Health inspection·December 4, 2024

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) were treated with respect and dignity. This failure had the potential for Resident 2 to suffer emotional distress. Findings: During a review of Resident 2's admission Record, (AR) the AR indicated, Resident 2 was admitted on [DATE], with diagnoses including hemiplegia (condition that causes paralysis or weakness on one side of the body) and hemiparesis (a condition that causes weakness or an inability to move on one side of the body) following cerebral (occurs as a result of disrupted blood flow to the brain and you may become paralyzed on one side of the body, or lose control of certain muscles), aphasia (a language disorder that makes it difficult to understand, speak, read, and write) following cerebral infraction (a serious condition that occurs when blood flow to the brain is blocked, resulting in brain tissue death), and anxiety disorder (mental health conditions that cause uncontrollable and excessive feelings of fear which can significantly impact a person's life). During a review of Resident 2's Minimum Data Set, (MDS - an assessment tool) dated 10/12/24, the MDS indicated, Resident 2 was unable to complete the brief interview for mental status (BIMS-tool used to evaluate cognitive [mental process involved in knowing, learning, and understanding things] function) due to not understanding the questions. Resident 2 had short term (seems or appears to recall after 5 minutes) and long-term (seems or appears to recall long past) memory problems. During a review of Resident 2 ' s SBAR (situation, background, appearance, and review) Communication Form. (SBAR) dated 11/1/24, the SBAR indicated, CNA (certified nursing assistant 3) overheard telling (Resident 2) stop yelling and earth to (Resident 2) in a loud voice. During a review of the facility provided 5-Day Investigation, dated 11/6/24, the investigation indicated, (CNA 3 acknowledged that she was yelling at (Resident 2) because (Resident 2) was yelling and displayed no remorse for her behavior (yelling). When the DSD (Director of Staff Development) informed (CNA 3) she was being suspended (CNA 3 ' s) response was; So you are going to suspend me knowing you (the facility) already have staffing problems? During an interview on 11/14/24 at 12:30 p.m. with the Director of Nursing (DON), DON stated when the DSD confronted CNA 3, CNA 3 admitted to making the statements to Resident 2. DON stated CNA 3 was terminated. During an interview on 11/19/24 at 10:28 a.m. with Marketer, Marketer stated on 11/1/24 at Page 1 of 6 555256 555256 12/04/2024 The Rehabilitation Center of Bakersfield 2211 Mount Vernon Avenue Bakersfield, CA 93306

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few approximately 1 p.m. she was sitting in her office with the office door open, when she heard Resident 2 who only says two words ([NAME] and [NAME]) depending on her mood the tone is either loud or soft and (Resident 2) voice was louder. Marketer stated she heard someone yelling, stop yelling stop yelling! She stated when she got up to see what was happening, she heard CNA 3 yell Earth to (Resident 2)! Marketer stated when she entered the hallway outside of her office, she saw CNA 3 standing next to Resident 2 ' s wheelchair. During a review of the facility ' s policy and procedure (P&P) titled, Resident Rights, revised 1/1/12, the P&P indicated, to promote and protect the rights of all residents at the Facility. Employees are to treat residents with kindness respect, and dignity . 555256 Page 2 of 6 555256 12/04/2024 The Rehabilitation Center of Bakersfield 2211 Mount Vernon Avenue Bakersfield, CA 93306

