Health inspection·October 27, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assess, recognize, escalate and properly respond to an emergency involving one of seven sampled residents (Resident 7) who experienced a physical change of condition (a significant change in a person's health, caregiver support, or functional status that will not usually resolve without further intervention). This failure resulted in a delay in transferring Resident 7 to the hospital for a higher level of care, resulted in a delay in treatment for a Cerebral Infarction (also known as a stroke, it is when blood flow to the brain is stopped, which can result in slurred speech, movement difficulties to one or both sides of the body, numbness, confusion, headache), and an intracranial hemorrhage (type of stroke that causes bleeding in the head), which resulted in Resident 7's functional decline in mobility, decline in ability to feed self, decline in ability to provide self with oral care, decline in ability to toilet self, decline in ability to shower and/or bathe self, decline in ability to dress upper and lower body, decline in ability to put on footwear, decline in ability to provide self with personal hygiene, and decline in ability to walk.Findings:During a review of Resident 7's MDS Assessment, dated [DATE], under the section titled, Brief Interview for Mental Status (BIMS - an assessment of cognition [how well a person thinks, remembers, and learns] with scores ranging from 0 - 15 with the higher the score the more intact their cognition is), the BIMS score was 15 (cognition intact).During a concurrent observation and interview on [DATE] at 1:21 p.m. with Resident 7 in the resident room, Resident 7 was observed in her wheelchair with her right side of face drooping. Resident 7 stated on the evening (no specific time provided) of [DATE] she started to experience slurred speech and right sided body weakness (change from her normal baseline status). She informed staff (no specific staff identified) that she was having a stroke. Resident 7 stated staff (no specific staff identified) called the Nurse Practitioner (NP - a registered nurse with a graduate degree who provides advanced healthcare, including diagnosing and treating illnesses, ordering and interpreting tests, and prescribing medication) who instructed the staff to place Resident 7 back in bed and just monitor. Resident 7 stated, I had cried and yelled for help telling them I'm having a stroke, and they (no specific staff identified) said okay and put me in bed. I don't think that was right because [NP] said he was not going to do anything about it because I am a DNR (Do not resuscitate - a medical order written by a health care provider which instructs providers not to perform CPR [cardiopulmonary resuscitation- an emergency life-saving procedure that is done when someone's breathing or heartbeat has stopped] if a patient's breathing stops or if the patient's heart stops beating).During an interview on [DATE] at 9:05 a.m. with LVN 2, LVN 2 stated she was assigned to Resident 7 on [DATE] during the night shift ([DATE] 7 p.m. to [DATE] 7 a.m.) when Resident 7 complained of right sided weakness and difficulty speaking. LVN 2 stated Resident 7 was stating she was having a stroke, and the right side of her body was having spasms (painful cramps from the tightening of muscles). LVN 2 stated she observed Resident 7 with difficulty Residents Affected - Few Page 1 of 8 555517 555517 10/27/2025 Kern Valley Healthcare District Dp Snf 6412 Laurel Ave Lake Isabella, CA 93240

F 0684 Level of Harm - Actual harm Residents Affected - Few speaking and new onset right sided weakness. LVN 2 stated she called the NP regarding Resident 7's worsening condition and he instructed her to place Resident 7 back in bed and make her comfortable because Resident 7 had these types of issues (stroke) in the past. LVN 2 stated she was told by NP, there was nothing that could be done about Resident 7's change in condition because she had a DNR order. LVN 2 stated, I wish I can [sic] take her [Resident 7] to ED [Emergency Department] but that was his [NP] orders. He [NP] never came to see her after I [LVN 2] called. She [Resident 7] is a DNR, but she was not needing resuscitation, she [Resident 7] was needing advanced level of care and assessment. LVN 2 stated she did not pursue any further action after notifying NP of Resident 7's physical change of condition including not calling the Medical Doctor (MD).During an interview on [DATE] at 2:16 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she was assigned to care for Resident 7 on [DATE] during the night shift (CNA shift is from 6:30 p.m. to 7 a.m.). CNA 1 stated at the beginning of her shift (6:30 p.m.) Resident 7 was smiling and happy, and able to move about the facility as well as her room using both legs and left arm in her wheelchair. CNA stated at approximately 9:30 p.m. she heard what sounded like a loud cry for help from Resident 7's room. CNA 1 stated she entered Resident 7's room and noticed immediately Resident 