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 Page 1 of 3 555260 555260 11/19/2025 Bakersfield Post Acute 6212 Tudor Way Bakersfield, CA 93306

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 3, LVN 3 stated he works pm shift. LVN 3 stated he will be assigned 25 to 32 residents. LVN 3 stated with 32 residents he is unable to take breaks without interruption. LVN 3 stated this happens one out of eight shifts worked. LVN 3 stated staff have complained about being short staffed. During an interview on 12/9/25 at 3:55p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she works pm shift she stated she will have 12 to 14 residents when the facility was fully staffed. CNA 1 stated that when the facility has staff call out, she will be assigned 15 to 18 residents to care for. CNA 1 stated the facility is short staff at least twice a week, sometimes three times a week. CNA 1 stated it can be difficult to meet the resident care needs when the facility is short staffed. CNA 1 stated she has had to not give residents showers due to short staffing. CNA 1 stated she has had to miss her 10-minute breaks to provide resident care. Policy and procedure for call light was requested but not provided. 555260 Page 2 of 3 555260 11/19/2025 Bakersfield Post Acute 6212 Tudor Way Bakersfield, CA 93306

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on interview and record review, the facility failed to ensure one of three sampled licensed staff (Certified Nursing Assistant [CNA] 2) had the skills and abilities necessary to provide adequate nursing care to the facility's residents. This failure had the potential for CNA 2 to be unable to appropriately care for residents, not meeting residents' needs. Findings:During a concurrent interview and record review, on 11/19/25 at 2:06 p.m. with the Administrator, CNA 2's employee file was reviewed. CNA 2's Job Description, signed on 12/13/23 by CNA 2 was reviewed. CNA 2's CNA Skills Checklist -Performance Objectives, (CNASCPO) dated 12/7/24 was reviewed. CNA 2's CNASCPO, indicated there were no completed skills competency check off. The Administrator confirmed the findings.During review of the facility's policy and procedure (P&P) titled, Competent Nursing, revised August 2022, the P&P indicated, 1. Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. 2. All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by state law. 4. Licensed nurses and nursing assistants are trained and must demonstrate competency in identifying, documenting and reporting resident changes of condition consistent with their scope of practice and responsibilities. 5. Licensed nurses and nursing assistants are trained and must demonstrate competency in identifying, documenting and reporting resident changes of condition consistent with their scope of practice and responsibilities. 555260 Page 3 of 3