Health inspection·July 11, 2025

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow their policy and procedure (P&P) on Urinary Catheter (a tube placed in the body to drain and collect urine from the bladder) Care for two of five sampled residents (Resident 1 and Resident 2) when:1. The facility did not monitor placement of urinary catheter for Resident 1.2. The facility did not document urine output according to the plan of care for Resident 2.These failures had the potential for Resident 1 and Resident 2 developing UTI (Urinary Tract Infection - bladder infection).Findings:1. During a review of Resident 1's admission Record (AR), dated 7/10/25, the AR indicated, Resident 1 is a [AGE] year-old male with a diagnosis of OBSTRUCTIVE AND REFLUX UROPATHY (blockage of flow of urine from the kidneys to the bladder and backward flow of urine from the bladder into the ureters and potentially back to the kidneys).During a review of Resident 1's Order Summary Report (OSR), dated 7/10/25, the OSR indicated, Suprapubic catheter:_16_F [French (refers to the size of the urinary catheter)]/ [per] 10cc [unit of measurement in cubic centimeter] for: obstructive uropathy [a condition where urine flow is blocked, causing it to back up and potentially damage the kidneys]. Change PRN [as needed] for accidental removal or blockage every shift. Order Date. 01/10/2025. During a review of Resident 1's SBAR (Situation, Background, Assessment, Recommendation), dated 6/25/25, the SBAR indicated, Resident [1] told nurse its [sic] burning when he urinates, nurse noticed residents [sic] catheter bag and tubing is empty, and urine and blood are coming from residents [sic] penis and catheter site. to send resident to ER [Emergency Room] for suprapubic catheter complications.During a concurrent interview and record review on 7/10/25 at 12:47 p.m. with Minimum Data Set Coordinator (MDSC), Resident 1's Care Plan (CP), dated 1/19/25 was reviewed, the CP indicated, [Resident 1] has a suprapubic catheter and is at risk for complications with urinary system. Change PRN for accidental removal or blockage. Goal. [Resident 1] will be/(or) remain free from (suprapubic) catheter-related trauma. Interventions. Check [Resident 1's] tubing [urinary catheter] for kinks [bend or twist] (#[number] TIMES) each shift. Monitor and document intake and output as per facility policy. MDSC stated, I don't see that it's [checking the tubing for kinks and urine output] being monitored. During a concurrent interview and record review on 7/10/25 at 12:47 p.m. with MDSC, Resident 1's Task: Bladder Continence (TBC), dated 6/11/25-7/10/25 was reviewed. The TBC indicated there was no documentation of urine output on 6/11/25-6/22/25. The TBC, dated 6/14/25 indicated, HIS [Resident 1] CATHETER CLOGGED AND HE USED THE RESTROOM TO URINATE. The TBC dated 6/15/25 indicated, catheter has been blocked, and he uses the restroom. MDSC stated there was no documentation of interventions to address when Resident 1's suprapubic catheter was clogged or blocked. MDSC stated when it was first noted there was no urine output, the licensed nurse and the physician should have been notified.During an interview on 7/31/25 at 3:33 p.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated she did not document Resident 1's suprapubic catheter was clogged on 6/25/25. CNA 2 (continued on next page) 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 Page 1 of 3 Event ID: 056294 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056294 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Joaquin Nursing Center and Rehabilitation Cent 3601 San Dimas Bakersfield, CA 93301 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)