7's right side of face and body were noticeably drooping more than her normal. CNA 1 stated, [Resident 7's] face looked like it was hanging, her mouth was hanging, and she was drooling (not her normal status), CNA 1 stated she immediately notified LVN 2 about Resident 7's condition and LVN 2 called NP. CNA 1 stated she was instructed to place Resident 7 back in bed. CNA 1 stated it took three staff members (not identified) to place Resident 7 back into bed. CNA 1 stated prior to this incident Resident 7 was able to place herself back to bed without assistance. CNA 1 stated LVN 2 had told her the NP would be in later in the night to assess Resident 7. CNA 1 stated NP never came by to assess Resident 7. CNA 1 stated she was upset that the NP never came to see Resident 7 and that nothing was done for Resident 7's change in condition other than placing her in bed.During an interview on [DATE] at 10 p.m. with NP, NP stated he was working in the facility on [DATE] (date of Resident 7's change of condition) in a different department. NP stated LVN 2 called him regarding Resident 7's change of condition. NP stated from previous discussions he had with Resident 7, Resident 7 did not want any advanced type of care and that she was a DNR, so he instructed LVN 2 to monitor Resident 7. NP stated he was unaware Resident 7 could receive medical treatment without restrictions. NP stated he did not recall if he told LVN 2 he would see Resident 7 on [DATE]. NP stated he was not aware nor made aware by the facility staff that Resident 7 was willing to go to the ED. NP stated had he been made aware of this, he would have instructed staff to ask Resident 7 if she wanted to be transferred to the ED and proceeded with care based on the resident's decision.During an interview on [DATE] at 1:02 p.m. with Director of Nursing (DON), DON stated a resident with a DNR order does not prohibit the facility from assessing and treating the resident for medical conditions. DON stated a resident with a DNR order does not prevent them from being transferred to the Emergency Department for further care and/or treatment/assessment.During an interview on [DATE] at 12:48 p.m. with MD, MD stated he did not receive a call regarding Resident 7's change of condition on the night of [DATE]. MD stated staff are aware he is available for calls or text messages regarding residents twenty-four hours a day, seven days a week. MD stated if had received a call concerning Resident 7's change of condition he would have asked the staff to review her POLST (Physician Orders for Life-Sustaining Treatment is a written order which outlines the specific treatment the resident wants or does not want during a medical emergency) and ask Resident 7 what type of further care she would allow to happen, then make decisions based on the resident's responses. If Resident 7 stated she wanted further care when questioned, then he would have pursued the 555517 Page 2 of 8 555517 10/27/2025 Kern Valley Healthcare District Dp Snf 6412 Laurel Ave Lake Isabella, CA 93240

F 0684 Level of Harm - Actual harm Residents Affected - Few appropriate treatment per her request. MD stated if staff were concerned about NP's response to Resident 7's condition, the staff were aware they could have called him for further instructions/clarification.During a review of Resident 7's TRANSFER/DISCHARGE REPORT (TDR), dated [DATE], the TDR indicated, Resident 7 admitted to the facility on [DATE] with a diagnosis of personal history of Transient Ischemic attack (TIA - a temporary blockage of blood flow to the brain) and Cerebral Infarction (also known as a stroke, it is when blood flow to the brain is stopped, which can result in slurred speech, movement difficulties to one or both sides of the body, numbness, confusion, headache). The TDR indicated Resident 7 was taking amlodipine (medication for high blood pressure [BP -the pressure of blood as your heart pumps blood through the body. A normal blood pressure is 120/80 millimeter of Mercury [mmHG - a unit of measurement]) 5 milligrams (mg - a unit of measurement) for hypertension (high BP - which can cause a heart attack, stroke and other medical complications), Lasix (medication for high BP) 40 mg, and carvedilol (medication for high BP) 3.125 mg.During a review of Resident 7's Minimum Data Set (MDS) Assessment (a standardized assessment to evaluate a resident's functional abilities and healthcare needs), dated [DATE], under the section titled, GG (assesses functional abilities and goals), the GG section indicated Resident 7 required the following:a. Set up or clean up assistance with eatingb. Set up or clean up assistance with oral hygienec. Set up or clean up assistance with toiletingd. Independently able to shower and/or bathe herselfe. Independently able to dress her upper and lower bodyf. Independently able to put on/take off footwearg. Set up or clean up assistance with personal hygieneh. Independently able to turn left and right, move from sitting to lying position, move from lying to sitting position in bed, move from a