Health inspection·February 25, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, for one of three sampled residents (Resident 1) when: Residents Affected - Few 1. Care plan for refusal of care was not developed and implemented. This failure resulted in Resident 1 not receiving showers or baths for 13 days. 2. Respiratory Care plan was not developed and implemented. This failure had the potential for Resident 1's respiratory signs and symptoms to go unnoticed. Findings: 1. During a concurrent interview and record review on 2/25/25 at 3:01 p.m. with Director of Nursing (DON), Resident 1's Shower Sheets, dated 2/6/25, 2/10/25, 2/13/25, and 2/17/25 were reviewed. DON confirmed Resident 1 refused all showers and baths offered. Resident 1's care plans were reviewed. DON confirmed no care plan was developed or implemented for Resident 1's refusals for showers and baths. DON confirmed a refusal care plan should have been developed and implemented for Resident 1's refusals for showers and baths. 2. During a review of Resident 1's admission Record, (AR) dated 2/5/25, the AR indicated, Resident 1 had a diagnosis of asthma (chronic lung disease caused by inflammation and muscle tightening around the airways, which makes it harder to breathe), interstitial pulmonary disease (group of chronic lung conditions that cause inflammation and scarring of the lungs; scarring leads to stiff and thickened lungs, making it difficult for oxygen to enter the bloodstream), chronic obstructive pulmonary disease (group of lung diseases that cause airflow obstruction and breathing difficulties), respiratory disorders, and atelectasis (a condition where part or all of a lung collapses, leading to a reduction in oxygen exchange). During a concurrent interview and record review on 2/25/25 at 3:01 p.m. with DON, Resident 1's AR was reviewed. DON confirmed Resident 1 had five diagnoses affecting the respiratory system. Resident 1's care plans were reviewed. DON confirmed no respiratory care plan was developed or implemented for Resident 1. DON stated a respiratory care plan should have been developed and implemented for Resident 1's respiratory care. During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, revised March 2022, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's needs is developed and implemented for each resident. (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: 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 02/25/2025 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)