Health inspection·July 30, 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 observation, interview, and record review, the facility failed to ensure call lights were answered timely for three of six sampled residents (Resident 1, Resident 2, and Resident 3). This failure had to potential to negatively impact Resident 1, Resident 2, and Resident 3, physical and psychosocial health.Findings:During a review of Resident 1's Minimum Data Set, (MDS - an assessment tool) dated 7/18/25, 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 13 (13 to 15 points indicated the resident had cognitive intactness).During a concurrent observation and interview, on 7/30/25 at 12:01 p.m. with Resident 1, Resident 1 stated the best call light wait time was five minutes and the worst was 45 minutes. Resident 1 stated some staff will just walk by and not look at her. Resident 1 stated she calculates the wait time by looking at the clock observed across the room from her bed. Resident 1 stated she used the call light for brief changes, assistance with turning and repositioning. Resident 1 stated, I have a bed sore (pressure injury- is localized damage to the skin and underlying soft tissue usually over a bony prominence) when I wet myself and when I need to be turned. The wait makes me feel a little anxious and not too good. Resident 1 stated she was told when she gets wet it could cause her bed sore to get worse.During a review of Resident 2's Minimum Data Set, dated [DATE], the MDS indicated, Resident 2's BIMS score was 14. During a review of Resident 3's Minimum Data Set, dated [DATE], the MDS indicated, Resident 3's BIMS score was 15. During a concurrent interview and observation, on 7/30/25 at 12:29 p.m. with Resident 2 and Resident 3, both Resident 2 and Resident 3 stated the call light can take 20 minutes to 2 hours to be answered. Resident 2 and Resident 3 stated they calculate the wait time by looking at the clock observed on the wall across from their beds. Resident 2 stated he uses the call light for brief changes and water. Resident 2 stated the wait time makes him angry. Resident 3 stated he uses call light for brief changes and ice water. Resident 3 stated, The wait makes me feel pissed last night I called the copsDuring a review of the facility's policy and procedure (P&P) titled, Communication - Call System, revised 10/24/22, the P&P indicated, To provide a mechanism for residents to promptly communicate with nursing staff. III. Nursing staff will answer call bells promptly, in a courteous manner. Residents Affected - Some 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: 555902 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 555902 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Height Street Skilled Care 1611 Height Street Bakersfield, CA 93305 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)