The Rehabilitation Center Of Bakersfield

During an interview on 1/13/2026 at 8:57 a.m. with CNA 7, CNA 7 stated that the disposable care equipment such as basins, urinals and emesis basin are to be changed on a weekly basis.

During an interview on 1/14/2026 9:24 a.m. with Infection Preventionist 1 (IP), IP 1 stated that these disposable items should be stored in a plastic bag labeled with their name and room number when not in use and it should be disposed of when soiled.

During an interview on 1/14/2026 at 9:31 a.m. with IP 2, IP 2 stated that her function was to oversee infection control and CNAs were expected to change the disposable equipment when it is soiled, and if the urinal lid was missing. IP 2 confirmed that all disposable equipment should be labeled with their name before use, it should be stored in a clean plastic bag and stored at their bedside.

The urinals should have a lid and it could be hung in their rails for use.

During an interview on 1/14/2026 at 9 a.m. with the Director of Nursing (DON), DON stated the facility had no policy on the care and disposal of residents' bedside care equipment.

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The Rehabilitation Center of Bakersfield 2211 Mount Vernon Avenue Bakersfield, CA 93306

bed-hold policies.

an interview and record review, the facility failed to inform the Office of the State Long-Term

sampled residents (Resident 159) was transferred urgently to the general acute care hospital (GACH) and subsequently discharged from the GACH to an assisted living.

This failure had the potential for Resident 159 to not receive the proper oversite, protection, and advocacy of the Office of the State Long-Term Ombudsman regarding continuity of care for future medical needs.During a review of Resident 159's admission Record (AR), dated 1/15/2026, the AR indicated that Resident 159 was admitted on [DATE] for management of an infection requiring intravenous (IV - medication administered directly into a vein) infusion of an antibiotic (medication used to treat infection).During a review of Resident 159's Order Summary Report (OSR), dated 10/19/2025, the OSR indicated that Resident 159 started IV antibiotic infusion on 10/20/2025 and was to continue until 11/2/2025.During a review of Resident 159's Physician Order, (PO) dated 10/26/2025, the PO indicated for Resident 159 to be sent urgently to a higher level of care for further evaluation of AMS (altered mental status) with a 7-day bed hold.During a review of Resident 159's eINTERACT Transfer Form V5, dated 10/25/2025, the transfer form had no indication of ombudsman notification.

During an interview on 1/15/2026 at 11:59 a.m. with the case manager (CM) 1, the CM1 indicated that it was her responsibility to notify the ombudsman of Resident 159's transfer to the hospital as soon as possible when urgently transferred.

CM1 verified this was not done.

During an interview on 1/15/2026 at 11:59 a.m. with the Social Services Director (SSD), the SSD indicated that it was her responsibility to track transfers and that Resident 159's transfer was not on her internal tracking list.

The SSD verified that Resident 159 did get admitted to the acute care hospital and did not return to the facility.

The SSD verified the ombudsman was not notified.During a review of the facility's policy and procedure titled, Notice of Transfer / Discharge (NTD), dated 10/2017, the NTD indicated that, the State Long Term Ombudsman . when a resident's urgent medical needs require immediate transfer . be provided notice as soon as practicable.

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The Rehabilitation Center of Bakersfield 2211 Mount Vernon Avenue Bakersfield, CA 93306

During a review of Resident 13's Order Summary Report dated 3/5/2025, it indicated, Resident has dialysis M, W, F {Monday, Wednesday, Friday} for end stage renal disease at {Name of dialysis Center}.

Chair time is at 4:30 a.m.p/u {pick up} time at 4 a.m.

During a follow up interview on 1/15/2026 at 4 p.m. with MDSC stated, We don't have a policy and procedure on data entry, per our DON (Director of Nursing) and consultant, we follow RAI (Resident Assessment Instrument).

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The Rehabilitation Center of Bakersfield 2211 Mount Vernon Avenue Bakersfield, CA 93306

During a concurrent observation and interview on 1/12/2026 at 3:03 p.m. with Resident 44 in his room, there was a kangaroo pump (machine to deliver enteral feedings) next to Resident 44's bed, actively infusing [brand of nutrients] 1.5 calories at 50 mL an hour. Resident 44 stated he was previously hospitalized and lost the ability to swallow so he elected for a tube to be inserted in his stomach to receive nutrition.During a review of Resident 44's Physician Orders (PO), dated 1/8/2026, the PO indicated to administer [brand of nutrients] 1.5 calories at 50 mL an hour for 20 hours a day.During a concurrent interview and record review on 1/15/2026 at 1:45 p.m. with the DON, Resident 44's care plans were reviewed.

