Health inspection·June 3, 2025

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 5/28/25 indicated Resident 1 had a score of 75. During a review of Resident 1's IDT Fall (IDTF - document used by the IDT during their meetings), dated 11/28/24, the IDTF indicated, on 11/27/24 at 2:30 p.m. Resident 1 was found in the facility outdoor patio on the floor. The IDTF indicated Resident 1 stated, I just fell. IDTF recommendations were for housekeeping to keep the area clean due to Resident 1 wanting to clean up the area by reaching down to the floor from wheelchair to pick up trash. The IDTF dated 1/9/25 indicated, on 1/8/25 at 3:18 p.m., Resident 1 was found on the floor face down in the outdoor facility patio. The IDTF recommendations were to provide Resident 1 with gardening tools and plants on a table to limit her need to reach down and garden around her area. The IDTF dated 5/26/25, indicated on 5/23/25 at 3:14 p.m. Resident 1 fell in the outdoor facility patio. The IDTF recommendations were to encourage and educate Resident 1 about taking medications due to Resident 1 falling after having a seizure. The IDTF on 6/4/25 indicated, on 5/28/25 at 5:20 a.m. Resident 1 was found on the floor in her room and was unable to state what happened. The IDTF indicated Resident 1 had a diagnosis of cognitive social (how we store, process, and use information about other people) or emotional deficit, following cerebral infarction that may have contributed to her fall. The IDTF indicated Resident 1's doctor was informed of Resident 1's fall on 5/28/25 and the physician ordered the licensed nurses to send Resident 1 to the emergency room for further evaluation. The IDTF recommendations were to place non-skid strips (sticky strips placed on surfaces to prevent slips and falls) on the right side of Resident 1's bed on the floor. During a review of Resident 1's acute hospital History and Physicals (H&P), dated 5/28/25, the H&P indicated, Resident 1 was brought into the acute hospital after being found at the facility on the ground in a fetal position (bodily posture where someone lies curled up on one side, with their arms and legs drawn toward their chest). The H&P indicated Resident 1 was diagnosed with an acute fracture of her pelvis S3 and S4 region and subluxation of S2 and S3. Resident 1 was admitted to the acute hospital for observation and laboratory studies. During a concurrent interview and record review on 6/3/25 at 11:58 a.m. with Charge Nurse (CN) 1, Resident 1's Care Plan Report (CP), was reviewed. The CP titled high risk for falls, dated 4/25/23, the CP indicated, Resident 1 had falls in the facility on 11/27/24,1/8/25, 5/23/25 and 5/28/25. CN 1 reviewed the CP for Resident 1's falls on 11/27/24,1/8/25, 5/23/25, and 5/28/25, and stated there were no revisions to the fall care plan to add and/or modify interventions to prevent further falls after the 1/8/25 fall on the facility outdoor patio, after the fall on 5/23/25, and after her fall on 5/28/25. During a concurrent interview and record review on 6/24/25 at 4:06 p.m. with Director of Nursing (DON), Resident 1's CP titled High risk for falls, dated 4/25/23, was reviewed. DON reviewed the CPs for Resident 1's falls on 11/27/24, 1/8/25, 5/23/25, and 5/28/25, and stated there were no new interventions to prevent Resident 1 from falling after 1/8/25. DON stated, We (facility) are not doing it correctly (revising/modifying interventions in the CP). We (facility) are talking about it (interventions) in the IDT and addressing different interventions in the IDT but not [adding the interventions to] the care plans. DON stated facility staff do not know what interventions the IDT decided to implement to prevent Resident 1's falls due to the IDT interventions not being documented or added into the care plans. DON stated staff are to follow the resident care plan to implement interventions. DON stated, The (facility) staff are not expected to read the IDT notes but expected to follow the (resident) care plan. DON stated she did not know what interventions the licensed nurses or Certified Nursing Assistants (CNA) are expected to implement due to the interventions not being added to the CPs resulting in staff not having the ability to decrease Resident 1's risk for falls. During a review of the facility's policy and procedure (P&P) titled, Response to Falls, dated 11/1/17, the P&P indicated, Purpose . To ensure the Facility responds quickly and appropriately to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555229 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 555229 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/03/2025 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)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete resident falls in a manner that addresses both the resident's immediate needs and longer?term fall prevention. The Interdisciplinary Team (IDT) will review the investigative reports on a regular basis, as they may occur, and make systemic changes to reasonably limit future occurrences, consider change in . interventions, system changes . Following each resident fall, the Interdisciplinary Team (IDT)?Falls Committee will review the Post?Fall Assessment & Assessment within 72 hours, or as soon as practicable. Based on the Post?Fall Assessment & Investigation, the IDT?Falls Committee will review fall prevention interventions and modify the plan of care as indicated. Documentation . Licensed Nurse . Revise resident's Care Plan as necessary. During a review of the facility's P&P titled, Fall Management Program, dated 11/1/17, the P&P indicated, Purpose . To prevent resident falls and minimize complications associated with falls through the development of a Fall Management Program. It is the policy of this facility to provide the highest quality care in the safest environment for the residents residing in the facility. The Facility has developed a Fall Management Program that strives to prevent resident falls through meaningful assessments, interventions, education, and reevaluation. Based on the information gathered from the history and assessment of the resident, the Nursing Staff and Interdisciplinary Team (IDT), with input from the Attending Physician, will identify and implement interventions to reduce the risk of falls. The Nursing Staff will develop a plan of care specific to the resident's needs with interventions to reduce the risk of falls. The Interdisciplinary Team will routinely review the plan of care at a minimum of quarterly, with a significant change in condition, and post fall. Interventions will be implemented or changed based on the resident's condition and response. Event ID: Facility ID: 555229 If continuation sheet Page 3 of 3