Health inspection·September 5, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on observation, interview, and record review, the facility failed to report an allegation of sexual abuse for one of three sampled residents (Resident 1) within 24 hours to the California Department of Public Health (CDPH) and complete an investigation within five business days. This failure had the potential for Resident 1 experiencing continued sexual abuse. Findings: During a review of Resident 1's Progress Notes (PN), dated September 1, 2024, the PN indicated, In charge nurse informed that resident [1] stated that she was raped here some days ago by two men. During a concurrent observation and interview on 9/5/24 at 1:21 p.m. with Resident 1, Resident 1 was sitting in a wheelchair in the dining room, holding a color crayons in a basket with rabbit stuffed animal on her lap. Resident 1 stated, I was raped four times by two men since I have been here. It ' s [allegation of asexual abuse] in the records. Its listed here. I ' m afraid to be alone. During a concurrent interview and record review on 9/5/24 at 2:55 p.m. with the Director of Nursing (DON), Resident 1's clinical record was reviewed, there was no documentation of completed investigation. DON stated staff reported to her that Resident 1 was making allegations of rape by two men. DON stated she instructed staff to call 911 and follow the abuse protocol. DON stated she did not report the allegation of sexual abuse to the CDPH because she (Resident 1) changed her (Resident 1) story to the nurse. During a review of the facility policy and procedure (P&P) titlled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, undated, the P&P indicated, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigation are documented and reported. Reporting Allegation to the Administrator and Authorities 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; 3. Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. Investigating Allegations 1. All allegations are thoroughly investigated. Follow-Up Report 1. Within five (5) business days of the incident, the administrator will provide a follow-up investigation report. 2. The follow-up investigation report will provide sufficient information to describe the results of the investigation, and indicate any corrective actions taken if the allegation was verified. 3. The follow-up investigation report will provide as much information as (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 2 Event ID: 555912 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 555912 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kern River Transitional Care 5151 Knudsen Drive Bakersfield, CA 93308 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)