Health inspection·July 2, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, sanitary, and comfortable environment for five of five sampled residents (Resident 1, Resident 2, Resident 3, Resident 4,and Resident 5). This failure had the potential to cause resident harm, decrease resident comfort, and affect resident dignity. During an observation on 7/2/25 at 1:31 p.m. in Resident 1's room, the following was observed in the shared resident restroom/shower room (Resident 1's restroom is also used by the facility to provide showers for the other residents): a. On the ceiling directly over the sink was an oval shaped approximately 12-inch (a unit of measurement) area of multiple orange and black shaped dots scattered around. b. On the ceiling toward the shower stall entry was approximately 24-inch in length by 24-inch in width area of exposed wood with three exposed screws.c. The tile ramp leading into the shower stall was a triangular shaped approximately two-inch piece of missing tile. d. The shower stall by the entrance, there were two hexagonal (a shape) shaped tiles missing that are approximately two-inch in length and two-inch in width each.e. The shower drain had three hexagonal shaped tiles missing, each tile measuring approximately two inches in length and two inches in width. f. In the bottom left corner of the shower is approximately a 10-inch circular area of grout (a substance that fills in the gaps between tile) that was discolored with an unknown slimy texture green to black in color.During an observation on 7/2/25 at 2:04 p.m. in Resident 2 and Resident 3's room, the following were observed:a. The right side of the room window had approximately 40-inch length of window which was not attached or sealed, creating a gap that is approximately one-inch wide allowing for hot air from outside to come into the room.b. The middle portion of the room window was approximately 12-inch in length and one-inch in width area of window that is not attached or sealed in creating a gap that is allowing hot air from outside to come through.c. The window by left side of the room was approximately 60 inches in length and one inch in width gap that allowed hot air from the outside to come through. During a review of the state cell phone weather application (app - a software program designed for a specific purpose) on 7/2/25 at 2:08 p.m., the app indicated the current weather conditions outside of the facility was 98 degrees Fahrenheit (a unit of measurement). During an interview on 7/2/25 at 2:14 p.m. with Resident 2, Resident 2 stated he sleeps in the bed closest to the room window which causes discomfort from the hot air coming through. During a review of Resident 2's Minimum Data Set (MDS) Assessment (comprehensive assessment tool), dated 4/4/25, the MDS indicated Brief Interview for Mental Status (BIMS - an assessment of cognition, how well a person thinks, remembers, and learns) score was 15 (score of 13-15 means cognitively intact).During an observation on 7/2/25 at 2:20 p.m. in Resident 4's room, the following were observed: a. The wall behind Resident 4's bed had three large deep scratches exposing the drywall (an interior facing panel used for walls and ceilings) approximately 12 inches in length, two inches in width, and one inch in depth. b. In Resident 4's restroom, the Page 1 of 2 555229 555229 07/02/2025 Valley Healthcare Center 1205 8th Street Bakersfield, CA 93304

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some ceiling above the sink is an approximately 10-inch square of peeling paint exposing the drywall surrounding the air vent. During an observation on 7/2/25 at 2:35 p.m. in Resident 5's room, the following were observed: a. By Resident 5's window, there was an approximately 60 inch in length area that was not attached or sealed, creating a gap that is approximately one inch wide allowing hot air from outside to come into the room. b. In the Resident 5's restroom, behind the toilet, there was a section of wall baseboard that is approximately 15 inches in length and half an inch in width that was discolored with a slimy textured substance that is red to orange in color. During an interview on 7/2/25 at 2:36 p.m. with Resident 5, Resident 5 stated at times his room gets warm from the outside hot air entering through the gap in his window. During a review of Resident 5's MDS dated [DATE], the MDS indicated the BIMS score was 12 (score of 8-12 means moderate cognitively intact). During a concurrent observation and interview on 7/2/25 at 3:50 p.m. with Administrator, Administrator went into Resident 1's, Resident 2's, Resident 3's, Resident 4's, and Resident 5's rooms, and stated the facility needed to fix the issues identified.During a concurrent interview and record review on 7/28/25 at 2:14 p.m. with Maintenance Worker Director (MWD), the facility MAINTENANCE LOG (ML), dated 2025 was reviewed. MWD reviewed the ML and stated request for maintenance to fix the issues identified in Resident 1, 2, 3, 4, and 5's rooms were not made. MWD stated his staff goes to residents' rooms Monday through Friday in order to identify any needs. MWD stated he was not aware of any issues in Resident 1, 2, 3 ,4, and 5's room.During a review of the facility's policy and procedure (P&P) titled, Resident Rooms and Environment, dated 11/1/17, the P&P indicated, Purpose . To provide residents with a safe, clean, comfortable and homelike environment. The Facility provides residents with a safe, clean, comfortable, and homelike environment. Facility Staff will provide residents with a pleasant environment and person-centered care that emphasizes the residents' comfort, independence, and personal needs and preferences. This shall include ensuring that residents can receive care and services safely and that the physical layout of the Facility maximizes resident independence and does not pose a safety risk. Facility Staff aim to create a personalized, homelike atmosphere, paying close attention to the following . Cleanliness and order . Comfortable levels of ventilation . Comfortable temperatures . 555229 Page 2 of 2