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
(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
02/11/2026
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 0558
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
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.
Event ID:
Facility ID:
555771
If continuation sheet
Page 2 of 2