Health inspection·March 19, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview and record review, the facility failed to ensure the allegation of sexual abuse for one of three sampled residents (Resident 1) was reported timely to California Department of Public Health (CDPH-local stated agency) and local ombudsman (representatives assist residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences). This failure had the potential for Resident 1 not to be protected from further abuse and resulted in emotional distress. Findings: During a review of the facility provided document titled, Incident Investigation For (Resident 1), dated 2/25/25, the document indicated, Interview conducted by Director of Nursing (DON) on 2/24/25 with (Resident 1) .(Resident 1) has a BIMs (Brief Interview for Mental Status) of 15 (a score of 13 to 15 suggests the resident is cognitively intact). (Resident 1) reported on the night of 02/19/2025 (Licensed Vocational Nurse [LVN] 1) went into her room and kissed her on the corner of her mouth. (Resident 1) stated, It made me feel uncomfortable and very unsafe. Staff member (LVN 1) suspended on 02/24/2025 During a concurrent interview and record review, on 3/6/25 at 10:21 a.m. with Director of Nursing (DON), the SOC 341 (Report of Suspected Dependent Adult/Elder Abuse), dated 2/25/25 was reviewed. DON confirmed the SOC 341's were faxed to CDPH and local ombudsman on 2/25/25. During an interview on 3/6/25 at 11:07 a.m. with Resident 1, Resident 1 stated LVN 1 entered her room on 2/19/25 and kissed her on the corner of her mouth which made her feel uncomfortable. Resident 1 stated she did not have a close relationship with LVN 1 where kisses or hugs were acceptable. Resident 1 stated she had seen LVN 1 once after the incident. During an interview on 3/19/25 at 3:54 p.m. with LVN 2, LVN 2 stated she was working on 2/19/25 at around 7 p.m. she noted LVN 1 entered the facility with her husband, baby and dog, so she texted the DON because she thought it was unusual for LVN 1 to show up to the facility after her shift was over and visit the staff and residents. LVN 2 stated Resident 1 reported to her LVN 1 kissed her by her lips (2/19/25). LVN 2 stated Resident 1 stated she felt drunk raped. LVN 2 stated Resident 1 told her LVN 1 smelled like alcohol and LVN 1 made her (Resident 1) feel uncomfortable. LVN 2 stated she reported the information to the DON on 2/19/25. LVN 2 stated after the incident with LVN 1 Resident 1 was more anxious (feelings of worry, tension, and fear, often in anticipation of future events or situations) than usual and quieter. LVN 2 stated Resident 1 was prescribed hydroxyzine (medication used to help control anxiety and tension caused by nervous and emotional conditions) for the anxiety after the incident. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 555260 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 555260 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bakersfield Post Acute 6212 Tudor Way Bakersfield, CA 93306 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)