Bakersfield Post Acute
Inspection Findings
F-Tag F0656
F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Based on interview and record review, the facility failed to develop a plan of care for one of two sampled residents (Resident 1) when Resident 1 was at risk for contracting head lice after her roommate (Resident 2) contracted head lice. This failure had the potential for Resident 1 to contract head lice and spread infection.Findings:During a review of Resident 2's Change in Condition Evaluation (CCE), dated 12/22/25,
the CCE indicated, resident [2] observe [sic] with hair lice.During a review of Resident 1's CCE, dated 12/24/25, the CCE indicated, Resident [1] observed with three counts of live head lice at scalp. One scab noted r/t [related to] Hx [history] of generalized itching.During a concurrent interview and record review on 12/26/25 at 3:37 p.m. with Infection Preventionist (IP), Resident 1's Care Plan (CP), dated 12/24/25, was reviewed. The CP indicated, Resident [1] has head lice. IP stated there was no care plan developed for Resident 1 when her roommate (Resident 2) contracted head lice on 12/22/25. IP stated Resident 1 should have had a care plan developed for at risk of contracting head lice because of Resident 1's close contact with her roommate (Resident 2) who contracted head lice on 12/22/25.During a concurrent interview and
record review on 12/26/25 at 3:37 p.m. with IP, Resident 1's Nurse's Note (NN), dated 12/24/25, was reviewed. The NN indicated, When assessing patients [Resident 1] scalp, myself and the infection preventionist found signs of pediculosis/lice and eggs in her hair. IP stated there was no documentation Resident 1 was monitored for head lice after 12/24/25. IP stated Resident 1 should have been monitored every shift for signs of itching, and for live head lice or nits (head lice eggs) from 12/24/25 until 12/27/25. IP stated if there was no documentation, it was not done.During an interview with Resident 1 on 12/26/25 at 4:41 p.m., Resident 1 stated Resident 2's children recently visited, and the children gave Resident 2 head lice. Resident 1 stated she was checked for head lice the day before Christmas (12/24/25) and she received treatment on 12/24/25 in the evening.During a review of Resident 1's Minimum Data Set (MDS - an assessment tool), dated 9/23/25, the MDS indicated Resident 1 had a BIMS (Brief Interview for Mental Status) score of 15 (score of 13-15 means cognitively intact).During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated March 2022, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.
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
Event ID:
BAKERSFIELD POST ACUTE in BAKERSFIELD, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in BAKERSFIELD, CA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from BAKERSFIELD POST ACUTE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.