Health inspection·March 26, 2025

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure medications were administered according to the physician's orders (PO) for one of three sampled residents (Resident 1) when Resident 1 did not receive two medications on time. This failure had the potential to result in Resident 1 developing adverse health outcomes due to delay in receiving his medications. Residents Affected - Few Findings: During a review of Resident 1's Order Summary Report, dated 3/26/25, the OSR indicated, Apixaban (medication that helps the blood flow more easily). two times a day for ATRIAL FIBRILLATION (irregular, often rapid heart rhythm) . Metoprolol (medication to treat high blood pressure). two times a day for HYPERTENSION (high blood pressure). During a review of Resident 1's Brief Interview for Mental Status (BIMS), dated 3/20/25, the BIMS indicated Resident 1 had a score of 15 (cognitively intact). During an interview on 3/26/25 at 2:34 p.m. with Resident 1, Resident 1 stated on 3/16/25, he was supposed to be administered his Metoprolol and Apixaban at 9 a.m. but were administered to him at around 12:30 p.m. Resident 1 stated at 9 a.m. Licensed Vocational Nurse (LVN) 1 checked his blood pressure and it was a little bit high due to him feeling excited trying to get the nurse to give him his medications because LVN 1 told him his Metoprolol and Apixaban were not in the medication cart. During a concurrent interview and record review on 3/26/25 at 4:10 p.m. with Director of Nursing (DON), Resident 1's EMAR (Electronic Medication Administration Record), dated 3/16/25 was reviewed. The EMAR indicated Resident 1 was administered Metoprolol and Apixaban at 12 p.m. Resident 1's PO, dated 3/26/25 were reviewed. The PO indicated Resident 1's Metoprolol and Apixaban were scheduled at 9 a.m. DON stated, (Metoprolol and Apixaban) were not administered at the time the physician ordered. DON stated medications should be administered one hour before and one hour after the prescribed time. During a concurrent interview and record review on 3/26/25 at 4:57 p.m. with DON, the facility's policy and procedure (P&P) titled, Administering Medications, dated April 2019 was reviewed. The P&P indicated, Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). DON stated the P&P was not followed. During an interview on 4/3/25 at 4:54 p.m. with LVN 1, LVN 1 stated she was the nurse assigned to Resident 1 on 3/16/25 day shift. LVN 1 stated on 3/16/25, Resident 1's Metoprolol and Apixaban were not in the medication cart and had to be taken out from the cubex (machine that dispenses medications). LVN 1 stated she administered Metoprolol and Apixaban to Resident 1 at 12 p.m. LVN 1 stated (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 03/26/2025 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)