Kern River Transitional Care

F-F623) not provided as identified by the survey team.

These failures placed all 126 facility residents at risk for acquiring infectious diseases and not receiving medically necessary services.

Findings:

During a concurrent interview and record review on 4/24/25 at 3:09 p.m. with the Administrator, the minutes of the facility's QAPI (a committee that identifies quality deficits and implements corrective plans) meeting dated 4/18/25 and 1/19/25 were reviwed. The Administrator stated meetings were held every Tuesday to

review new residents assessments.

The facility's deficient practices reviewed included failure to assess each resident and care planning of residents. The Administrator stated the above resident assessment deficient practices had not been identified by the facility and were not covered during the most recent (

F-F658). Dental referral for one of one sampled resident (Resident 133) had not been made for a resident admitted on [DATE REDACTED]. A physician order dated 4/4/25 indicated dental referral. (Cross-reference to

F-F687). SSD stated she had not visited one of one resident (Resident 133) who expressed concerns about his mail and his ability to pay his bill. SSD stated she does not do resident visits in the room but waits for the residents in care conferences. SSD stated she does not do just-in-time documentation. SSD stated she documents after two days in medical records. SSD had not completed Resident 133's Initial Social History Assessment to determine Resident 133's needs. (Cross-reference to

F-F790). Podiatry referral for one of one sampled resident (Resident 72) had not been made for Resident 72 who showed signs and symptoms of foot problem, possible fungal infection, and toenail deformity. (Cross-refence to

F-F842). The Notice of Transfer and Discharge to the Ombudsman (representatives who assist residents in long-term care facilities with issues related to day-to-day care, health, safety and personal preferences) for one of six sampled resident's (Resident 40) was not completed and sent to the Ombudsman. SSD stated it was not her responsibility to notify the Ombudsman. (Cross-reference to

F-F880) QAPI meeting.

During an interview on 4/24/25 at 3:13 p.m.with the Administrator, Administrator stated previous Social Services Director (SSD) was not competent in job duties and was let go in December of 2024. Administer stated the Director of Nursing had taken on duties and our admission records are reviewed every Tuesday. Administer stated we are at 100% compliance.

During a review of the facility policy and procedure (P&P) titled Quality Assurance and Performance Improvement (QAPI) program dated February 2020, the P&P indicated, This facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI Program that is focused on indicators of

the outcome of care and quality of life for our residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 46 555912 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555912 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Kern River Transitional Care 5151 Knudsen Drive Bakersfield, CA 93308

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)

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Level of Harm - Minimal harm or 51320 potential for actual harm Based on interview and record review, the facility failed to ensure the facility's Infection Preventionist (IP) Residents Affected - Some attended two of three sampled Quality Assessment and Performance Improvement (QAPI, committee that identifies quality deficits and implements corrective plans) committee's meetings during 2024 and 2025. This failure had the potential for the facility to not be aware of infection control issues and develop a plan to address infection control issues.

Findings:

During a concurrent interview and record review on 4/24/25 at 3:09 p.m. with the Administrator, the QAPI committee sign in sheets dated 9/24/245, 1/19/25, and 4/18/25 were reviewed. The Administrator stated the IP attends the QAPI meetings. Administrator was unable to verify IPs attendance at the QAPI meetings on 9/24/245 and 4/18/25 with the QAPI attendance sheets. The Administrator stated the QAPI committee met September 2024, January 2025, and April 2025.

The sign in sheet dated, 9/24/24 indicated the following signatures: Administrator, Director of Nursing (DON), Business Office Manager (BOM), Director of Staff Development (DSD), Minimum Data Set (resident assessment tool) Coordinator (MDS), Medical Records (MR), (Environmental Services (EVS) Supervisor, and Medical Doctor (MD).

The sign in sheet dated, 1/19/25 indicated the following signatures: Administrator, DON, Assistant Director of Nursing (ADON), MD, DSD, MDS, MR, Director of Rehabilitation (DOR), Social Services Director (SSD), BOM, EVS Supervisor, and IP.

The sign in sheet dated, 4/18/25 indicated the following signatures: Administrator, DON, BOM, DOR, and four illegible signatures.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 46 555912 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555912 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Kern River Transitional Care 5151 Knudsen Drive Bakersfield, CA 93308

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)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 35649 potential for actual harm Based on observation, interview, and record review, the facility failed to follow and implement the Center for Residents Affected - Many Disease Control and Prevention (CDC, nationally recognized health organization) infection control practices when:

1. Licensed Vocational Nurse (LVN) 2 did not follow Enhanced Barrier Precaution (EBP, precautions to reduce transmission of infectious organisms) protocols during closed contact with one of one sampled resident (Resident 72).

