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.
Quality Assurance Oversight Gaps
The inspection also revealed significant weaknesses in the facility's quality improvement oversight. The facility's Infection Preventionist, a key position responsible for monitoring and improving infection control practices, failed to attend two of three sampled Quality Assessment and Performance Improvement committee meetings during the review period.
This absence represents a critical gap in infection control oversight, as the IP plays an essential role in identifying trends, implementing corrective actions, and ensuring compliance with infection prevention standards. Without consistent participation in quality improvement activities, the facility lacks adequate surveillance and response capabilities for infection control issues.
The administrator acknowledged during interviews that the facility had experienced leadership turnover, with the previous Social Services Director being terminated in December 2024 for incompetence in job duties. Such administrative instability can contribute to lapses in oversight and training that manifest as the infection control failures observed during the survey.
Widespread Training Deficiencies
Beyond infection control issues, inspectors found systemic failures in required staff education. The facility failed to ensure that 108 out of 108 certified nursing assistants received the mandated minimum of 5 hours annual dementia-specific training. This represents a 100% failure rate for compliance with federal training requirements.
Documentation showed that across multiple training sessions throughout 2024 and early 2025, only partial groups of CNAs attended dementia education programs. The largest single session had 68 attendees out of 108 required participants, while some sessions had as few as 33 CNAs present.
This training deficiency is particularly concerning given that dementia affects a significant portion of nursing home residents. Proper dementia care requires specialized knowledge about communication techniques, behavioral management, person-centered approaches, and safety considerations. Without adequate training, CNAs may struggle to provide appropriate care or may inadvertently use approaches that increase confusion, agitation, or risk of injury for residents with cognitive impairment.
Industry Standards and Regulatory Requirements
Federal regulations require nursing homes to maintain comprehensive infection prevention and control programs that include proper staff training, appropriate use of personal protective equipment, and adherence to evidence-based protocols. The Centers for Disease Control and Prevention provides specific guidance on Enhanced Barrier Precautions as an important tool for preventing transmission of multi-drug resistant organisms in healthcare settings.
Standard infection control practice requires healthcare workers to perform hand hygiene before and after resident contact, use appropriate personal protective equipment based on transmission risks, properly dispose of contaminated materials in designated biohazard containers, and maintain sterile technique during wound care procedures.
Quality assurance programs must include participation from key personnel including infection preventionists, who bring specialized expertise in surveillance, prevention, and control of healthcare-associated infections. Regular attendance at quality improvement meetings ensures that infection control concerns are identified promptly and addressed systematically.
Additional Issues Identified
Inspectors documented several other infection control lapses, including Central Supply staff accessing disinfectant wipe containers that were left uncovered, potentially compromising the sterility and effectiveness of cleaning materials. The facility's Infection Preventionist confirmed this was not acceptable practice, indicating awareness of proper procedures but inconsistent implementation.
The inspection findings reflect broader systemic issues with staff education, policy implementation, and oversight mechanisms that allowed multiple types of infection control failures to occur simultaneously across different departments and roles within the facility.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Kern River Transitional Care from 2025-04-24 including all violations, facility responses, and corrective action plans.
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