Health inspection·August 27, 2025

F 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to follow its policy and procedure (P&P) titled, Referrals, Social Services, when the facility failed to schedule a follow-up surgeon's (a doctor who removes or repairs a part of the body by operating on the patient) appointment for one of four sampled residents (Resident 1). This failure had the potential for a delay in follow-up care for Resident 1 after surgery (the branch of medical practice that treats injuries, diseases, and deformities by the physical removal, repair, or readjustment of organs and tissues, often involving cutting into the body). Findings:During a review of Resident 1's History and Physical Reports (HPR), dated 7/5/25, the HPR indicated, [Resident 1] who is direct transfer back after suffering a fall resulting in C5-6 fracture [broken neck bone] requiring discectomy [removal] and fusion [joining] as well as R V2 vertebral artery stenosis [artery blockage] at injury site.f/u [follow up] w/ [with] their surgeon in 2 weeks. During a concurrent interview and record review on 8/27/25 at 9:41 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 1's clinical records were reviewed. There was no documentation of follow-up appointment scheduled with the surgeon. LVN 1 stated, I don't see any follow up appointments. LVN 1 stated when a resident is admitted , the admission nurse reviews the transfer paperwork, which included the history and physical, and if a follow-up appointment is needed the information is sent to social services to schedule the appointment. During a concurrent interview and record review on 8/27/25 at 9:50 a.m. with Director of Nursing (DON), Resident 1's Social Service Notes (SSN), undated were reviewed. The SSN indicated Resident 1 did not have a scheduled follow-up appointment with the surgeon. DON stated there was no follow-up appointment with the surgeon for Resident 1. During an interview on 8/27/25 at 10:05 a.m. with Resident 1, Resident 1 stated he had a neck surgery in (name of city) around June 30th (2025). Resident 1 stated after the surgery he was transferred to a hospital in (name of city) for recovery. Resident 1 stated he was then admitted to this facility for physical therapy. Resident 1 stated there were no follow up appointments since his admission (to the skilled nursing facility). Resident 1 stated he spoke with social services inquiring (seeking knowledge) about a follow-up appointment with the surgeon. Resident 1 stated no appointment has been scheduled. During a concurrent interview and record review on 8/28/25 at 8:51 a.m. with Social Services Director (SSD), Resident 1's HPR dated 7/2/25 was reviewed. Resident 1's HPR indicated, . f/u [follow-up] w/their surgeons in 2 weeks. SSD stated she spoke to Resident 1 approximately two weeks ago as Resident 1 inquired (seeking information) about a follow-up appointment with his surgeon. SSD stated she was unable to find any information in Resident 1's chart to schedule a follow-up appointment. SSD stated she asked Resident 1 to contact family to see if they had the information to the surgeon. SSD stated when a resident is admitted to the facility her responsibility is to review the hospital paperwork, which was uploaded into the resident's medical record, and note any follow up appointments which need to be scheduled. SSD stated she reviewed Resident 1's HPR but did not see the follow up appointment. SSD stated after further review of Resident 1's HPR, she should Residents Affected - Few Page 1 of 2 056294 056294 08/27/2025 San Joaquin Nursing Center and Rehabilitation Cent 3601 San Dimas Bakersfield, CA 93301

F 0745 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few have had a follow-up appointment two weeks after surgery. SSD stated the information needed to schedule a follow-up appointment was in the HPR, which was placed in Resident 1's clinical record on 7/6/25. During a review of Resident 1's Care Plan (CP), dated 7/7/25, the CP indicated, Surgical Incision [a cut or wound made in the body during surgery]: Resident [1] has a surgical incision at the C5-6 spine. Interventions: .follow up with surgeon as indicate.During a concurrent interview and record review on 9/2/25 at 11:34 a.m. with DON, Resident 1's HPR, dated 7/2/25 was reviewed. The HPR indicated the name of the surgeon and the hospital where Resident 1 had a surgery. DON stated the information for the surgeon and facility were in this (HPR) document. DON stated social services could have used this information to schedule a follow up appointment for Resident 1. DON stated this was a delay in care. During a review of the facility's P&P titled, Referrals, Social Services, dated 12/2008, the P&P indicated, Policy statement: Social Services personnel shall coordinate most resident referrals with outside agencies.Referrals for medical services must be based on physician evaluation of resident need.Social services will document the referral in the resident's medical record.Social services will help arrange transportation to outside agencies, clinic appointment, etc. as appropriate. 056294 Page 2 of 2