Inspection·July 28, 2025

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure physician's orders were followed when:1. Oxygen was not administered as prescribed by the physician for one of three sampled residents (Resident 1).2. Medications were not administered timely for one of three sampled residents (Resident 4). 3. Medications were not administered for one of three sampled residents (Resident 4).These failures had the potential for Resident 1 and Resident 4 to suffer adverse outcomes.Findings:1. During a concurrent observation and interview, on 7/16/25 at 11:43 a.m. in Resident 1's room, Resident 1 was observed wearing a nasal canula and her oxygen was set at 4 liters per minute. During a review of Resident 1 O2 (oxygen) @ (at) 3 LPM (liters per minute) Via Nasal Cannula (thin flexible tube that gives additional oxygen through the nose) Per Concentrator Continuous every Shift . Order Date 07/07/2025 Start Date 07/07/2025During a concurrent observation, interview, and record review, on 7/16/25 at 11:57 a.m. in Resident 1's room, with Licensed Vocational Nurse (LVN) LVN 1, stated he was checking resident on continuous oxygen once a shift to ensure they were at the correct setting. LVN 1 confirmed Resident 1's oxygen was set at 4 liters per minute. Resident 1's physician's orders were reviewed. LVN 1 confirmed Resident 1's oxygen order was for 3 liters per minute.During an interview on 7/16/25 at 4:30 p.m. with Director of Nursing (DON), DON stated the nurse is the person who can initiate oxygen. DON stated the nurses were supposed to do walking rounds and check the flow rate was at the prescribed level. During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, the P&P indicated, The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation 1. Verify that there is a physician's order for this procedure. Review the physician's order .1. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered.2. During a concurrent interview and record review on 7/28/25 at 2:54 p.m. with DON, Resident 4's Medication Administration Record, (MAR) dated July 2025 was reviewed. DON confirmed the following:Insulin Glargine Solution (long-acting medication used to treat high blood sugar) 100 UNIT/ML (milliliter- unit of measure) inject10 units subcutaneously (the passage of medications beneath the skin) at bedtime for type 2 DM (diabetes mellitus- a long-term condition in which the body has trouble controlling blood sugar and using it for energy) -Start Date-5/31/2025 2100 (9 p.m.) -D/C (discontinue) Date- 07/25/2025 2055 (8:55 p.m.)The MAR indicated, on 7/1/25 for the 9 p.m. administration time, Resident 4's insulin was administered at 12:46 a.m. on 7/2/25 (3 hours and 46 minutes late).The MAR indicated, on 7/5/25 for the 9 p.m. administration time, Resident 4's insulin was administered at 12:18 a.m. on 7/6/25 (3 hours and 46 minutes late).The MAR indicated, on 7/6/25 for the 9 p.m. administration time, Resident 4's insulin was administered at 11:14 p.m. (2 hours and 14 minutes late).The MAR indicated, on 7/7/25 for the 9 p.m. administration time, Resident 4's insulin was administered at 11:25 p.m. (2 hours and 25 minutes late).The MAR indicated, on 7/8/25 for the 9 p.m. administration time, Resident 4's insulin was administered at 12:47 a.m. on 7/9/25 (3 hours and 47 minutes late).The MAR indicated, on 7/11/25 for the 9 p.m. administration time, Resident 4's insulin was administered at 10:45 p.m. (1 hour and 45 minutes late).The MAR indicated, on 7/14/25 for the 9 p.m. administration time, Resident 4's insulin was administered at 2:23 a.m. on 7/15/25 (5 hours and 23 minutes late).The MAR indicated, on 7/15/25 for the 9 p.m. administration time, Resident 4's insulin was administered at 1:31 a.m. on 7/16/25 (4 hours and 31 minutes late).The MAR indicated, on 7/21/25 for the 9 p.m. administration time, Resident 4's insulin was administered at 11:22 p.m. (2 hours and 22 minutes late).The MAR indicated, on 7/22/25 for the 9 p.m. administration time, Resident 4's insulin was administered at 1:56 a.m. on 7/23/25 (4 hours and 56 minutes late). Diclofenac (medication used to treat pain) . Gel 1% . Apply to Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555912 If continuation sheet Page 2 of 7 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 07/28/2025 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)

