Kern Valley Healthcare District DP SNF

In the surveyor’s words

From the most serious findings on record at Kern Valley Healthcare District DP SNF, in the surveyor’s own words.

• Actual harm, patternF600Aug 10, 2022

  Based on interview and record review, the facility failed to implement the ABUSE PREVENTION PROGRAM - DEFINITIONS AND INDICATORS policy and procedure (P & P) for 10 (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, and Resident 10) of 15 sampled residents. This failure resulted in the facility neglecting personal hygiene care needs of Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, and Resident 10, which negatively impacted their quality of life and had the potential to negatively impact their emotional wellbeing. […]

• Actual harm, patternF607Aug 10, 2022

  Based on interview and record review, the facility failed to report alleged abuse and neglect for 10 (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, and Resident 6, Resident 7, Resident 8, Resident 9, Resident 10) of 15 sampled residents. This failure resulted in alleged abuse to continue with no facility intervention. Findings: During a review of the facility record (FR), dated 12/24/21, the FR indicated, On December 19, 2021 at approximately [7:30 PM], I [Director of Nursing - DON] was performing a yearly evaluation with one of my [night shift] nurses. During the process of this evaluation, [Licensed Vocational Nurse - LVN 1] had stated 'there was a problem with [CNAs 1] leaving her residents in bed soaked with urine'. […]

• Actual harm, isolatedF684Oct 27, 2025

  Based on observation, interview, and record review, the facility failed to assess, recognize, escalate and properly respond to an emergency involving one of seven sampled residents (Resident 7) who experienced a physical change of condition (a significant change in a person's health, caregiver support, or functional status that will not usually resolve without further intervention). This failure resulted in a delay in transferring Resident 7 to the hospital for a higher level of care, resulted in a delay in treatment for a Cerebral Infarction (also known as a stroke, it is when blood flow to the brain is stopped, which can result in slurred speech, movement difficulties to one or both sides of the body, numbness, confusion, headache), and an intracranial hemorrhage (type of stroke that… […]

• Actual harm, isolatedF689Nov 25, 2024

  Based on observation, interview, and record review, the facility failed to implement their policy and procedure (P&P) on ELOPEMENT (when a resident leaves the facility without the knowledge of the staff)/WANDERING (moving from place to place without a fixed plan) to evaluate for elopement, initiate a care plan (document that outlines the specific needs, goals, and interventions for a resident) and notify the physician for one of three sampled residents (Resident 1) who expressed and attempted to leave the facility. […]

• Actual harm, isolatedF689Oct 26, 2022

  Based on interview and record review, the facility failed to ensure one of one sampled residents (Resident 1) received one-to-one (also written as 1:1) supervision from staff as ordered by her physician. This failure resulted in actual harm to Resident 1 when the one-to-one staff assigned to her (Monitor 1) left Resident 1 unsupervised, resulting in a fall with multiple fractures to her face, lacerations (tears in the skin) to her forehead which required sutures (also known as stitches), subdural hematoma (a dangerous, potentially life-threatening bleed into brain tissue) decreased mobility, and pain. Findings: During a review of the Physician's Orders for Resident 1, an order dated 12/14/21, indicated Resident 1 was to have 1:1 resident monitoring daily as needed. […]