The DON stated Resident 44 should have had a care plan completed within 48 hours of admission (by 1/10/2026) to include enteral feeding.

The care plan for enteral feeding was not completed until 1/13/2026, five days after admission.During a review of the facility's policy and procedures (P&P) titled, Person-Centered Care Planning, dated 5/22/2025, the P&P indicated, The baseline care plan will be developed and implemented, using the necessary combination of problem specific care plans to promote continuity of care and communication among facility staff. within 48 hours of the resident's admission. It will include, at minimum, the following information necessary on each care plan to properly care for a resident: initial goals based on the admission orders, physician orders, dietary orders.

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The Rehabilitation Center of Bakersfield 2211 Mount Vernon Avenue Bakersfield, CA 93306

therapy five times a week.

The DOR further stated he was not aware of Resident 152 not receiving

the ADOR stated she scheduled Resident 152 for physical therapy five times a week and was unaware

11/17/2025, the MDS indicated Resident 152 needed maximum assistance to stand from a sitting position and Resident 152 was unable to ambulate 10 feet due to safety concerns.During a review of Resident 152's Care Plan Report, dated 11/17/2025, the report indicated, at risk for further function decline due to muscle weakness and reduced mobility. pt [patient] will ambulate 150 ? [feet] FWW [front wheel walker]. PT [physical therapy] 5W4W [five times a week for four weeks].

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The Rehabilitation Center of Bakersfield 2211 Mount Vernon Avenue Bakersfield, CA 93306

provide appropriate care for a resident with a feeding tube.

observation, interview, and record review, the facility failed to ensure safe administration of enteral

for one of 29 sampled residents (Resident 44), when Resident 44 was observed lying flat while receiving nutrition via gastrostomy tube (surgical opening in the stomach to receive nutrients and fluids via a tube).

This failure had the potential to result in aspiration (when food, liquid or saliva accidentally go down the airway) and pneumonia (lung infection).Findings:During a review of Resident 44's Face Sheet (demographics), Resident 44 was readmitted to the facility on [DATE] with diagnoses to include dysphagia (difficulty swallowing), gastrostomy status (surgical opening in the stomach to receive nutrients and fluids via a tube), and type 2 diabetes mellitus (chronic condition when the body doesn't produce or use sugar effectively).During a concurrent observation and interview on 1/12/2026 at 4:05 p.m. with Infection Preventionist (IP) 2, in Resident 44's room, Resident 44 was observed lying flat while receiving enteral feeding. IP 2 stated Resident 44 needed to be sitting up while receiving enteral feeding to prevent aspiration and infection.

During an interview on 1/15/2026 at 1:45 p.m. with the Director of Nursing (DON), the DON stated no resident should ever lay flat while receiving enteral feeding for risk of aspiration.During a review of Resident 44's Physician Order (PO), dated 1/8/2026, the PO indicated to elevate the head of the bed 30-45 degrees while receiving enteral feedings.

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The Rehabilitation Center of Bakersfield 2211 Mount Vernon Avenue Bakersfield, CA 93306

During a review of undated admission Record, it indicated Resident 61 was admitted to the facility on [DATE] with diagnosis that included COPD {Chronic Obstructive Pulmonary disease, asthma {a chronic lung condition where airways become inflamed, swollen, and narrow, producing excess mucus, making breathing difficult, dependence on supplemental oxygen.

During a concurrent observation and interview on 1/12/2026 at 1:55 p.m. in room [ROOM NUMBER] Bed B, Resident 61 was observed receiving Oxygen treatment via a nasal cannula {NC} at 3 liters per minute. Resident 61 stated, They change the tubing but not sure how often.

During a review of Order Summary Report for Resident 61, dated 5/29/26, it indicated Check O2 tubing date to ensure current for the week every night shift every Sunday.

During a concurrent observation and interview on 1/12/26 at 2:28 p.m. with the Licensed Vocational Nurse (LVN 4), LVN 4 stated, the NC tubing was changed, weekly, dated and timed. LVN 4 also stated that Resident 61 was receiving O2 treatment for COPD, a progressive lung condition causing airflow obstruction, making breathing difficult.