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Left Knee topically (on top of the skin) three times a day for Chronic (long term) left knee pain -Start Date06/09/2025 2200 (10 p.m.) -D/C Date- 07/252025 2055The MAR indicated, on 7/5/25 for the 2 p.m. administration time, Resident 4's Diclofenac was administered at 8:50 a.m. (4 hours and 10 minutes early).The MAR indicated, on 7/5/25 for the 10 p.m. administration time, Resident 4's Diclofenac was administered at 12:18 a.m. on 7/6/25 (2 hours and 18 minutes late).The MAR indicated, on 7/7/25 for the 10 p.m. administration time, Resident 4's Diclofenac was administered at 11:26 p.m. (1 hour and 26 minutes late).The MAR indicated, on 7/12/25 for the 10 p.m. administration time, Resident 4's Diclofenac was administered at 12:40 a.m. on 7/13/25 (2 hours and 40 minutes late).The MAR indicated, on 7/18/25 for the 10 p.m. administration time, Resident 4's Diclofenac was administered at 11:28 p.m. (1 hour and 28 minutes late). Diclofenac . Gel 1% . Apply to Right Knee topically three times a day for Chronic left knee pain -Start Date- 06/09/2025 2200 (10 p.m.) -D/C Date- 07/25/2025 2055(10:55 p.m.)The MAR indicated, on 7/5/25 for the 10 p.m. administration time, Resident 4's Diclofenac was administered at 12:19 a.m. on 7/6/25 (2 hours and 19 minutes late).The MAR indicated, on 7/7/25 for the 10 p.m. administration time, Resident 4's Diclofenac was administered at 11:26 p.m. (1 hour and 26 minutes late).The MAR indicated, on 7/12/25 for the 10 p.m. administration time, Resident 4's Diclofenac was administered at 12:39 a.m. on 7/13/25 (2 hours and 39 minutes late).The MAR indicated, on 7/13/25 for the 2 p.m. administration time, Resident 4's Diclofenac was administered at 4:09 p.m. (2 hours and 9 minutes late).The MAR indicated, on 7/13/25 for the 2 p.m. administration time, Resident 4's Diclofenac was administered at 4:09 p.m. (2 hours and 9 minutes late).The MAR indicated, on 7/18/25 for the 10 p.m. administration time, Resident 4's Diclofenac was administered at 11:29 p.m. (1 hour and 29 minutes late). Nystatin Powder (an antifungal medication used to treat fungal skin infections) . Apply to bilateral (both sides) under breast topically three times a day for redness to bilateral under breast -Start Date-07/11/2025 1400 (2 p.m.) -D/C Date- 07/14/2025 1227 (12:27 p.m.)The MAR indicated, on 7/12/25 for the 10 p.m. administration time, Resident 4's Nystatin Powder was administered at 12:39 a.m. on 7/13/25 (2 hours and 39 minutes late).The MAR indicated, on 7/13/25 for the 2 p.m. administration time, Resident 4's Nystatin Powder was administered at 4:09 p.m. (2 hours and 9 minutes late) Nystatin Powder . Apply to bilateral under breast topically three times a day for redness to bilateral under breast for 19 Days -Start Date-07/14/2025 1400 (2 p.m.) -D/C Date- 07/25/2025 2055 (8:55 p.m.)The MAR indicated, on 7/14/25 for the 10 p.m. administration time, Resident 4's Nystatin Powder was administered at 2:25 a.m. on 7/15/25 (4 hours and 25 minutes late).The MAR indicated, on 7/15/25 for the 10 p.m. administration time, Resident 4's Nystatin Powder was administered at 1:33 a.m. on 7/16/25 (3 hours and 33 minutes late).The MAR indicated, on 7/16/25 for the 6 a.m. administration time, Resident 4's Nystatin Powder was administered at 7:15 a.m. (1 hour and 15 minutes late).The MAR indicated, on 7/18/25 for the 10 p.m. administration time, Resident 4's Nystatin Powder was administered at 11:29 p.m. (1 hour and 29 minutes late).The MAR indicated, on 7/20/25 for the 10 p.m. administration time, Resident 4's Nystatin Powder was administered at 11:22 p.m. (1 hour and 22 minutes late).The MAR indicated, on 7/21/25 for the 10 p.m. administration time, Resident 4's Nystatin Powder was administered at 11:23 p.m. (1 hour and 23 minutes late).The MAR indicated, on 7/22/25 for the 10 p.m. administration time, Resident 4's Nystatin Powder was administered at 1:58 a.m. on 7/23/25 (3 hours and 58 minutes late). Humalog . (short acting insulin- medication used to treat high blood sugar) Inject as per sliding scale: . subcutaneously before meals and at bedtime for type 2 DM . -Start Date-5/31/2025 2100 -D/C Date07/25/2025 2055The MAR indicated, on 7/1/25 for the 7:30 a.m. administration time, Resident 4's Humalog was administered at 2:47 p.m. (7 hours and 17 minutes late).The MAR indicated, on 7/1/25 for the 9 p.m. administration time, Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555912 If continuation sheet Page 3 of 7 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 07/28/2025 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)