sitting to standing position, move from bed to chair or chair to bed, move herself on and off the toilet, move self in and out of shower and/or tub, walk 50 feet (ft - a unit of measurement) with two turns, and walk 150 feet.During a review of Resident 7's Physician Orders for Life-Sustaining Treatment, dated [DATE], the POLST indicated, Resident 7 signed the POLST on [DATE] and NP signed the POLST on [DATE] acknowledging Resident 7 did not want to be resuscitated (the act of reviving someone from unconsciousness or apparent death, typically by restoring breathing or heartbeat) but did want selective treatment with a goal of treating medical conditions while avoiding burdensome measures (not defined or specified). The medical treatments Resident 7 agreed to included: medical treatment, Intravenous (IV - into or within the vein) antibiotics (medication for infections), IV fluids, use of non-invasive airway pressure (delivery of oxygen into the lungs), and artificial nutrition (a method of providing nutrition).During a review of Resident 7's Care Plan Report (CP), dated [DATE], the CP indicated, Resident 7 had a history of stroke with right sided weakness. The CP indicated the goal was for Resident 1 to be independent with most ADLs (activities of daily living - Basic routine tasks that most healthy individuals can perform without assistance, these activities include bathing, dressing, walking, eating, using the toilet and transferring positions). Interventions for Resident 7's stroke with right sided weakness included calling the MD as needed.During a review of Resident 7's Progress Notes (PN), dated 10/2025, the PN indicated:a. [DATE] at 2:36 a.m. Licensed Vocational Nurse (LVN) 2 documented, (Resident 7) c/o (complained of) right sided weakness, speech difficult to understand . Called in [NP], no new order. Resident [7] back to bed . will continue to monitor. The PN indicated Resident 7 had an oxygen saturation (a measurement of how much oxygen your blood is carrying. Normal levels are 90 to 100 % [% - a unit of measurement].) of 86 %. The PN indicated Resident 7 was placed on three liters (a unit of measurement) of oxygen.b. [DATE] at 7:28 a.m. - LVN 2 documented on [DATE] at 9:59 p.m., Blood pressure warning . [Resident 7's BP was 143/68 mmHG] . High of 130 exceeded .c. [DATE] at 7:37 a.m. - LVN 2 documented, [Oxygen saturation warning] low of 90 [%] . The PN indicated Resident 7 555517 Page 3 of 8 555517 10/27/2025 Kern Valley Healthcare District Dp Snf 6412 Laurel Ave Lake Isabella, CA 93240

F 0684 Level of Harm - Actual harm Residents Affected - Few was placed on three liters (a unit of measurement) of oxygen.d. [DATE] at 10:08 a.m. - Registered Nurse (RN) 1 documented, Resident [7] inquired [questioned] ‘Do you think I had a stroke?' Speech is slurred and mumbled, ability to be understood is decreased from baseline . Left hand grasp is WNL (within normal limits) minimal right hand flexion (grasp) upon request.e. [DATE] at 10:30 a.m. - RN 1 documented, Resident 7 had, facial droop [weakness to one side of the face] is increasingly pronounced with smile, and slight tongue deviation [departure from normal] is observed. [NP] notified. Resident [7] will be sent to [emergency department] per family request.f. [DATE] at 1:03 p.m. - LVN 3 documented, resident [7] is being transferred ER [emergency room] to ER via ambulance [related to] left side brain bleed.During a review of Resident 7's ED Physician Notes (EDPN), dated [DATE], the EDPN indicated, Patient (Resident 7) presented at 11:52 AM today at outside (hospital). She (Resident 7) was complaining of difficulty speaking and some right facial droop (when your face muscles are not working properly) (sic) And (sic) increased right-sided weakness. Patient (Resident 7) apparently has had a stroke in the past with right sided weakness apparently symptoms started several days earlier. CT (computed tomography - an imaging procedure) of the head is showing a left thalamic (a portion of the brain that deals with movement and sensation) intracranial hemorrhage (type of stroke that causes bleeding in the head) with possible mass effect (surrounding areas of brain tissue or brain structures that is compressed and injured due to the degree of space from leaking blood). Critical Care Statement . Due to a probability of clinically significant, life threatening deterioration of their clinical condition, the patient (Resident 7) required my (ED doctor) highest level of preparedness to intervene emergently in case of deterioration of their condition. I (ED doctor) personally spent 32 minutes of critical care time directly and personally managing the patient (Resident 7). critical care time was performed to assess and manage the high probability of imminent, life-threatening deterioration that could result in the loss of life or limb. Condition (of Resident 7) . guarded (there's not enough information yet to make a judgment about likely outcomes) and critical (needs immediate medical care due to life-threatening injuries or a serious illness). The EDPN