During an observation of the NC tubing for Resident 61 with LVN 4, the date on tubing indicated ;1/3/2026. LVN 4 stated, It should have been changed on 1/10/2026.

During a review of Order Summary Report for Resident 61, dated 12/12/2024, it indicated Oxygen @ 3 LPM via nasal Cannula continuously for COPD.

During a review of facility's policy and procedure (P&P) titled, P- N P94 Oxygen Therapy, dated October 30, 2025, the P&P indicated. a.

Oxygen equipment shall be maintained as follows: i.

The tubing and mask should be changed at least every 7 days and labeled with the date of change.

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The Rehabilitation Center of Bakersfield 2211 Mount Vernon Avenue Bakersfield, CA 93306

cold soup during the meal.

This failure had the potential to result in decreased meal satisfaction,

loss or dehydration.

Findings:During an observation on 1/12/2026 at 5:02 p.m. in the dining hall, Certified Nursing Assistant (CNA) 5 served Resident 102 a cup of French onion soup. Resident 102 took a sip of the soup and shouted the soup was cold and she did not want the soup anymore.During an observation on 1/12/2026 at 5:05 p.m. in the dining hall, CNA 5 got a replacement cup of French onion soup and served again to Resident 102. Resident 102 took a sip of the soup and shouted, that is cold, I don't want it. Resident 102 pushed the cup of soup towards the other end of the dining table.During a concurrent observation and interview on 1/12/2026 at 5:07 p.m. with the Dietary Manager (DM) in the dining hall, the DM took Resident 102's second soup and checked the temperature, it read 116 degrees Fahrenheit.

The DM stated the soup should have been hotter.During a concurrent observation and interview on 1/12/2026 at 5:27 p.m. with the DM in the kitchen, the DM went to the warmer and removed one of the cups of soup and checked the temperature.

The temperature read 145 degrees Fahrenheit.

The DM stated soups should be served at 170 degrees Fahrenheit.During a review of Recipe: French Onion Soup, dated 2025, the Recipe: French Onion Soup indicated, Serve on trayline at the recommended temperature of 170 F - 190 F .During a review of the facility's policy and procedures (P&P) titled, Food Temperatures, dated 10/10/2023, the P&P indicated, Acceptable serving temperatures.

Soup.

Preferable temperature 160 F - 175 F.

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The Rehabilitation Center of Bakersfield 2211 Mount Vernon Avenue Bakersfield, CA 93306

During a concurrent observation and interview on 1/12/2026 at 1:44 p.m. with the Dietary Manager (DM) in the kitchen, a small white freezer had numerous vanilla ice cream cups that were not frozen, with no thermometer in the freezer. DM retrieved a thermometer and placed it in the freezer. At 1:55 p.m. (11 minutes later) DM checked the thermometer, and it read 11 degrees Fahrenheit. DM stated the freezer temperature should have been 0 degrees Fahrenheit or below and should not be used.During a review of the facility's policy and procedures (P&P) titled, Refrigerator/Freezer Temperature Records, dated 11/1/2014, the P&P indicated, The freezer temperature must be 0 F [Fahrenheit] or below.

Corrective action should be taken to correct the temperature or the items should be moved to another storage area to maintain acceptable temperature.6.

During a concurrent observation and interview on 1/12/2026 at 1:49 p.m. with the Dietary Manager (DM) in the kitchen, [NAME] 1 cleaned a stove top while not wearing a hair restraint. DM stated all personnel in the kitchen needed to wear hair restraints.During a review of the facility's policy and procedures (P&P) titled, Dietary Department- Infection Control for Dietary Employees, undated, the P&P indicated, Personal cleanliness is required in sanitary food preparation.

Clean hair- covered with an effective hair restraint while in all kitchen and food storage areas.7.

During a concurrent observation and interview on 1/14/2026 at 2:40 p.m. with Maintenance in the C-Wing hydration room, Maintenance opened the lid to ice machine to visualize cleanliness.

Observed ice chute with thick white build up and when the inside of the ice chute was wiped with a paper towel there was an unknown slimy brown residue.

