Health inspection·April 21, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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: Residents Affected - Few 1. Resident 1's Docusate Sodium (medication for constipation [problem with passing stool]) was not held for episodes of loose stools. 2. Resident 1 was not administered Imodium or Loperamide (medications to treat diarrhea [loose stools]) for episodes of loose stools. These failures had the potential for Resident 1 to develop skin breakdown due to episodes of loose stools. Findings: 1. During a review of Resident 1's PO, dated 4/10/25, the PO indicated, Docusate Sodium. Give 1 capsule by mouth two times a day for constipation. Hold for loose stool. During an interview on 4/21/25 at 12:50 p.m. with Resident 1, Resident 1 stated she has been having diarrhea since 4/11/25, and the licensed nurses and CNAs (Certified Nursing Assistants) have been aware. During a concurrent interview and record review on 4/21/25 at 4:00 p.m. with Director of Nursing (DON), Resident 1's ADL (Activities of Daily Living – basic self-care tasks needed to live independently) flowsheet (ADLF), dated April 2025 was reviewed. Resident 1's ADLF indicated Resident 1 had episodes of loose stools on 4/11/25 at 1:59 p.m., 4/12/25 at 10:04 p.m., 4/13/25 at 1:45 p.m. and 4:12 p.m., 4/14/25 at 11:32 a.m., 4/16/25 at 1:59 p.m., and 4/19/25 at 3:57 p.m. (Resident 1 had seven episodes of loose stools from 4/11/25 - 4/19/25). Resident 1's Medication Administration Record (MAR) , dated April 2025 was reviewed. Resident 1's MAR indicated her Docusate Sodium was not held on 4/11/25 at 5 pm, 4/14 25 at 9 am, 4/16 at 9 am and 5 pm, and 4/19 at 5 pm. DON stated, It (Docusate Sodium) should have been held (on 4/11/25, 4/14/25, 4/16/25, and 4/19/25). 2. During a review of Resident 1's PO, dated 4/14/25, the PO indicated, Imodium. Give 1 tablet by mouth every 4 hours as needed for Diarrhea. During a review of Resident 1's PO, dated 4/18/25, the PO indicated, Loperamide. Give 2 tablet by mouth every 6 hours as needed for diarrhea. During a concurrent interview and record review on 4/21/25 at 4:00 p.m. with DON, Resident 1's MAR, (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 04/21/2025 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)