Kern River Transitional Care Infection Control Failures CA
BAKERSFIELD, CA - State inspectors found serious infection prevention lapses and training deficiencies at Kern River Transitional Care during an April 2025 survey, documenting multiple instances where staff failed to follow proper infection control protocols while caring for residents requiring enhanced barrier precautions.
Critical Infection Control Violations
The facility's most concerning deficiencies centered around Enhanced Barrier Precautions (EBP), specialized infection control measures designed to prevent the spread of multi-drug resistant organisms. Inspectors observed multiple healthcare workers improperly following these critical safety protocols while caring for vulnerable residents.
During the inspection, a Licensed Vocational Nurse was observed providing care to a resident with a wound on their right ankle who was under EBP protocols. Despite clear signage indicating the enhanced precautions were required, the nurse wore only gloves but failed to don the required isolation gown during close contact with the resident. When questioned, the nurse acknowledged the resident was on EBP and stated "she should have worn a gown, but she did not."
The facility's own policy clearly mandated that staff wear both gowns and gloves during any care activity where close contact with the resident is expected. This type of direct care interaction represents exactly the scenario where enhanced barriers are most critical for preventing disease transmission.
In a separate incident, an X-ray technician committed multiple infection control violations while working with another EBP resident. After properly putting on protective equipment to take x-rays, the technician stepped out of the room while still wearing contaminated gloves and isolation gown to answer a cell phone call. The technician then returned to complete the procedure but removed protective equipment without performing proper hand hygiene before touching the x-ray machine and leaving the room.
Wound Care Protocol Failures
Perhaps most troubling were the violations observed during wound care procedures, where proper sterile technique is essential to prevent serious infections. During treatment of a resident's open leg wound resulting from a ruptured hematoma, inspectors documented multiple concerning practices by nursing staff.
The treatment nurse disposed of contaminated wound dressing with serosanguinous drainage into a regular trash bin rather than appropriate biohazard waste containers. The nurse acknowledged that no biohazard bin was available in the room, indicating a systemic failure in infection control infrastructure.
During the same procedure, the nurse failed to perform hand hygiene before putting on new gloves after removing contaminated ones. This basic infection control principle is fundamental to preventing cross-contamination between different aspects of wound care.
Most concerning, the nurse used non-sterile scissors to cut sterile gauze packing material during the wound care procedure. This practice directly compromised the sterility of materials being placed inside an open wound, creating significant risk for introducing bacteria and other pathogens into the healing tissue.
Medical Significance of Infection Control Lapses
These infection prevention failures carry serious medical consequences for nursing home residents, who often have compromised immune systems and multiple chronic conditions that make them particularly vulnerable to healthcare-associated infections. Enhanced Barrier Precautions exist specifically because certain residents harbor multi-drug resistant organisms that can cause life-threatening infections if transmitted to other patients.
When healthcare workers fail to properly use protective equipment during EBP protocols, they risk spreading dangerous bacteria like MRSA, VRE, or carbapenem-resistant organisms to other residents through contaminated hands, clothing, or equipment. These infections can be extremely difficult to treat and may result in prolonged illness, complications, or death in frail elderly residents.
Proper wound care technique is equally critical because open wounds provide a direct pathway for bacteria to enter the bloodstream. Using non-sterile instruments on sterile materials can introduce harmful microorganisms directly into vulnerable tissue, potentially causing wound infections, cellulitis, or systemic sepsis. For residents with compromised healing ability due to diabetes, circulation problems, or advanced age, such infections can be particularly devastating.
The failure to properly dispose of contaminated materials creates environmental reservoirs of infectious organisms that can persist and spread throughout the facility. Biohazard waste contains concentrated amounts of potentially dangerous pathogens that require special handling and disposal to prevent environmental contamination.
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
KERN RIVER TRANSITIONAL CARE in BAKERSFIELD, CA was cited for violations during a health inspection on April 24, 2025.
Inspectors observed multiple healthcare workers improperly following these critical safety protocols while caring for vulnerable residents.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.