indicated Resident 7 was to be placed in the Intensive Care Unit (a department of a hospital in which patients who are dangerously ill are kept under constant observation).During a review of Resident 7's acute hospital neurology (branch of medicine that specializes in issues and diseases of the brain) Consultation (NC), dated [DATE], the NC indicated, Resident 7 had, Increased symptoms of right facial droop and right hemiparesis (weakness to one side of the body). She did notice that she had a facial droop and increased right upper extremity [arm] weakness compared to her baseline (her normal condition).During a review of Resident 7's acute hospital Discharge Summary (DS), dated [DATE], the DS indicated, Resident 7 was discharged from the acute hospital on [DATE] back to the facility. The DS indicated Resident 7's discharge diagnosis was:a. Left thalamic intercranial hemorrhageb. Right sided weakness and facial droop with dysarthria (difficulty speaking because the muscles you use for speech are weak)c. CVA (cerebral vascular accident - also known as a stroke)d. Atrial fibrillation (an irregular heartbeat which causes the heart to beat faster than normal).During a review of Resident 7's MDS Assessment, dated [DATE], under the section titled, GG, the GG section indicated Resident 7 required the following:a. Supervision and/or touching assistance for eating (a decline from previous MDS assessment)b. Substantial (large amount) and/or maximal assistance with oral hygiene a (decline from previous MDS assessment)c. Substantial and/or maximal assistance with toileting (decline from previous MDS assessment)d. Dependent on staff to shower or bathe (decline from previous MDS assessment)e. Substantial and/or maximal assistance with upper body dressing (decline from previous MDS assessment)f. Substantial and/or maximal assistance with lower body dressing (decline from previous MDS assessment)g. 555517 Page 4 of 8 555517 10/27/2025 Kern Valley Healthcare District Dp Snf 6412 Laurel Ave Lake Isabella, CA 93240

F 0684 Level of Harm - Actual harm Residents Affected - Few Substantial and/or maximal assistance with putting on/taking off footwear (decline from previous MDS assessment)h. Substantial and/or maximal assistance with personal hygiene (decline from previous MDS assessment)i. Substantial and/or maximal assistance with turning left and right, moving from sit to lying position, moving from lying to sitting position in bed, moving from sitting to standing position, moving from bed to chair of chair to bed, and moving herself on and off the toilet (decline from previous MDS assessment)j. Was not able to be assessed with walking 50 feet with two turns and 150 feet due to medical condition and/or safety concerns (decline from previous MDS assessment).During a review of the facility's policy and procedure (P&P) titled, Do Not Resuscitate (DNR), dated [DATE], the P&P indicated, In addition to the advance directive and DNR forms, state specific forms include: Physician Orders for Life-Sustaining Treatment (POLST) .The resident's attending physician will clarify and present any relevant medical issues and decisions to the resident or legal representative as the resident's condition changes in an effort to clarify and adhere to the resident's wishes. Inquiries concerning DNR orders/request should be referred to the Administrator, Director of Nursing, or the Social Services Director.During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, dated [DATE], the P&P indicated, Licensed staff shall promptly notify the resident, his or her attending physician, and family/representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). The Care Manager/Charge Nurse will notify the resident's Attending Physician or On-Call Physician and the Director of Nursing Services when there has been . A significant change in the resident's physical/emotional/mental condition . A need to alter the resident's medical treatment significantly . A need to transfer the resident to a hospital/treatment center . Regardless of the resident's current mental or physical condition, the Care Manager/Charge Nurse will inform the resident of any changes in his/her medical care or nursing treatments. 555517 Page 5 of 8 555517 10/27/2025 Kern Valley Healthcare District Dp Snf 6412 Laurel Ave Lake Isabella, CA 93240

