponding visual or auditory alarm outside the rooms or in the nurse's station. Level of Harm - Minimal harm or potential for actual harm The call light in the bathroom shared by residents in Rooms #23 and #24 was activated but there was no corresponding visual or auditory alarm outside the rooms or in the nurse's station. A sign next to the toilet indicated: Do not get up alone. Pull the string to call for the nurse, and wait for help. Residents Affected - Many The call light in the bathroom shared by residents in Rooms #25 and #26 was activated but there was no corresponding visual or auditory alarm outside the rooms or in the nurse's station. The call light in the bathroom shared by residents in Rooms #27 and #28 was activated but there was no corresponding visual or auditory alarm outside the rooms or in the nurse's station. There was no call light system in the bathroom shared by residents in rooms #29 and #30. The call light in the bathroom shared by residents in Rooms #31 and #32 was activated but there was no corresponding visual or auditory alarm outside the rooms or in the nurse's station. The bathroom shared by residents in rooms #33 and #34, which also functioned as a shower room, had no call light system. The call light in the bathroom shared by residents in Rooms #35 and #36 was activated but there was no corresponding visual or auditory alarm outside the rooms or in the nurse's station. The MS stated none of the bathroom call lights system in the facility were working. During a review of the facility's policy and procedure (P&P) titled Maintenance Services, dated 11/1/17, the P&P indicated: The Maintenance Department is responsible for . Maintaining all mechanical, electrical, and patient care equipment in safe operating condition. During a review of the facility's P&P titled, Communication - Call System, dated 11/1/17, the P&P indicated, The Facility will provide a call system to enable residents to alert the nursing staff from their rooms and toileting/bathing facilities. 555229 Page 14 of 14