Maintenance confirmed the ice machine was dirty and needed to be cleaned.During an interview on 1/14/2026 at 2:53 p.m. with Maintenance Director (Main D), Main D stated the ice machine chute is cleaned once a month and should not have been dirty.During a review of the facility's policy and procedure (P&P) titled, Ice Machine- Operation and Cleaning, dated 10/1/2014, the P&P indicated, On no less than a monthly basis, remove the ice to wash the inside of the machine. wash the inside of the machine. sanitize the inside of the machine

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The Rehabilitation Center of Bakersfield 2211 Mount Vernon Avenue Bakersfield, CA 93306

diseases and could result in food borne illness (a sickness caused by consuming food, or drinks

residents.Findings:During a concurrent observation and interview on 1/12/2026 at 1:57 p.m. with the Dietary Manager (DM) outside in the trash area, four of four dumpsters had overflowing trash with lids being unable to close, and multiple items of trash scattered around the dumpsters on the ground that contained food items.

The DM confirmed that trash should not be laying on the ground and the lids should be covering all trash in the dumpsters.

During an interview on 1/14/2026 at 2:03 p.m. with the Registered Dietician (RD), the RD stated she oversees the kitchen and lids to the dumpsters should be fully closed, to keep rodents out.During a review of the U.S [United States] Food and Drug Administration's (FDA) Food Code, dated 2022, the FDA Food Code indicated in Section 5-501.15 Outside Receptacles, (A) Receptacles and waste handling units for REFUSE, recyclables, and returnables used with materials containing FOOD residue and used outside the FOOD ESTABLISHMENT shall be designed and constructed to have tight-fitting lids, doors, or covers .

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The Rehabilitation Center of Bakersfield 2211 Mount Vernon Avenue Bakersfield, CA 93306

During a concurrent observation and interview on 1/12/2026 at 2:27 p.m., with HK 1, in the 'C-Wing' Biohazard room, there was a cluttered area that contained nine bags of trash, one plastic container with yellow fluid, and cardboard boxes that were stacked on the biohazard receptacle (bin) and room counter.

Trash bags were also stuffed underneath the counter.

The large black trash bin used to store and transport trash was empty.

During an interview on 1/13/2026 at 10:10 a.m., with the Environmental Services Manager (ESM), the ESM stated facility trash was not collected at the regular scheduled time, therefore the trash was left on the floor.

The ESM stated the trash was removed from the bin to make room for the excess and that this practice occurred on occasion when the trash not picked up by the vendor.

The ESM stated there was no process in place to address the excess trash when not collected as scheduled.

During an interview on 1/15/2026 at 4:10 p.m., with IP 2, IP 2 stated discarded trash left on the floor was unsanitary.

The IP 2 stated trash should be stored in the appropriate containers to prevent contamination and transmission of germs.

The IP 2 stated she was aware that trash service was delayed, however staff should have promptly removed the trash from the floor and stored the trash in the assigned trash bin.

During a review of the facility's P&P titled Medical Waste- Containers and Storage dated 1/01/2012, the P&P indicated, .waste is stored so that it is protected from animals and does not provide a breeding place or a food source for insects and rodents .The infection control coordinator or designee monitors the medical waste storage areas to assure that medical waste is treated, disposed of, or picked up by the authorized vendor on a timely basis .

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The Rehabilitation Center of Bakersfield 2211 Mount Vernon Avenue Bakersfield, CA 93306

According to recent guidelines by multiple clinical societies, antibiotic therapy is not recommended . -Resident 44's Medication Administration Record (MAR), dated December 2025, the MAR confirmed Resident 44 received 13 doses of Cefdinir from 12/12/2025 to 12/18/2025 and three doses of Azithromycin from 12/16/2025 to 12/18/2025.-Facility Antibiotic tracking log, undated, the Antibiotic tracking log indicated Resident 44 was not being monitored for antibiotic use of azithromycin and cefdinir.The IP 2 confirmed there was no tracking or monitoring for Resident 44 while receiving two different antibiotics and stated Resident 44 should have been monitored by the IPs for antibiotic usage.During a review of the facility's policy and procedures (P&P) titled, Antibiotic Stewardship, dated 5/20/2021, the P&P indicated, The IP is responsible for tracking the following antibiotic stewardship processes.

The antibiotic ordered, dose, route, and ordering physician as well as the cost of the drug.

Whether or not the resident's condition met McGeer's Criteria [standardized set of rules used in nursing homes to consistently identify when a resident has an infection such as a UTI] when the antibiotic was ordered. if cultures were ordered. any changes in antibiotic orders during therapy.

Outcomes of antibiotic therapy.

The IP will provide results of tracking antibiotic use.

