Health inspection·February 11, 2026

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the call lights were answered timely for three of four sampled residents (Resident 1, Resident 2, and Resident 3). This failure had the potential to result in Resident 1, Resident 2, and Resident 3's unmet care needs and emotional distress.Findings:During a review of Resident 1's Minimum Data Set, (MDS - an assessment tool) dated 1/21/26, the MDS indicated, Resident 1's BIMS (Brief Interview for Mental Status- standardized assessment tool used to evaluate the mental processes that allow individuals to think, learn, and remember) score was 15 (13 to 15 points indicates the resident has cognitive intactness). The MDS indicated Resident 1 needed substantial/maximal assistance (helper does more than half the effort) for toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having bowel movement).During a review of Resident 1's care plan with the focus on (Resident 1) has an ADL (Activities of Daily Living - basic self-care tasks like eating, bathing, transferring, and toileting) Self Care Performance Deficit r/t (related to) left femur (long leg bone) fracture (break in bone), initiated 1/15/26, the care plan indicated, a few of the interventions were to Encourage (Resident 1) to use call bell for assistance and (Resident 1) requires assistance for ADLs.During an interview on 2/11/26 at 9:32 a.m. with Resident 1, Resident 1 stated he used his call light for brief changes. Resident 1 stated he was on a diuretic (medication used to reduce excess fluid in the body by helping kidneys remove sodium and water through increased urination), so he was wet constantly. Resident 1 stated he would look at the clock to calculate call light wait time. Resident 1 stated he could wait up to 40 minutes for the call light to be answered. Resident 1 stated every time he would ask for something the staff would tell him they would notify someone else to get it and nobody ever did anything. Resident 1 stated it made him angry.During a review of Resident 2's MDS, dated 11/12/25, the MDS indicated, Resident 2's BIMS score was 15. The MDS indicated, Resident 2 needed patrial/moderate assistance (Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) 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 2's care plan with the focus on (Resident 2) has an ADL Self Care Performance Deficit, initiated 12/18/25, the care plan indicated, a few of the interventions were to Encourage the (Resident 2) to use call bell for assistance. and (Resident 2) requires assistance for ADLs.During a review of Resident 3's MDS, dated 11/12/25, the MDS indicated, Resident 3's BIMS score was 15.During a concurrent observation and interview on 2/11/26 at 2:42 p.m. with Resident 2 and Resident 3 in Resident 2 and Resident 3's room, Resident 2 stated she used the call light for assistance to go to the restroom and for water. Resident 2 stated she looked at the clock observed across from her bed to calculate wait time. Resident 2 stated she had waited up to an hour for the call light to be answered. Resident 2 stated sometimes if a staff member did not answer the call light, she would yell out until someone came. Resident 3 stated she would get up to go to the nurses' station to find a staff member to help Residents Affected - Few Page 1 of 2 555771 555771 02/11/2026 Brookdale Riverwalk Snf (CA) 350 Calloway Drive, Building C Bakersfield, CA 93312

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 2 because Resident 2 had waited so long. Resident 2 stated the wait time made her feel like I am nothing.During an interview on 2/11/26 at 3:10 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated when multiple call lights were on, she would get to them when she could. CNA 1 stated if there was an emergency, a resident's call light might not be answered timely.During a review of the facility's policy and procedure (P&P) titled, Resident Rights, revised October 2022, the P&P indicated, 1. Federal and state laws guarantee certain basic rights to residents Skilled Nursing communities. Resident Rights Provider Residents have certain rights and protections under the law, as follows: . The resident has the right to receive the services and/or items included in the plan of care. Respect: The resident has a right to a dignified existence, . Resident have the right to be treated with dignity and respect. Consistent with the individualized plan of care .During a review of the facility's P&P titled, Resident Call System and Door Alarm, revised October 2022, the P&P indicated, Associates should respond to resident call system alerts . in a reasonable and timely manner. B. Responding to resident call system alerts. 1. Follow these directions for responding to resident call systems alerts: a) When an associate receives a resident call system alert, he or she should respond within a timely manner. 555771 Page 2 of 2