2. The X-ray Technician (XRT) stepped out of the room with contaminated gloves and isolation gown to answer a phone call after in close contact with one of one resident (Resident 96) on EBP.

3a. Treatment Nurse (TN) 1 threw the contaminated dressing with serosanguinous (thin, watery, and pinkish red in color fluid from a wound) drainage onto a regular trash bin.

3b. TN 1 did not perform hand hygiene before putting on a new pair of gloves.

3c. TN 1 used a pair of unsterile (free from germs) pair of scissors to cut the sterile not packing strip during wound packing for one of one sampled resident (Resident 96).

4. Central Supply Staff (CS) 1 accessed a disinfectant wipe container without a lid with her hand.

These failures had the potential to cause cross-contamination and transmit infectious diseases to other residents, staff and visitors.

Findings:

1. During a concurrent observation and interview on 4/21/25 at 3:40 p.m. with LVN 2 in Resident 72's room, Resident 72 had a wound on the right ankle. Signage was posted on the wall indicated Resident 72 was on EBP. LVN 2 put on a pair of gloves but did not wear an isolation gown. LVN 2 measured the left and right toenails without required Personal Protective Equipment (PPE- refers to gowns, gloves, masks, goggles, face shield worn to protect the individual from infection or injury). LVN 2 stated Resident 72 was on EBP and stated she should have worn a gown, but she did not.

During a review of Resident 72's Physician Order (PO), dated 4/16/25, the PO indicated, Requires Enhanced Barrier Precautions.

During a review of the facility's policy and procedure (P&P) titled, Isolation-Transmission-Based Precautions & Enhanced Barrier Precautions, revised 9/2023, the P&P indicated, The facility has a framework for reducing MDRO [multi-drug resistant organism] transmission through staff use of gowns and gloves while caring for patients at high risk for MDRO transmission at the point of care during specific activities. 1. Wear gowns and gloves while performing the following high-contact tasks associated with the greatest risk for MDRO contamination of staff hands, clothes, and the environment such as: c. Any care activity where close contact with the resident is expected .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 46 555912 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555912 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Kern River Transitional Care 5151 Knudsen Drive Bakersfield, CA 93308

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)

F 0880 2. During an observation on 4/22/25 at 11:34 a.m. in Resident 96's room, with Administrator, the X-Ray Technician (XRT) entered Resident 96's room to take x-rays of Resident 96. Signage posted indicated Level of Harm - Minimal harm or Resident 96 was on EBP precautions. XRT had gloves on and an isolation gown on during the procedure. potential for actual harm XRT stepped out of the room with his contaminated gloves and isolation gown to answer a call on his cell phone. The Administrator saw XRT step out of Resident 96's room, still wearing gloves and isolation gown Residents Affected - Many while using his cell phone in the hallway. XRT returned to Resident 96's room, removed his gown and gloves, but did not perform hand hygiene prior to touching the x-ray machine and re-exiting Resident 96's room.

During an interview on 4/22/25 at 11:41 a.m. with XRT, XRT stated he did not remove his gloves and gown when he stepped out of the room to answer the phone call. XRT also stated he did not perform hand hygiene when he exited the room.

During a review of the facility's P&P titled, Isolation-Transmission-Based Precaution & Enhanced Barrier Precaution, revised 9/2022, the P&P indicated, e. Gowns and gloves should always be removed inside the room when the care activity is complete. Gowns and gloves should not be worn outside of the room when resident care is not being performed.

3a. During a concurrent observation and interview on 4/22/25 at 12 p.m. with Treatment Nurse (TN) 1 and TN 2, in Resident 96's room, TN 1 and TN 2 entered Resident 96's room to clean and change Resident 96's wound dressing on the left leg. With gloves and gown on, TN 1 removed the old dressing and stated Resident 96 has an open wound on the left shin resulting from a ruptured hematoma. TN 1 stated the wound was draining serosanguinous fluid. After cleaning the wound with normal saline, TN 1 disposed of the contaminated dressing onto the regular trash bin. TN 1 stated there was no biohazard bin inside the room.

3b. During an observation on 4/22/25 at 12:05 p.m. with TN 1 in Resident 96's room, TN 1 removed the contaminated gloves and put on a new pair of gloves without performing hand hygiene. TN 1 irrigated the wound with normal saline and started to prepare for the wound packing (specialized techniques for deep wounds to encourage healing).