F 0602 Protect each resident from the wrongful use of the resident's belongings or money. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to investigate timely and protect one of three sampled residents (Resident 1) when Resident 1 reported missing money and reports of Resident 1 giving money to a staff member (Activity Director). This failure had the potential for Resident 1 to have funds misappropriated. Residents Affected - Few Findings: During a review of Resident 1's AR, the AR indicated, Resident 1 was admitted on [DATE], with diagnoses including unspecified dementia (a decline in mental ability that affects a person's daily life; characterized by a loss of cognitive functioning, such as thinking, remembering, and reasoning, that worsens over time), Bipolar disorder (a serious mental illness that causes extreme shifts in mood, energy, thinking, behavior, and sleep), and schizophrenia (a serious mental disorder in which people interpret reality abnormally). During a review of Resident 1's MDS, dated 9/22/24, the MDS indicated, Resident 1's BIMS score was 11 (a score of 8 to 12 indicates moderately impaired cognition). During a review of Resident 1 ' s Resident Grievance/Complaint Investigation Report, (RGCIR) dated 8/22/24, the RGCIR indicated, (Resident 1) keeps stating that he has money missing & then goes to the front desk for more money. (Resident 1) states that he gave some money to a staff member (name not indicated) to buy soap to wash her clothes. (Resident 1) has some money in an envelope (amount not indicated) & was going for more. When asked why (Resident 1) wanted more (Resident 1) said he had 2 things to do today some money for him & some for the Staff member (name not indicated). During an interview on 10/28/24 at 12:43 p.m. with Resident 1, Resident 1 stated, One time (no date given) there was a woman (AD) who works here, and she did not have enough money for a spare tire. Resident 1 stated I gave her money; I gave her just a little bit (no amount given) because she needed a spare tire. Resident 1 stated he remembered the facility staff first name was (AD first name). During an interview on 10/28/24 at 1:00 p.m. with Licensed Vocational Nurse (LVN) LVN 1 stated, on 8/22/24 Resident 1 was looking for her activities staff (AD) to give her money for personal use. LVN 1 stated she filed a grievance on Resident 1 ' s behalf because that should not be happening (Resident 1 giving money to AD). During an interview on 10/28/24 at 3:56 p.m. with AD, AD stated AD denied having an issue with her tire in the past weeks, and AD denied taking money from Resident 1. During a concurrent interview and record review on 10/28/24 at 4:08 p.m. with Case Manager, Resident 1 ' s Case Management, (CM) dated 10/8/24, the CM indicated, (Resident 1) . offered to give AD (Activities Director) money (reason not indicated). Case Manager stated Resident 1 was trying to give AD money, Case Manager stated Resident 1 'just said here, here ' s the money.' During an interview on 11/6/24 at 8:43 a.m. with [NAME] (financial professionals who create and manage financial documents and resident accounts), she stated she handle trust money accounts (an optional account that a facility manages for a resident to help cover extra expenses). [NAME] stated every time she asked Resident 1 the reason for withdrawal, Resident 1 would say it was for personal use. 555256 Page 3 of 6 555256 12/04/2024 The Rehabilitation Center of Bakersfield 2211 Mount Vernon Avenue Bakersfield, CA 93306

F 0602 Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on 11/6/24 at 9:20 a.m. with DON, Resident 1 ' s Resident Statement Landscape (RSL- trust account statement of withdrawals and deposits) for the months of August 2024, September 2024, and October 2024 were reviewed. The RSL indicated Resident 1 made the following withdrawals: Residents Affected - Few The RLS indicated, on 8/2/24, Resident 1 withdrew $100.00, for personal needs. The RLS indicated, on 8/5/24, Resident 1 withdrew $120.00, for personal needs. The RLS indicated, on 8/7/24, Resident 1 withdrew $80.00, for personal needs. The RLS indicated, on 8/19/24, Resident 1 withdrew $40.00, for personal needs. The RLS indicated, on 8/22/24, Resident 1 withdrew $45.00, for personal needs. The RLS indicated, on 8/27/24, Resident 1 withdrew $30.00, for personal needs. The RLS indicated, on 8/27/24, Resident 1 withdrew $120.00, for personal needs. The RLS indicated, on 9/16/24, Resident 1 withdrew $120.00, for personal needs. The RLS indicated, on 9/16/24, Resident 1 withdrew $125.00, for personal needs. The RLS indicated, on 9/24/24, Resident 1 withdrew $120.00, for personal needs. The RLS indicated, on 10/1/24, Resident 1 withdrew $120.00, for personal needs. The RLS indicated, on 10/8/2, Resident 1 withdrew $120.00, for personal needs. The RLS indicated, on 10/10/24, Resident 1 withdrew $120.00, for personal needs. DON stated, That was a lot of money for a resident who does not leave the building. During a review of the facility provided AD ' s written statement dated 11/6/24, the statement indicated, I (AD), had a problem with my tire . During a review of the facility provided document titled Summary of Incident, (SI- facility ' s investigation) dated 11/6/24, the SI indicated, (Resident 1) said he gave (AD) $120 then said he gave her $80 and $30 was for detergent. (Resident 1) states it was for (AD ' s) kids laundry. During a concurrent interview and record review on 12/5/24 at 1:57 p.m. with DON, Resident 1 ' s RGCIR, dated 8/22/24, was reviewed. DON stated the RGCIR should have been reported as financial abuse, there was missing money and Resident 1 was stating he was giving money to a staff member (AD). DON stated there was a delay in the investigation (the facility started the investigation on 10/28/24), and there was no protection provided to Resident 1. DON stated, No protocol was followed (investigate and protect). During a review of the facility ' s P&P titled, P-ANO1 Abuse Prevention and Management, effective date 6/12/24, Definitions: a. Abuse is defined as the willful, . exploitation, misappropriation of 555256 Page 4 of 6 555256 12/04/2024 The Rehabilitation Center of Bakersfield 2211 Mount Vernon Avenue Bakersfield, CA 93306

