San Joaquin Nursing Center And Rehabilitation Cent
SAN JOAQUIN NURSING CENTER AND REHABILITATION CENT in BAKERSFIELD, CA — inspection on March 12, 2026.
Found 10 citations. 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
During an interview on 3/12/26 at 9:26 a.m., with Social Services (SS), SS stated she was responsible for notifying the Ombudsman of resident transfers and discharges. SS stated her process was to notify the Ombudsman of all facility transfers and discharges on a monthly basis. SS stated notification of Resident 1's transfer to the hospital on [DATE] should have been recorded in Resident 1's medical record.
During an interview on 3/12/26 at 3:30 p.m., with SS, SS stated the facility did not have a record of notifying the Ombudsman of Resident 1's transfer to the hospital in October 2025.
During a review of the facility's policy and procedure (P&P) titled Transfer or Discharge Notice version 2.1, the P&P indicated, .
Residents are permitted to stay in the facility and not be transferred or discharged unless . the transfer or discharge is necessary for the residents welfare and the residence needs cannot be met by the facility .
The resident and representative are notified in writing of the following information . the specific reason for the transfer .
The effective date of the transfer .the location to which the resident is being transferred . a copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer .
056294 03/12/2026
San Joaquin Nursing Center and Rehabilitation Cent 3601 San Dimas Bakersfield, CA 93301
During a review of Resident 123's Order Summary Report (OSR) dated 3/6/26, the OSR indicated, .Rivaroxaban [blood thinner] 20 mg [milligrams- unit of measure] Give 1 tablet by mouth one time a day for Atrial Fibrillation [irregular heartbeat].
The order included a black box warning (a serious safety warning given for drugs or drug classes that may cause serious harm or death).
During a concurrent interview and record review on 3/12/26 at 12:03 p.m., with the Director of Nursing (DON), the DON reviewed Resident 123's medication orders and care plan.
The DON confirmed the black box warning symbol indicated Rivaroxaban was a high-risk medication that could cause bleeding.
The DON stated Resident 123's care plan did not address Resident 123's use of the high-risk medication and anticoagulation therapy.
The DON stated it should have been care planned to help establish interventions to monitor and prevent bleeding with the goal of safe anticoagulation therapy for Resident 123.
During a review of the facility's policy and procedure (P&P) titled Care Plans, Comprehensive Person- Centered dated 3/2022, the P&P indicated, . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the residents physical, psychosocial and functional needs is developed and implemented for each resident .
The comprehensive, person-centered care plan . describes the services that are to be furnished to attain or maintain the residence highest practicable physical, mental, and psychosocial well-being .reflects currently recognized standards of practice for problem areas and conditions .
056294 03/12/2026
San Joaquin Nursing Center and Rehabilitation Cent 3601 San Dimas Bakersfield, CA 93301
During an interview on 3/12/2026 at 2:38 p.m. with the Director of Nursing (DON), DON stated, The [Apixaban brand] care plan should have been resolved, care plan closed.
Since resident [Resident 3] is not taking it anymore. DON stated the care plan should have been updated and current so staff could provide the appropriate care to the resident.
During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 3/2022, the P&P indicated, .
Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change .
056294 03/12/2026
San Joaquin Nursing Center and Rehabilitation Cent 3601 San Dimas Bakersfield, CA 93301
During a concurrent interview and record review on 3/12/2026 at 12:03 p.m. with the Director of Nursing (DON), the DON reviewed Resident 1's assessment, including admission and discharge assessments, and care plan.
The DON stated there was no indication a RN evaluated the care provided to Resident 1.
The DON stated Resident 1 should have been assessed by an RN due to the complexity of Resident 1's condition.
The DON acknowledged the importance of RN oversight for accurate and safe provision of care to the residents.
During a review of the facility's document titled Job Description: Registered Nurse (RN) undated, the job description indicated, .
Admit, transfer, and discharge residents as required .Ensure that direct nursing care be provided by a licensed nurse, a certified nursing assistant, and or a nurse aid trainee qualified to perform the procedure . review nurses notes to ensure that they are informative and descriptive of the nursing care being provided, that they reflect the residents response to the care, and that such care is provided in accordance with the residents wishes .Review medication cards for completeness of information, accuracy in the transcription of physician orders, and adherence to stop order policies .
