Federal inspectors found that 11 of 25 licensed vocational nurses and four of six registered nurses at Ridgecrest Regional Transitional Care and Rehabilitation had not received required infection prevention training. The failures left nursing staff unaware of basic safety measures while caring for vulnerable residents.
Licensed Vocational Nurse 3 told inspectors on March 6 that "he could not remember the last Infection Control training he attended." The facility's infection preventionist stated he "did not remember what he trained staff on and did not provide training documents."
The knowledge gaps had immediate consequences for resident safety. Inspectors found residents with serious infections and medical devices receiving care without proper protective measures.
Resident 6 had an open ulcer on her right heel and additional wounds on both legs requiring daily dressing changes. When inspectors observed her room on March 3, no safety signage or protective equipment supplies were visible inside or outside her room.
Resident 34 suffered from cellulitis — a bacterial skin infection causing swelling and redness — in both legs. Like Resident 6, her room lacked the required safety equipment and warning signs.
Resident 11 used a Foley catheter to drain urine, placing her at higher risk for infection. Her room also had no protective equipment readily available for staff.
The facility had written policies requiring enhanced safety precautions for residents with wounds or medical devices, but staff didn't know the requirements existed. When inspectors asked about Enhanced Barrier Precautions — a CDC-recommended infection control measure — they found widespread ignorance throughout the nursing staff.
Licensed Vocational Nurse 13 stated "this was the first time hearing about EBP." Certified Nursing Assistant 9 said "she did not know what EBP was." The Assistant Director of Nursing admitted "she did not know much about EBP."
The Director of Staff Development told inspectors: "I haven't heard much about Evidence Based Precaution."
Even the Director of Nursing, who had attended an infection prevention conference, said she "was not sure when EBP or the AFL was rolled out." The state had issued guidance on Enhanced Barrier Precautions in June 2024, nine months before the inspection.
The infection preventionist's surveillance activities were equally inadequate. He told inspectors he "only monitored hand hygiene" and tried to observe staff "every other day and on every shift." But his monitoring tools from January through March 2025 showed no adherence rates or corrective actions for problems he identified.
"I did on-the-spot education but did not document it," the infection preventionist said. "I only collected data." He provided no tracking reports, trend analysis, or evidence that identified problems were being addressed.
The facility's own policies required the infection prevention program to provide surveillance data to the quality assurance committee, but this wasn't happening.
Meanwhile, serious equipment failures created additional infection risks throughout the building. In the kitchen, a food preparation sink was connected directly to the sewage system without required safety gaps — a violation that could contaminate food and surfaces.
The Maintenance Supervisor told inspectors he was "unaware of the requirement for a food prep sink to have an air gap per the FDA Food Code 2022." A state compliance officer who reviewed photographs of the plumbing said the setup was "a problem" requiring immediate correction.
Two ice machines near nursing stations also lacked proper drainage systems. One had no visible air gap or drain, while the other had a pipe incorrectly inserted into the drainage system. A compliance officer warned that "any blockage would contaminate the pipe."
The ice machine near the 300 hall nursing station sat in conditions that could harbor pests. Inspectors found "opened holes/crevices between the baseboard and wall, peeling paint coming off the wall" and dirty floors with cracked tiles.
Federal food safety guidelines warn that dirt on surfaces "may provide a suitable environment for the growth of microorganisms" and "harborage for insects, rodents, and other pests."
The facility had written policies addressing these issues. Its infection control program was supposed to be "a facility-wide effort involving all disciplines" and "an integral part of the quality assurance and performance improvement program." Staff were supposed to receive training on "proper techniques and procedures" following CDC guidelines.
Its policy on walls and ceilings required surfaces to be "free of chipped and/or peeling paint" with repairs made "as soon as they appear."
None of these policies were being followed effectively.
The inspection revealed a fundamental breakdown in infection prevention at a facility caring for some of California's most vulnerable residents. With staff untrained on basic safety measures and equipment creating contamination risks, the conditions posed ongoing threats to resident health and safety.
The facility's infection preventionist was supposed to lead "the identification and implementation of infection prevention goals and objectives throughout the facility." Instead, he was collecting data without acting on it while licensed nurses forgot their training and residents with serious infections went without proper protection.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ridgecrest Regional Transitional Care and Rehabili from 2025-03-06 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Ridgecrest Regional Transitional Care and Rehabili
- Browse all CA nursing home inspections