3c. During a concurrent observation and interview on 4/22/25 at 12:10 p.m. with TN 1 in Resident 96's room, TN 1 used a pair of non-sterile scissors to cut a sterile strip of gauze for wound packing. With the same gloves on used during wound irrigation, TN 1 soaked the sterile strip of gauze into a cup with Daikin (a strong topical antiseptic widely used to clean infected wounds, ulcers, and burns) solution and then put the wet sterile strip of gauze inside the wound. After the procedure, TN 1 stated he disinfects the scissors after using them. TN 1 stated he cut the sterile strip of gauze with the scissors and the used gauze were discarded.

During a review of the facility's P&P titled, Wound Care, revised 10/2010, the P&P indicated, 5. Pull glove over dressing and discard into appropriate receptacle. Wash and dry hands thoroughly.

During a review of the facility's P&P titled, Handwashing/Hand Hygiene, revised 10/2023, the P&P indicated, Administrative Practices to Promote Hand Hygiene: 2. All personnel are expected to adhere to hand hygiene policies and practices to prevent spread of infection to other personnel, residents, and visitors.Indications for Hand Hygiene: 1. Hand Hygiene is indicated for: c. after contact with blood, body fluids, or contaminated surfaces. d. after touching a resident. f. before moving from work on a soiled body site to a clean body site

on the same resident g. immediately after love removal.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 46 555912 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555912 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Kern River Transitional Care 5151 Knudsen Drive Bakersfield, CA 93308

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)

F 0880 45654

Level of Harm - Minimal harm or During a concurrent observation and interview on 4/21/25 at 12:35 p.m. with Central Supply (CS), in hallway potential for actual harm A, CS wiped a resident's oxygen contractor machine (machine increases the percentage of oxygen in room air) with a Sani Cloth (wipes, sanitizing and disinfecting wipe). There was no lid on top of the Sani Cloth Residents Affected - Many container. CS stated I just wiped down the concentrator and the lid should be placed back on the Sani wipes.

During an interview on 4/24/25 at 10:44 a.m. with IP, IP stated no the staff member should not have the top off the Sani wipe container that was not an acceptable practice.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 46 555912 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555912 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Kern River Transitional Care 5151 Knudsen Drive Bakersfield, CA 93308

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)

F 0947 Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Level of Harm - Minimal harm or potential for actual harm 46958

Residents Affected - Many Based on interview and record review, the facility failed to ensure that 108 out of 108 sampled Certified Nursing Assistants (CNAs) were attending at least 5 hours of dementia (a loss of mental function)-specific in-service training on an annual basis. This failure had the potential for CNAs to be uneducated how to meet care need of residents with dementia.

Findings:

During a concurrent interview and record review on 4/23/25 at 9:09 a.m. with Director of Staff Development (DSD), Dementia Mod [module] 4 (DM 4), dated 6/12/24 was reviewed. The DM 4 attendance sheet indicted 35 out of 108 CNAs attended dementia training. DSD stated only 35 CNAs attended the one-hour Dementia training.

During a concurrent interview and record review on 4/23/25 at 9:11 a.m. with DSD, Dementia Review Annual (DRA), dated 8/23/24 were reviewed. The DRA attendance sheet indicated 60 out of 108 CNAs attended dementia training. DSD stated only 60 CNAs attended the one-hour training.

During a concurrent interview and record review on 4/23/25 at 9:13 a.m. with DSD, DM 4 dated 9/19/24 was reviewed. The DM 4 attendance sheet indicated 56 out of 108 CNAs attended dementia training. DSD stated only 56 CNAs attended the one-hour training.

During a concurrent interview and record review on 4/23/25 at 9:15 a.m. with DSD, DM 3 dated 9/29/24 was reviewed. The DM 3 attendance sheet indicated 68 out of 108 CNAs attended dementia training. DSD stated only 68 CNAs attended the one-hour training.

During a concurrent interview and record review on 4/23/25 at 9:17 a.m. with DSD, DM 1 attendance sheet dated 1/21/25 was reviewed. The DM 1 indicated 35 out of 108 CNAs attended dementia training. DSD stated only 35 CNAs attended the one-hour training.

During a concurrent interview and record review on 4/23/25 at 9:19 a.m. with DSD, Dementia attendance sheet dated 4/2/25 was reviewed. The Dementia attendance sheet indicated 33 out of 108 CNAs attended dementia training. DSD stated only 33 CNAs attended the one-hour training.

During a review of the facility's policy and procedure (P&P) titled, In-Service Training, All Staff, dated 2001,

the P&P indicated, All staff must participate in initial orientation and annual in-service training.2.For the purpose of this policy, staff means all new and existing personnel.(3) dementia management and resident abuse prevention.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 46 555912