Participate in the development of written preliminary and comprehensive assessments of the nursing needs of each resident as necessary .
Ensure that all personnel involved in providing care to the resident are aware of the residents care plan.
Ensure that nursing personnel refer to the residents care plan prior to administering daily care to the resident .
056294 03/12/2026
San Joaquin Nursing Center and Rehabilitation Cent 3601 San Dimas Bakersfield, CA 93301
During a concurrent observation and interview on 3/9/2026 at 3:45 pm. with Restorative Nursing Assistant (RNA) in Resident 106's room, RNA checked Resident 106's oxygen concentrator. RNA stated, It's [oxygen flow rate] at 4L/min. RNA stated Resident 106 had been on oxygen for some time.
During a review of Resident 106's Minimum Data Set Assessment (MDS - a comprehensive assessment used for screening, clinical and functional status elements for nursing home residents), dated 12/23/2025, the MDS indicated, .
Section O - Special Treatments . C1.
Oxygen Therapy . b.
While a Resident . [marked X] .
During a review of Resident 106's Care Plan, dated 12/23/2025, the Care Plan indicated, . at risk for changes in respiratory status . O2 @ 3L/min via NC Continuously .
Date Initiated: 08/20/2023 .
During a concurrent observation, interview and record review on 3/11/2026 at 2:57 p.m. with Licensed Vocational Nurse (LVN) 2, in Resident 106's room. Resident 106 had oxygen via nasal cannula. LVN 2 stated, It's at 3L/min. Resident 106's Physician's Orders was reviewed. LVN 2 stated there was no order for oxygen therapy. LVN 2 stated there should have been an order since Resident 106 had been on oxygen for a long time. LVN 2 stated the physician order was needed to let staff know how much oxygen was safe to give to the resident.
During an interview on 3/12/2026 at 2:35 p.m. with the Director of Nursing (DON), the DON stated there should have been an order for oxygen therapy for Resident 106. DON stated, So that we give the O2 rate as prescribed by the doctor, provide the proper care.
During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, dated 10/2010, the P&P indicated, Verify that there is a physician's order .
Review the resident's care plan to assess for any special needs of the resident .
056294 03/12/2026
San Joaquin Nursing Center and Rehabilitation Cent 3601 San Dimas Bakersfield, CA 93301
following categories of licensed and unlicensed nursing staff directly responsible for resident care per
aides.
This failure resulted in the public not knowing the correct number of staff working per shift.During a concurrent interview and record review on 3/11/2026 at 2:20 p.m. with Director of Staff Development (DSD), the Census and Nursing Hour Posting, dated Wednesday, March 11, 2026 was reviewed.
The census did not have the name of the facility or the correct number of staff or staffing hours for AM (morning shift), PM (afternoon shift), and NOC (night shift) shifts posted. DSD stated, the facility name is not on the posting, also the correct number of staff and hours for each shift (AM, PM & NOC) is not correct.
056294 03/12/2026
San Joaquin Nursing Center and Rehabilitation Cent 3601 San Dimas Bakersfield, CA 93301
Based on observation, interview, and record review, the facility failed to ensure two of 12 ointment
wrong medication ointment to be given to another resident.Findings: During a concurrent observation and interview on 3/11/2026 at 3:11 p.m. with Treatment Licensed Nurse (TLN) by the nurses' station hallway was a treatment cart.
The second drawer contained ointment medications in clear bags with resident labels (pharmacy label).
There were two tubes without labels.
One medication was collagenase (brand) ointment (medication that helps remove dead tissue from a wound) 250 u/gm (units per gram - unit of measure) and the other one silver sulfadiazine (medication used to prevent and treat infections) Cream USP 1% 50 gm (grams - unit of measure). TLN stated, It [medications] is for residents. I don't see a resident label. I don't know whose it is. TLN stated the residents' ointments should have been labeled with a resident label. TLN stated medications without resident label could be used on a different resident.
