Health inspection·August 19, 2025

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the responsible party (RP) and hospice provider for one of three sampled residents (Resident 1) were notified when a psychotherapeutic medication (a class of drugs that alter brain chemistry to treat cognitive, emotional, and behavioral conditions) was discontinued. This failure resulted in Resident 1's RP and hospice provider not to be part of the decision-making process. Findings:During a review of Resident 1's admission Record, (AR) the AR indicated, Resident 1 was admitted on [DATE], with diagnoses included senile degeneration of the brain (a syndrome of progressive decline in mental functions; impacting memory, reasoning, and the ability to perform everyday activities, caused by an underlying disease of the brain), 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), and major depressive disorder with severe psychotic symptoms (a severe mental illness where an individual experiences both major depression and psychosis, typically as delusions or hallucinations that align with their depressed mood). The AR indicated Resident 1 had an RP and was under the care of hospice. During a concurrent interview and record review, on 8/19/25 at 2:45 p.m. with Quality Assurance Nurse (QAN), Resident 1's IDT (Interdisciplinary Team - a group of health care professionals with various areas of expertise who work together to improve patient safety and outcomes. The IDT must, at a minimum, consist of the resident's attending physician, a registered nurse and nurse aide with responsibility for the resident, . the resident and resident representative, if applicable) Psychotherapeutic Review, dated 3/27/25 was reviewed. QAN stated the IDT indicated Physician's Assistant gave the recommendation to discontinue Quetiapine (used to treat serious mental illness), and the IDT team agreed to discontinue the Quetiapine. Resident 1's medical record was reviewed. QAN stated there was no documentation Resident 1's RP or hospice provider were notified of the discontinued medication. QAN stated Resident 1's RP and hospice provider should have been notified. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised March 2022, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 1. The interdisciplinary Team (IDT) in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 4. Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to: a. participate in the planning process; . h. see the care plan and sign it after significant changes are made. 11. The resident has the right to refuse to participate in the development of his/her care plan and medical and nursing treatments. Such refusals are documented in the resident's clinical record in accordance with Page 1 of 2 555260 555260 08/19/2025 Bakersfield Post Acute 6212 Tudor Way Bakersfield, CA 93306

F 0657 established polices.Hospice communication policy and procedure was requested but not received. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555260 Page 2 of 2