Health inspection·June 3, 2025

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to revise the care plan (a detailed document outlining how the facility staff will provide care to meet the resident's specific needs) interventions as recommended by the Interdisciplinary Team (IDT - a group of healthcare professionals who collaborate to provide comprehensive care to a patient) for one of three sampled residents (Resident 1). This failure resulted in Resident 1 falling on 5/28/25 and sustaining an acute fracture (clean and immediate break in the bone) of her pelvis (bowl-shaped bony structure in the lower part of your body located between your lower back and your legs) S3 and S4 region (third and fourth sacral [triangular bone at the base of the spine] vertebrae [backbone]) and subluxation (when bones are moved out of place resulting in pressure and irritation) of S2 and S3 (second and third sacral bone -area of the pelvis) requiring the resident to be transferred to the acute hospital (from 5/28/25 to 6/1/25).Findings: During a review of Resident 1's admission RECORD (AR), dated 6/4/25, the AR indicated, Resident 1 was admitted to the facility on [DATE] with a diagnosis of epilepsy (a brain condition that causes recurring seizures [electrical disturbances in the brain]), dementia (a progressive state of decline in mental abilities), muscle weakness, cognitive (the way our brains think, learn, and understand things) or emotional (having to do with feelings) deficit (absence of) following cerebral infarction (loss of blood flow and/or oxygen to part of the brain), and osteoporosis (weak and brittle bones). During a review of Resident 1's Minimum Data Set (MDS) Assessment (a standardized assessment to evaluate a resident's functional abilities and healthcare needs), dated 5/16/25, under the section titled, Brief Interview for Mental Status (BIMS - an assessment of cognition [how well a person thinks, remembers, and learns] with scores ranging from 0 - 15, the higher the score the more intact the resident's cognition is. A score of 0 - 7 suggests severe cognitive impairment, 8 - 12 suggests moderate cognitive impairment and 13 - 15 suggests the cognition is intact. A score of 99 suggest the resident was unable to complete the interview and therefore the assessor is unable to determine the resident's cognition), the BIMS score was 07. Under section GG (assesses functional abilities and goals), Resident 1 was documented to require supervision or touching assistance (staff provides verbal cues and/ or physical contact like touching, steadying as the resident performs an activity) for the following physical movements: A. Move from sitting to standing position B. Transfer from bed to chair or chair to bed C. Transfer on and off toilet D. Walk 10 feet (a unit of measurement) E. Walk 50 feet with two turns F. Walk 150 feet G. Wheel herself in a wheelchair 50 feet with two turns H. Wheel herself 150 feet in a wheelchair. During a review of Resident 1's Morse Fall Scale (MFS - a tool used to assess a patient's risk of falling. A score of 0-24 indicates low fall risk, 25-45 indicates moderate fall risk, and scores above 45 indicates high fall risk), dated 11/27/24 the MSF indicated, Resident 1 had a score of 70. The MSF dated 1/8/25 indicated Resident 1 had a score of 75. The MSF dated 5/23/25 indicated Resident 1 had a score of 75. The MSF dated Page 1 of 3 555229 555229 06/03/2025 Valley Healthcare Center 1205 8th Street Bakersfield, CA 93304

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 555229 Page 2 of 3 555229 06/03/2025 Valley Healthcare Center 1205 8th Street Bakersfield, CA 93304

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. 555229 Page 3 of 3