During an interview on 3/12/2026 at 2:26 p.m. with the Director of Nursing (DON), DON stated if the medication was resident specific it should have a pharmacy label.
The DON stated an ointment medication without a resident label could be used on a different resident.
During a review of the facility's policy and procedure (P&P) titled, Medication Labeling and Storage, dated 2/2023, the P&P indicated, .
Labelling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and accepted pharmaceutical practices .
The medication label includes . medication name . resident's name .
056294 03/12/2026
San Joaquin Nursing Center and Rehabilitation Cent 3601 San Dimas Bakersfield, CA 93301
During a concurrent observation and interview on
as [Brand] floor mixer had thick black residue at the attachment hub where the splash guard set.
The mixing bowl had light brown food residue adhered to the inside of metal bowel.
The DD confirmed the mixer was not thoroughly cleaned and stated staff did not remove the splash guard as part of staff's daily routine cleaning.
During a review of the P&P titled Sanitization dated 11/2022, the P&P indicated, .When cleaning fixed equipment (e.g., mixers .the removable parts are .
Washed and sanitized and non-removable parts cleaned with detergent and hot water, rinsed, air dried and sprayed with a sanitizing solution (at the effective concentration) . 5.
During a concurrent observation and interview on 3/9/2026 at 2:35 p.m. with the DD, in the kitchen, the commercial can opener's cutting blade had thick black buildup adhered to it.
The DD stated the condition of the can opener was unclean and had the potential to contaminate food items opened by the can opener.
During a review of the P&P titled Sanitization dated 11/2022, the P&P indicated, .
All equipment, food contact surfaces and utensils are cleaned and sanitized . 6.
During an observation on 3/10/2026 at 11:55 a.m. in the kitchen, the DC plated hot foods held on the steam table during tray line (a fast-paced assembly line used to prepare resident food).
The DC dropped a meal slip, and the corner of the slip contacted the edge of the gravy pan.
The DC immediately removed the meal slip from the side of the gravy pan, then continued to plate the gravy.
During an interview on 3/10/2026 at 12:45 p.m. with the DD, the DD stated the DC should have discarded the gravy after the meal slip fell near the gravy pan.
The DD stated it was unsanitary and potentially posed a risk to the residents.
During a review of the P&P titled Food Preparation and Service dated 11/2022, the P&P indicated, .
Food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices . appropriate measures are used to prevent cross contamination [transfer of germs from on surface, food, or person to another] . 7.
During an observation on 3/10/2026 at 12:03 p.m. in the kitchen, Dietary Aid (DA) 1, removed fruit salad from the refrigerator.
During a concurrent observation and interview on 3/10/2026 at 12:29 p.m. with DA 1, in the kitchen, DA 1 used a 1/3 cup scoop to plate the fruit salad into small bowls in preparation for dinner service. DA 1 plated eight bowls then rechecked the menu. DA 1 stopped plating the fruit salad and stated he used the incorrect scoop size.
Eight bowls of fruit salad and original container were left on the preparation table.
During an observation on 3/10/2026 at 12:40 p.m. in the kitchen, with the DD, DA 1 returned the fruit salad plated earlier to the original container. DA 1 took the fruit salad's temperature which registered at 43 F. DA 1 covered the container with foil and placed it back into the refrigerator.
During an interview on 3/10/2026 at 12:45 p.m. with the DD, the DD stated the fruit salad sat out for too long and came up to temperature, therefore should not be refrigerated again.
The DD stated there was a risk for bacteria to grow and the fruit salad and was discarded for resident safety.
During a review of the P&P titled Food Preparation and Service dated 11/2022, the P&P indicated, .
Food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices . the danger zone for food temperature is above 41 Fahrenheit and below 135 F.
This temperature range promotes the rapid growth of pathogenic microorganisms [germs] that cause foodborne illness . the longer foods remain in the danger zone the greater the risk for growth of harmful pathogens [germs].
Therefore, PHF [potentially hazardous foods]must be maintained at or below 41 F or at above 135 degrees Fahrenheit .
