Complaint Investigation

San Joaquin Nursing Center And Rehabilitation Cent

August 18, 2025 · Bakersfield, CA · 3601 San Dimas

Citations 1

CMS Rating 3/5

Beds 99

Provider ID 056294

Healthcare Facility

San Joaquin Nursing Center And Rehabilitation Cent

Bakersfield, CA · View full profile →

Source Document

Official CMS Inspection Report (Medicare.gov)

Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.

Inspection Summary

SAN JOAQUIN NURSING CENTER AND REHABILITATION CENT in BAKERSFIELD, CA — inspection on August 18, 2025.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0676

Quality of Life and Care Deficiencies

reason.

clean and trimmed for one of four sampled residents (Resident 1).

This failure had the potential to

admission Record (AR), dated 8/18/25, the AR indicated, DIAGNOSIS. NEED FOR ASSISTANCE WITH PERSONAL CARE.During a review of Resident 1's SBAR (Situation, Background, Assessment, Recommendations), dated 7/31/25, the SBAR indicated, Change in skin color or condition.

Other relevant information: Resident (1) has history of picking at himself and scratching.

Nurses noted old scratches over body.

Bleeding noted.

Resident (1) states he is itching.During a review of Resident 1's Minimum Data Set (MDS - an assessment tool), dated 5/15/25, the MDS indicated on section C (Cognitive Patterns), Resident 1 had a BIMS (Brief Interview for Mental Status) score of 10 (score of 8 - 12 indicates moderately impaired cognition).

The MDS indicated on section GG (Functional Abilities), Resident 1 required substantial/maximal assist (staff does more than half the effort) with personal hygiene.During a concurrent observation and interview on 8/18/25 at 1:45 p.m. with Resident 1 in Resident 1's room, Resident 1's fingernails on both hands were long and had dark debris underneath. Resident 1 had multiple scratches and open skin areas on both arms and abdomen. Resident 1 stated he would scratch his skin because it would itch a lot. Resident 1 stated he wanted his fingernails trimmed.During a concurrent observation and interview on 8/18/25 at 2:00 p.m. with Certified Nursing Assistant (CNA) 1 in Resident 1's room, CNA 1 stated Resident 1's fingernails on both hands were supposed to be cleaned and trimmed because they were long and had black dirt underneath. CNA 1 stated Resident 1 would be at risk for developing infection because he has been scratching and he had long and dirty fingernails.During a concurrent interview and record review on 8/18/25 at 2:49 p.m. with Infection Control Preventionist (ICP), Resident 1's care plan (CP), dated 6/18/25 was reviewed.

The CP indicated, Resident has impaired skin integrity as evidenced by skin tear/abrasion/scratches to Left upper abdomen related to trauma and is at risk for infection.

Interventions.

Nails are to be kept short to reduce the risk of scratching or injury from picking at skin.

ICP stated the CP was not followed. ICP stated Resident 1's nails were supposed to be kept short and clean to prevent infection and injury to the skin from scratching.During a review of the facility's policy and procedure (P&P) titled, Fingernails/Toenails, Care of, dated February 2018, the P&P indicated, The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections.

Nail care includes daily cleaning and regular trimming.

Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin.

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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

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 SAN JOAQUIN NURSING CENTER AND REHABILITATION CENT or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.

More Reports

About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.