Health inspection·November 19, 2025

F 0558 Reasonably accommodate the needs and preferences of each resident. 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 ensure call lights were answered timely for two of five sampled residents (Resident 4 and Resident 5). This failure had the potential to result in unmet care needs, and to negatively impact the physical, mental, and psychosocial well-being for Resident 4 and Resident 5.Findings:During a concurrent observation and interview, on 11/19/25 at 1:23 p.m. with Resident 4 in his room, Resident 4 stated he uses the call light to request water and to be changed. Resident 4 stated he looks at the clock observed across from his bed to calculate his wait time. Resident 4 stated his best wait time is 30 minutes, but he has waited an hour for his call light to be answered. Resident 1 stated the call light wait time makes him just want to leave the facility.During a review of Resident 4's Minimum Data Set, (MDS - an assessment tool) dated 9/16/25, the MDS indicated, Resident 4's BIMS (Brief Interview for Mental Status) score was 15 (13 to 15 points indicates the resident has cognitive intactness). The MDS indicated Resident 1 needed setup and clean up assistance (helper sets up or cleans up; residents completes activity, helper assists only prior to or following the activity) for eating, dependent (helper does all of the effort) for toileting for toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement).During a review of Resident 4's care plan with the focus on ADL/Mobility: Resident [x] has actual [x] is at risk for ADL/mobility decline and requires assistance related to bed bound status, initiated 6/13/25. The care plan indicated a few of the interventions were to Encourage to use call light for assistance. and Toileting: Total.During an interview on 11/19/25 at 1:51 p.m. with Certified Nursing Assistant (CNA) 3, CNA 3 stated at times CNA 3 will have up to 13 residents assigned on a shift. CNA 3 stated, Sometimes I do have to leave my break if I forget something (for a resident). During an interview on 11/19/25 at 3:14 p.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated on a shift where the facility has had call offs LVN 3 will be assigned up to 27- 28 depending on census. LVN 3 stated that when the facility has staff that has called off some residents will have to wait due to emergencies and severities of other residents. During an interview on 12/5/25 at 1:05 p.m. with Resident 5, Resident 5 stated on the second shift (2:30 p.m. to 10 p.m.) sometime when he requested a breathing treatment; Resident 5 stated he has waited up to 45minutes. Resident 5 stated he gets mad and just goes to the nurses' station to ask for the breathing treatment. Resident 5 stated he looks at his cell phone to calculate his wait. During a review of Resident 5's MDS, dated [DATE], the MDS indicated Resident 5's BIMS score was 15.During a review of Resident 5's care plan with the focus on ADL/Mobility: Resident has actual is at risk for ADL/mobility decline . initiated 7/25/25, one of the interventions were to Encourage to use call light for assistance.During a review of Resident 5's care plan with the focus on Respiratory: Resident is at risk for complications with the respiratory system due to Chronic Obstructive Pulmonary Disease . initiated 7/24/25, one of the interventions was to Administer medications as ordered.During an interview on 12/5/25 at 2:30 p.m. Licensed Vocational Nurse (LVN) Residents Affected - Some (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 3 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 11/19/2025 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)