During a review of the P&P titled Food receiving and Storage dated 11/2022, the P&P indicated, .
Foods shall be received and stored in a manner that complies with safe food handling practices . PHF/TCS [temperature control for safety- must be kept out of the 41 F to 135 F danger zone] foods are stored at or below 41 F, unless otherwise specified by law .
056294 03/12/2026
San Joaquin Nursing Center and Rehabilitation Cent 3601 San Dimas Bakersfield, CA 93301
During a concurrent interview and record review on 3/12/2026 at 9:05 a.m. with LVN 5, Resident 70's MAR was reviewed.
The MAR indicated the 9 am and 9 pm doses on 3/8/2026 were given. LVN 5 stated the 9 am dose of the Lacosamide was not given to Resident 70. LVN 5 stated, It [MAR] is not accurate since only one [pm dose] was given. I do not remember why I did not get to give the medication and I signed it. LVN 5 stated the resident's clinical record should have accurately reflected what was given to the resident to be able to monitor the medication effectiveness.
During an interview on 3/12/2026 at 2:34 p.m. with the Director of Nursing (DON), the DON stated the MAR should not have been signed if the medication was not given.
The DON stated the MAR should accurately reflect if Resident 70 received or refused his medication for clinical record accuracy and resident safety.
During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated 4/2019, the P&P indicated, .
The individual administering the medication initials the resident's MAR on the appropriate line after giving the medication .
During a review of the facility's policy and procedure (P&P) titled, Documentation Accuracy in the Health Record, dated 11/2023, the P&P indicated, .
Clinical records should accurately reflect the care given by each member of the health care team .
Accurate records are vital to the individual, and to the staff . serves as proof of work done .
During an interview on 3/9/2026 at 4:25 p.m. with LVN 1, LVN 1 stated Resident 66 was on transmission-based precautions for C. difficile.
During an observation on 3/9/2026 at 4:36 p.m. outside Resident 66's room, LVN 1 exited the room holding a blue medication tray and placed the tray on a personal protective equipment (PPE) cart. LVN 1 did not disinfect the tray. LVN 1 then placed the contaminated medication tray on her medication cart.
During an observation on 3/9/2026 at 4:38 p.m. in Resident 121's room, LVN 1 donned PPE and placed the contaminated medication tray on Resident 121's bedside table upon entrance to the room.
Signage posted next to Resident 121's name indicated Resident 121 was on EBP.
During an interview on 3/9/2026 at 4:40 p.m. with LVN 1, LVN 1 stated Resident 121 was placed on EBP because Resident 121 had a peripherally inserted central catheter (PICC- a tube inserted into a major vein above the heart) and wounds. LVN 1 acknowledged she did not disinfect the medication tray. LVN 1 stated I should have disinfected it to prevent cross-contamination (transfer of germs from one surface to another) of both carts (PPE and medication) and Resident 121's bedside table with C. difficile.
During an interview on 3/12/2026 at 12:30 p.m. with the Director of Nursing (DON), the DON stated LVN 1 potentially spread C. difficile by cross contaminating multiple surfaces with the medication tray.
The DON stated LVN 1 failed to follow infection control guidelines for C. difficile.
During an interview on 3/12/2026 at 3:15 p.m. with the IP, the IP confirmed LVN 1's actions potentially caused the cross contamination of C. difficile and placed Resident 121 at risk for C. difficile infection.
During a review of the facility's P&P titled Clostridioides (Clostridium) Difficile dated 12/2024, the P&P indicated, .
Residents considered at high risk of developing symptoms associated with C difficile include .serious underlying illness . antibiotic [medicine to treat infections] .the primary reservoirs for C difficile are infected people and surfaces .Steps toward prevention and early intervention include .disinfection of items with potential fecal soiling .
During a review of the facility's P&P titled Enhanced Barrier Precautions dated 2/2025, the P&P indicated, .
Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention .for residents with wounds and/ or indwelling medical devices . indwelling medical devices include central lines [catheter] .
056294 03/12/2026
San Joaquin Nursing Center and Rehabilitation Cent 3601 San Dimas Bakersfield, CA 93301