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 4's Humalog was administered at 12:47 a.m. on 7/2/25 (3 hours and 47 minutes late).The MAR indicated, on 7/2/25 for the 7:30 a.m. administration time, Resident 4's Humalog was administered at 9 a.m. (1 hour and 30 minutes late).The MAR indicated, on 7/3/25 for the 12 p.m. administration time, Resident 4's Humalog was administered at 1:40 p.m. (1 hour and 40 minutes late).The MAR indicated, on 7/3/25 for the 5 p.m. administration time, Resident 4's Humalog was administered at 6:27 p.m. (1 hour and 27 minutes late).The MAR indicated, on 7/4/25 for the 7:30 a.m. administration time, Resident 4's Humalog was administered at 2:21 p.m. (6 hours and 51 minutes late).The MAR indicated, on 7/5/25 for the 9 p.m. administration time, Resident 4's Humalog was administered at 12:17 a.m. on 7/6/25 (3 hours and 17 minutes late).The MAR indicated, on 7/6/25 for the 9 p.m. administration time, Resident 4's Humalog was administered at 11:14 p.m. (2 hours and 14 minutes late).The MAR indicated, on 7/7/25 for the 9 p.m. administration time, Resident 4's Humalog was administered at 11:25 p.m. (2 hours and 25 minutes late).The MAR indicated, on 7/8/25 for the 9 p.m. administration time, Resident 4's Humalog was administered at 12:47 a.m. on 7/9/25 (3 hours and 47 minutes late).The MAR indicated, on 7/11/25 for the 12 p.m. administration time, Resident 4's Humalog was administered at 1:09 p.m. (1 hour and 9 minutes late).The MAR indicated, on 7/11/25 for the 5 p.m. administration time, Resident 4's Humalog was administered at 6:22 p.m. (1 hour and 22 minutes late).The MAR indicated, on 7/11/25 for the 9 p.m. administration time, Resident 4's Humalog was administered at 10:45 p.m. (1 hour and 45 minutes late).The MAR indicated, on 7/12/25 for the 9 p.m. administration time, Resident 4's Humalog was administered at 10:03 p.m. (1 hour and 3 minutes late).The MAR indicated, on 7/13/25 for the 7:30 a.m. administration time, Resident 4's Humalog was administered at 10:23 a.m. (2 hours and 53 minutes late).The MAR indicated, on 7/14/25 for the 9 p.m. administration time, Resident 4's Humalog was administered at 2:23 a.m. on 7/15/25 (5 hours and 23 minutes late).The MAR indicated, on 7/15/25 for the 9 p.m. administration time, Resident 4's Humalog was administered at 1:31 a.m. on 7/16/25 (4 hours and 31 minutes late).The MAR indicated, on 7/17/25 for the 12 p.m. administration time, Resident 4's Humalog was administered at 1:06 p.m. (1 hour and 6 minutes late).The MAR indicated, on 7/19/25 for the 9 p.m. administration time, Resident 4's Humalog was administered at 10:15 p.m. (1 hour and 15 minutes late).The MAR indicated, on 7/21/25 for the 9 p.m. administration time, Resident 4's Humalog was administered at 11:19 p.m. (2 hours and 19 minutes late).The MAR indicated, on 7/22/25 for the 7:30 a.m. administration time, Resident 4's Humalog was administered at 10:18 a.m. (2 hours and 48 minutes late).The MAR indicated, on 7/22/25 for the 9 p.m. administration time, Resident 4's Humalog was administered at 1:56 a.m. on 7/23/25 (4 hours and 56 minutes late).During a concurrent interview and record review on 7/28/25 at 2:54 p.m. with DON, DON stated the nurses have one hour before and one hour after the ordered administration time to administer medications. DON stated if the medications were administered outside of that time frame the nurse should notify the physician to ensure the medications were safe to administer and document the response in a progress note. Resident 4's progress notes were reviewed. DON stated the physician was not notified of the multiple late medications.3. During a concurrent interview and record review on 7/28/25 at 3:49 p.m. with DON, Resident 4's MAR, dated July 2025 was reviewed. DON confirmed the following: Xarelto (medication used to thin the blood to prevent and treat blood clots) Oral Tablet 20 MG (milligram - unit of measure) . Give 1 tablet by mouth in the evening for A-Fib (Atrial fibrillation- irregularly and often rapidly heartbeat) -Start Date-5/31/2025 2100 -D/C Date- 07/25/2025 2055The MAR indicated, on 7/6/25 for the 6 p.m. administration time, Resident 4's Xarelto was not documented as administered. Humalog . Inject as per sliding scale: . subcutaneously before meals and at bedtime for type 2 DM . -Start Date-5/31/2025 2100 -D/C Date- 07/25/2025 2055The MAR indicated, on 7/13/25 for the 12 p.m. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555912 If continuation sheet Page 4 of 7 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 07/28/2025 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)

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete administration time, Resident 4's Humalog was not documented as administered.DON stated the dated were blank and could not confirm if the medications were administered or not. During a review of the facility's P&P titled, Administering Medications, revised April 2019, the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed. 4. Medications are administered in accordance with prescriber orders, including any required time frame. 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders) . 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. 21. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose. 22. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. 23. