Bakersfield Post Acute

In the surveyor’s words

From the most serious findings on record at Bakersfield Post Acute, in the surveyor’s own words.

• Actual harm, isolatedF686Nov 25, 2024

  Based on observation, interview, and record review, the facility failed to follow their policy and procedures (P&P) titled, Prevention of Pressure Injuries (localized damage to the skin and underlying soft tissue usually over a bony prominence), for one of three sampled residents (Resident 79) when staff did not evaluate, report and document potential changes in the skin. This failure resulted in Resident 79 developing a facility acquired right heel injury which progressed to a pressure ulcer (open sore caused by poor blood flow or pressure) causing pain to Resident 79. […]

• Actual harm, isolatedF656Oct 26, 2023

  Based on observation, interview, and record review, the facility failed to develop and implement comprehensive plan of care (helps nurses and other care team members organize aspects of resident care according to a timeline) to address risk for falls for one of two sampled residents (Resident 1). This failure resulted in Resident 1 sustaining a fall with fracture (break in the bone) to the anterior (near the front of the body or nearer to the head) column of the left acetabulum (the socket portion of the ball-and-socket hip joint) with extension of the fracture into the left superior (higher in position) and left inferior (lower in position) pubic rami (pubic rami are a group of bones that make up part of the pelvis (basin-shaped complex of bones that connects the trunk [central part of… […]

• Actual harm, isolatedF689Feb 23, 2022

  Based on interview and record review, the facility failed to provide a safe environment for one of nine sampled residents (Resident 1) when the facility failed to: 1. Ensure an air mattress was appropriately deflated prior to provision of care for Resident 1. 2. Ensure one staff (Certified Nursing Assistant [CNA] 1) was competent to perform a task prior to providing that task for Resident 1. These failures resulted in Resident 1 falling off her bed onto the floor and sustaining a right arm skin tear, laceration to the scalp and a collarbone fracture, which required the resident to be transferred to the acute care hospital. Findings: During an interview on 11/17/21, at 12:15 PM, with CNA 1, CNA 1 stated, she was providing care to Resident 1 when she fell on [DATE]. […]

• No harm, potential for more than minimal, widespreadF880Nov 25, 2024

  Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. The treatment nurse had long artificial nails. 2. One of one linen cart cover was a mesh (uniform small openings) material, and the mesh cover was frayed in the center. 3. Two of two housekeeping carts trash bins did not have lids. 4. Three of four sample resident rooms (Resident 36, Resident 14 and Resident 133) who were on Enhanced Barrier Precaution (EBP-infection control strategy that uses PPE to reduce the spread infections) had no Personal Protective Equipment supplies (PPE-equipment worn to minimize exposure to a variety of hazards). These failures had the potential to spread infections to residents, staff, and visitors. Findings: 1. […]

• No harm, potential for more than minimal, widespreadF725Aug 24, 2023

  Based on interview and record review, the facility failed to ensure call light was answered timely for two of five sampled residents (Resident 2 and Resident 3). This failure had the potential to result in unmet care needs, and negatively impact safety, physical, mental, and psychosocial well-being for Resident 2 and Resident 3. Findings: During an interview on 7/24/23, 1:52 p.m. Resident 2, Resident 2 stated she waited three hours on Saturday for her call light to be answered. During a review of Resident 2's Minimum Data Set, (MDS - an assessment tool) dated 6/15/23, the MDS indicated, Resident 2's BIMS (Brief Interview for Mental Status with a range of 0-15) score was 15 (a score of 13 to 15 suggests the resident is cognitively intact). During an interview on 7/24/23, 2:08 p.m. […]