F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper
authorities.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to report an allegation of abuse to the California Department
of Public Health (CDPH-state agency) for one of three sampled residents (Resident 1). This failure resulted
in delayed investigation of the allegation of abuse and potential for continued abuse towards Resident 1.
Findings:
During a review of Resident 1's admission Record (AR), dated 11/7/24, the AR indicated Resident 1 was
admitted to the facility on [DATE] with diagnoses including, fracture [broken] of thoracic [upper spine]
vertebra [spine bone], muscle weakness and history of falls.
During a review of Resident 1's Minimum Data Set (MDS – assessment tool), dated 10/8/24, the
MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS - assessment of cognitive function)
score was 15 (a score of 13-15 suggests resident is cognitively intact).
During an interview on 11/05/24 at 9:15 a.m. with Resident 1 and Resident 1's Family Member (FM) 1,
Resident 1 stated she told her daughter (within the first week of being admitted to the facility) Certified
Nursing Assistant (CNA) 1 was rough and rude to her while providing care. FM 1 stated a request was
made to Clinical Manager (CM) on 10/30/24 for CNA 1 not be scheduled to care for Resident 1 due to CNA
1's attitude and being rough during care. Resident 1 stated CNA 1 had been assigned to care for Resident
1 after the request was made on 10/30/24.
During an interview on 11/07/24 at 10:37 a.m. with CM, CM stated Resident 1's daughter (FM 2) reported
to CM on 10/30/24, CNA 1 had an attitude and was rough during care of Resident 1. CM stated Resident
1's daughter requested CNA 1 not be assigned to care for Resident 1. CM stated he did not report Resident
1's concerns or request regarding CNA 1 to the Administrator or other member of the leadership team.
During an interview on 11/07/24 at 11:26 a.m. with Resident 1, Resident 1 stated during her first week in
the facility, she asked CNA 1 to help her move up in bed. Resident 1 stated CNA 1 grabbed the collar of her
gown, got in her face, and yelled I am not going to hurt myself to move you up. Resident 1 stated she was
afraid of CNA 1.
During a concurrent interview and record review on 1/17/25 at 12:05 p.m. with Administrator, the facility's
Summary Of Incident (SOI), dated 11/12/24 was reviewed. The SOI indicated, 10/30/24 – The
daughter of [Resident 1], [FM 2], requests CNA, [CNA 1], not be her Mom's CNA due to [CNA 1]
(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:
555771
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
555771
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/17/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Brookdale Riverwalk Snf (CA)
350 Calloway Drive, Building C
Bakersfield, CA 93312
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)
F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
being rough when providing care per [CM]. Administrator stated it was the expectation the staff submitted a
grievance report or contacted Administrator, or a member of the leadership team, for resident, family or
staff reported care concerns. Administrator stated she was made aware of Resident 1's concerns regarding
care provided by CNA 1 on 11/7/24 (eight days later). Administrator stated Resident 1 and FM 2 were
interviewed and allegations of abuse by CNA 1 toward Resident 1 were identified and reported to CDPH on
11/7/24 (eight days later). Administrator stated CM needed to report Resident 1's concerns of CNA 1 being
rough and rude during care to Administrator or a member of leadership on 10/30/24 to help protect
Resident 1 from potential continued abuse.
During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect & Exploitation Policy,
dated 10/2022 the P&P indicated, Responsibility: The Administrator has the overall responsibility for the
coordination and implementation of the community's abuse, neglect and exploitation policy. E. Protection 1.
Protection of Resident. Upon learning of alleged abuse, neglect, mistreatment or exploitation, the
Administrator or supervisor on duty should attempt to take necessary steps to verify residents are protected
from subsequent episodes of abuse, neglect, mistreatment, or exploitation. a. If an associate encounters an
abusive situation involving a resident, they should attempt to: . ii. Follow up with reporting of the incident to
the supervisor/manager on duty or Executive Director as soon as possible. G. External Reporting 1. Alleged
violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and
misappropriation of resident property should be reported: a. As soon as practical, but not later than 2 hours
after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily
injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not
result in serious bodily injury. c. Such alleged violation shall be reported to: i. The State Survey Agency; and
ii. Adult protective services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555771
If continuation sheet
Page 2 of 2