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: a. the date and time the medication was administered; . g. the signature and title of the person administering the drug. Event ID: Facility ID: 555912 If continuation sheet Page 5 of 7 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 07/28/2025 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)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Bowel Management Protocol, for one of six sampled residents (Resident 3) when Resident 3 was not administered needed medication. This failure had the potential for Resident 3 to experience pain and constipation.Findings:During a review of Resident 3's Task: Bowel Continence, (TBC) dated 6/22/25 to 7/20/25, the TBC indicated Resident 3 did not have a bowel movement (BM) from 6/24/25 to 6/30/25 (six days).During a concurrent interview and record review on 7/16/25 at 4:12 p.m. with the Director of Nursing (DON), Resident 3's TBC was reviewed. DON stated Resident 3 did not have a BM for six days. Resident 3's Medication Administration Record, (MAR) dated June 2025 was reviewed. DON stated bowel protocol was not initiated (a series of medications used to treat and prevent constipation). DON stated no medications were given to Resident 3. DON stated bowel protocol should have been initiated.During a review of the facility P&P titled, Bowel Management Protocol, undated, the P&P indicated, It is the policy of this facility to ensure that residents are free from complications secondary to constipation. This will be accomplished through adequate assessment, tracking and treatment as indicated. Definition Normal bowel pattern is once every day up to once every three (3) days. Constipation results from factors such as immobility, decreased activity, and as a side effect of numerous medications. Procedure . 5. The 3-11 House Supervisor (or charge nurse in the event of no HS) will review the resident flow record daily and compose a list of those residents not having had a BM in three (3) days and record it on the appropriate bowel care list. 6. The 3-11 nurse will provide medications as order by the physician or obtain a physician's order, to the residents on the bowel care list. The medication given should be recorded on the MAR and the bowel care list. The medication could consist of: a. Suppository b. MOM 30-60 cc (cubic centimeters-unit of measure) . 7. The 11-7 nurse is to follow up on those residents on the bowel care list for results. The nurse will document results on the bowel care list and on the MAR. Event ID: Facility ID: 555912 If continuation sheet Page 6 of 7 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 07/28/2025 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)

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on interview and record review, the facility failed to ensure three of three sampled License Vocational Nurses (LVN) ( LVN 1, LVN 2, and LVN 3) had competencies for continuous positive airway pressure, (CPAP- is a common treatment for sleep apnea, a condition where breathing repeatedly stops and starts during sleep) and bilevel positive airway pressure (BIPAP is a type of non-invasive ventilation that provides breathing support by delivering air at two different pressure levels, one for inhalation and another for exhalation). This failure had the potential for the facility's residents who require the use of CPAP or BIPAP to have improper application.Findings:During an interview on 7/16/25 at 11:43 a.m. with Resident 1, Resident 1 stated when her BIPAP mask is applied by the LVN it depends on who applies the mask if there is a good seal or not.During a concurrent interview and record review on 7/28/25 at 3:36 p.m. with Staffing Coordinator (SC), LVN 1, LVN 2, and LVN 3's training files were reviewed. SC stated there were no skills training for CPAP or BIPAP for the LVN 1, LVN 2, and LVN 3.During an interview on 7/28/25 at 3:49 p.m. with Director of Nursing (DON), DON stated the facility had seven residents with physician orders for CPAP and BIPAP. DON stated based on the facility's population the facility should have training for CPAP and BIPAP because if not performed properly there is no benefit and could make it uncomfortable for the residents.During a review of the facility's policy and procedure (P&P) titled, Staffing, Sufficient and Competent Nursing, revised August 2022, the P&P indicated, Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and facility assessment. Competent Staff 1. Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. 3. Staff must demonstrate the skills and techniques necessary to care for resident needs .5. Competency requirements and training for nursing staff are established and monitored by nursing leadership with input from the medical director to ensure that: . c. education topics and skills needed are determined based on the resident population . Event ID: Facility ID: 555912 If continuation sheet Page 7 of 7