F 0712 Ensure that the resident and his/her doctor meet face-to-face at all required visits. 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 conduct Medical Doctor (MD) and/or Nurse Practitioner (NP - a registered nurse with a graduate degree who provides advanced healthcare, including diagnosing and treating illnesses, ordering and interpreting tests, and prescribing medication) resident assessments per the facility policy and procedure for seven out of seven residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7). This failure had the potential for residents' medical conditions to change without appropriate interventions by the MD or NP. Findings: During a review of Resident 1's Minimum Data Set (MDS) Assessment (a standardized assessment to evaluate a resident's functional abilities and healthcare needs), dated 9/19/25, under the section titled, Brief Interview for Mental Status (BIMS - an assessment of cognition [how well a person thinks, remembers, and learns] with scores ranging from 0 to 15 with the higher the score the more intact the cognitive status is), the BIMS score was 10 (moderately impaired cognition). During an interview on 10/27/25 at 12:11 p.m. with Resident 1, Resident 1 stated MD or NP had not seen the resident for over a year. During a review of Resident 1's PROGRESS NOTE (PN), the PN indicated NP had documented assessing Resident 1 on 12/31/24 under the section titled BIMS, the BIMS score was 15 (cognition intact). During an interview on 10/27/25 at 12:16 p.m. with Resident 2, Resident 2 stated MD or NP had not seen the resident in months (not able to give exact amount of time). During a review of Resident 2's PN, the PN indicated NP had documented a review of Resident 3's MDS assessment dated [DATE], under the section titled BIMS, the BIMS score was 15. During an interview on 10/27/25 at 12:25 p.m. with Resident 3, Resident 3 stated she has not seen her MD or NP in the facility for over three months. During a review of Resident 3's PN, the PN indicated NP Resident 4's MDS assessment dated [DATE], under the section titled BIMS, the BIMS score was 15.During an interview on 10/27/25 at 12:36 p.m. with Resident 4, Resident 4 stated she has been in the facility for two years this coming May (2026). Resident 4 stated she saw an MD when she first arrived to the facility almost two years ago and has not seen the MD or NP in a very long time (could not specify how much time has passed but stated it has been a few months).During a review of Resident 4's PN, the PN indicated NP Residents Affected - Some 555517 Page 6 of 8 555517 10/27/2025 Kern Valley Healthcare District Dp Snf 6412 Laurel Ave Lake Isabella, CA 93240

F 0712 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some under the section titled BIMS, the BIMS score was 15.During an interview on 10/27/25 at 12:49 p.m. with Resident 5, Resident 5 stated she has seen the NP two or three times since she admitted to the facility (2/2024) and the MD maybe once. Resident 5 stated, I don't think they (NP and MD) come as they should be and they don't follow up.During a review of Resident 5's PN, the PN indicated NP had documented review of Resident 6's MDS assessment dated [DATE], under the section titled BIMS, the BIMS score was 15.During an interview on 10/27/25 at 12:51 p.m. with Resident 6, Resident 6 stated he could not recall the last time he saw MD because it had been a long time. Resident 6 stated he saw NP the prior month due to having to get clearance for surgery but prior to that it had been a very long time (greater than 8 months) since he saw the NP.During a review of Resident 6's PN, the PN indicated NP had documented assessing review of Resident 7's MDS assessment dated [DATE], under the section titled BIMS, the BIMS score was 15.During an interview on 10/27/25 at 1:21 p.m. with Resident 7, Resident 7 stated she had never seen MD or NP prior to seeing them on Friday (10/24/25). During a review of Resident 7's PN, the PN indicated NP Director of Nursing (ADON), ADON stated she had heard staff members (cannot recall who) complain the NP and/or MD had not been seeing the residents. During an interview on 12/1/25 at 12:55 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she cannot recall who but over the last year there had been complaints from residents and staff that the MD and/or the NP have not been in to see the residents to conduct assessments and/or address a medical concern. LVN 1 stated residents (cannot recall who) will state they have never met the MD or NP. LVN 1 stated staff (cannot recall who) have mentioned residents complaining of not seeing there MD and/or NP. During an interview on 12/1/25 at 1:02 p.m. with Director of Nursing (DON), DON stated she had not heard from staff or residents regarding concerns of not being seen by the MD and/or NP. DON stated her expectation is for residents to be seen for their assessments. During a review of the facility's policy and procedure (P&P) titled, HEALTH INFORMATION MANAGEMENT, dated 1/26/15, the P&P indicated, The medical record should contain complete information about the resident's illness and his treatment. Events should be recorded in the order in which they occur. Such complete chronological recording justifies the diagnosis and 555517 Page 7 of 8 555517 10/27/2025 Kern Valley Healthcare District Dp Snf 6412 Laurel Ave Lake Isabella, CA 93240

F 0712 Level of Harm - Minimal harm or potential for actual harm proves that the condition warrants the treatment and the end result. All medical records shall be completed and filed within 30 days after discharge date . Residents shall be visited by their physician a minimum of every 30 days. Each visit must be documented with a progress note by the attending physician. Residents Affected - Some 555517 Page 8 of 8