F 0602 Level of Harm - Minimal harm or potential for actual harm resident property, . i.Exploitation is defined as taking advantage of a resident for personal gain using manipulation, intimidation, threats, or coercion. 4. Prevention . d. The Facility identifies, corrects, and intervenes, in situations in which abuse, neglect, exploitation, misappropriation of resident property and/or mistreatment is more likely to occur. Residents Affected - Few 555256 Page 5 of 6 555256 12/04/2024 The Rehabilitation Center of Bakersfield 2211 Mount Vernon Avenue Bakersfield, CA 93306

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure food prepared by the facility were prepared in accordance with professional standards for food service safety. This failure had the potential for the facility ' s resident to suffer from food born illnesses. Findings: During a review of facility Menu for 11/6/24 (breakfast) the menu indicated, French Toast with warm syrup breakfast Meat (sausage and bacon) Corn Flakes Grape Juice. During a review of facility Menu for 11/5/24 (dinner) the menu indicated, Crispy Fish Fillet Seasoned Fries Fresh Vegetable Blend Baked Apricot Crunch. During an observation on 11/6/24 at 6:46 a.m. in the facility ' s kitchen, tray line was observed. The following foods were noted: eggs, French toast, sausage, beacon, hashbrowns, hot cereal, cold cereal, milk, and juice were served. During concurrent observation, interview, and record review, on 11/6/24 at 8 a.m. with Dietary Supervisor (DS), confirmed sausage, bacon, and hashbrowns were served for the breakfast meal service. DS confirmed dinner was prepared and served in the facility kitchen on 11/5/24. The facility ' s Food Temperature Log, for November 2024 was reviewed. DS confirmed no food temperatures were documented for the sausage, bacon, hashbrowns for breakfast meal service and no food temperature were documented for dinner meal service on 11/5/24 (no temperature for the entire meal). During a review of the facility ' s policy and procedure (P&P) titled, Food Temperatures, undated, the P&P indicated, Foods prepared and served in the facility will be served at proper temperatures to ensure food safety. E. Record the reading on . Food Temperature Log at the beginning of the tray line. Take the temperature of each pan of product before serving. II. Acceptable Serving Temperatures . Food Item Meats, entrees Temperature Required (F-Fahrenheit- temperature scale) > [greater than] 140 (F) Preferable Temperature (F) 160-175 Food Item Potatoes, pasta Temperature Required (F) 140 (F) Preferable Temperature (F) 160-175 . Food Item Vegetables Temperature Required (F) 140 (F) Preferable Temperature (F) 160-175 . Food Item Pastries, cakes Temperature Required (F) < (less than) 60 (F) Eggs Temperature Required (F) 140 (F) . 555256 Page 6 of 6