Kern River Transitional Care

In the surveyor’s words

From the most serious findings on record at Kern River Transitional Care, in the surveyor’s own words.

• Actual harm, isolatedF600Dec 7, 2023

  Based on observation, interview and record review the facility failed to prevent abuse for one of 10 sampled residents (Resident 3). This failure resulted in Resident 3 to express feelings of sadness, cry, verbalize a fear of retaliation from staff and had the potential to affect other residents in a negative manner. Findings: During a review of Resident 3's Minimum Data Set (Assessment tool) BIMS (Brief Interview for Mental Status- an assessment tool for cognition), dated 9/8/23, the BIMS indicated, Resident 3 had a score of 12 (moderate impairment). During a concurrent observation and interview on 10/19/23 at 11:46 a.m. with Resident 3 in Resident 3's room, Resident 3 stated, Certified Nursing Assistant (CNA) 9 had been shouting at her. […]

• Actual harm, isolatedF697Sep 1, 2022

  Based on interview and record review the facility failed to ensure: 1. An accurate pain assessment was done for one of one sampled resident (Resident 1). 2. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . These failures resulted in Resident 1 suffering from severe pain (scale of 0 = no pain, 1 to 3 = mild pain, 4 to 6 = moderate pain, 7 to 10 = severe pain) and caused a delay in treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: 1. During a review of Resident 1's Physicians Order (PO), dated 2/10/22, the PO indicated, Resident 1 had an order/start date on 12/30/21 for Monitor and Record Pain Assessment Level q [every] shift 0 = No pain, 1-3 = Mild, 4-8 = Moderate, 7-10 = Severe. During a review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF552Apr 24, 2025

  Based on interview, and record review, the facility failed to: 1. Follow their policy and procedure titled Psychoactive/Psychotropic Medication Use, when Informed Consents (process to ensure the provider has discussed the risks, benefits, and alternatives with the patient and the patient agrees to the provider performing the intervention) were not provided by the physician or consistently witnessed by a licensed nurse for eight of 14 sampled residents (Resident 437, Resident 111, Resident 10, Resident 338, Resident 25, Resident 8, Resident 55, and Resident 36 ) on psychotropic medications, (medications to treat mental health disorders). This failure had the potential for residents or their responsible party to be unaware of alternatives to medications or side effects of medications. 2. […]

• No harm, potential for more than minimal, widespreadF726Apr 24, 2025

  Based on interview and record review, the facility failed to: 1.Ensure three of 32 sampled licensed vocational nurses (LVN 2, LVN 3, and TN 2) were competent (verified ability to perform skill) to perform care for one of one sampled resident (Resident 72) on dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly). 2. Ensure three of 32 sampled licensed vocational nurses (LVN 2, LVN 3, and treatment nurse [TN] 2) were competent to provide care for one of one sampled resident (Resident 36) with suprapubic catheter (a tube inserted into the bladder to drain urine). 3. […]

• No harm, potential for more than minimal, widespreadF880Apr 24, 2025

  Based on observation, interview, and record review, the facility failed to follow and implement the Center for Disease Control and Prevention (CDC, nationally recognized health organization) infection control practices when: 1. Licensed Vocational Nurse (LVN) 2 did not follow Enhanced Barrier Precaution (EBP, precautions to reduce transmission of infectious organisms) protocols during closed contact with one of one sampled resident (Resident 72). 2. The X-ray Technician (XRT) stepped out of the room with contaminated gloves and isolation gown to answer a phone call after in close contact with one of one resident (Resident 96) on EBP. 3a. […]