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The Rehabilitation Center of Bakersfield 2211 Mount Vernon Avenue Bakersfield, CA 93306

influenza (a highly contagious viral infection of the respiratory tract) and pneumococcal (a bacterial

accordance with facility policy to one of five residents (Resident 2) reviewed for immunizations.

This failure placed Resident 2 at risk for acquiring influenza and/or pneumococcal disease.During a review of Resident 2's face sheet (a document containing demographic information), it was noted that the resident was admitted to the facility on [DATE] with diagnoses that included Metabolic Encephalopathy (brain dysfunction caused by a chemical imbalance related to an underlying illness) and Pneumonitis (inflammation of lung tissue) due to aspiration of food and vomit.During a concurrent interview and record review on 1/15/2026 at 9:24 a.m. with the Infection Preventionist (IP) 2, IP 2 stated she was unable to locate documentation in the Resident 2's electronic medical record indicating that influenza and pneumococcal vaccines were offered or administered. IP 2 stated these immunizations should have been offered; however, the documentation was missing. Resident 2 was admitted to the facility on [DATE].During a review of the facility P&P titled, Pneumococcal Vaccination, dated 4/27/2023, the P&P indicated, .The facility will provide all residents the opportunity to receive the pneumococcal vaccine, unless it is medically contraindicated, or the Resident is already immunized according to the Centers for Disease Prevention and Control recommendations or state/local public health guidelines. To prevent pneumococcal disease and its complications to residents. To properly administer pneumococcal vaccination and monitor for complications .During a review of the facility policy and procedure (P&P) titled, Influenza Prevention and Control, dated October 2020, P&P indicated, .The facility will follow infection prevention and control policies and procedures to minimize the risk of Residents acquiring, transmitting or experiencing complications from influenza.

Before offering the influenza vaccine, each Resident or the Resident's representative will be given education regarding the risk and benefits and potential side effects of the immunization.

The CDC Vaccination Information Statement (VIS) will be used as part of the Resident's (representative's) education. B.

Residents are offered an influenza immunization every year during flu season, unless the immunization is medically contraindicated, or the Resident has already been immunized during the current flu season. C.

The Resident or representative must give consent prior to receiving the vaccine.

They can refuse the immunization-with such refusal being noted in the Resident's medical record. 4.

The Resident's medical record will include documentation that indicates, at a minimum, the following: i.

The Resident or the Resident's representative was provided education regarding the risk and benefits and potential side effects of the influenza vaccination.

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The Rehabilitation Center of Bakersfield 2211 Mount Vernon Avenue Bakersfield, CA 93306

During a review of Resident 124's face sheet (a document containing demographic information), it was noted that the resident was admitted to the facility on [DATE] with a diagnosis that included Diabetes Mellitus (a chronic disease associated with abnormally high levels of the sugar glucose in the blood).

During a concurrent interview and record review on 1/15/2026 at 9:39 a.m. with the Infection Preventionist (IP) 2, IP 2 stated that Resident 124 declined the COVID-19 vaccination. IP 2 further stated that she was unable to locate documentation indicating that the facility had provided education regarding the risks and benefits of the vaccine to Resident 124 or the resident's responsible party.During a review of the facility P&P titled, COVID-19 Vaccination Program, date 4/27/2023, the P&P indicated, .

The Facility will offer SARS-CoV-2 vaccinations (including additional and booster doses) to all Residents.

They will be encouraged but are not required to be vaccinated or boosted. In this case, all requirements of education, consent, administration, reporting and documentation will be the responsibility of the Facility.2.

During a concurrent interview and record review on 1/15/2026 at 10:05 a.m. with the IP 2, IP 2 stated CNA 1 had consented to the influenza and COVID-19 vaccines; however, there was no documentation provided, confirming that the vaccines were administered.During a review of the facility P&P titled, COVID-19 Vaccination Program, date 4/27/2023, the P&P indicated, .

All Health Care Personnel (HCP) are required to be fully vaccinated.

Federal health inspectors cited THE REHABILITATION CENTER OF BAKERSFIELD in BAKERSFIELD, CA for a deficiency under regulatory tag F-F0940 during a standard health inspection conducted on 2026-01-16.

Category: Administration Deficiencies

The facility was found deficient in the following area: Develop, implement, and/or maintain an effective training program for all new and existing staff members.

Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 16 deficiencies cited during this inspection of THE REHABILITATION CENTER OF BAKERSFIELD.

Correction Status: Deficient, Provider has no plan of correction.