Kern Valley Healthcare District Dp SNF

Inspectors wroteBased on interview and record review the facility failed to follow its policies and procedures (P&P) titled, Staffing, Sufficient and Competent Nursing, for all residents when a Registered Nurse (RN) was not present in the facility for eight working hours. This failure had the potential for residents needs to go unmet.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement effective infection control practices when:Facility staff did not provide hand hygiene to three of five sampled residents (Resident 26, Resident 30, and Resident 15). This failure had the potential to spread infection to residents. Housekeeping staff did not follow Enhanced Barrier Precautions (EBP - gown and gloves are used during care of residents with indwelling medical devices and open wounds, to prevent infection) for one of one sampled resident (Resident 6) when cleaning Resident 6's room. This failure had the potential to result in Resident 6 developing an infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its Policy and Procedure (P&P) tiled, Medication Storage, for one of one medication cart when Licensed Vocational Nurse (LVN) 1, left the medication cart unlocked in the hallway. This failure had the potential for accidental ingestion of medication by a wondering resident.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of two sampled housekeeping carts (Cart 1 and Cart 2) were secured and cleaning chemicals were not accessible by residents. These failures had the potential to result in residents accessing the cleaning chemicals causing injury or death.

Inspectors wroteDuring an observation, interview, and record review, the facility failed to ensure one of two cooks (Cook 2) followed the Hair and beard Restraint policy and procedures (P&P), when [NAME] 2 did not have a beard cover. This failure had the potential for food contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physician orders (PO) to monitor oxygen saturation (O2 Sat- a measurement of how much oxygen your blood is carrying as a percentage of the maximum it could carry) was followed for one of eight sampled residents (Resident 1). This failure had the potential for Resident 1 not to receive the appropriate oxygenation that is required to maintain the parameters the physician ordered.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P), titled Foods Brought in by Family or Visitors, when a designated refrigerator was not provided for resident's food that is brought in by family. This failure had the potential to place residents at risk of foodborne illness due to unmonitored food brought in by the family and could limit food choices and options for residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a policy and procedure (P&P) for smoking for one of one resident (Resident 45). This failure had the potential to result in Resident 45 being unsafe while smoking and injury of Resident 45 and other residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 2) was able to exercise the right to refuse physician ordered meal consistency. This failure resulted in Resident 2's rights to make decisions on her care to be violated and had the potential for not meeting Resident 2's nutritional needs .

Inspectors wroteBased on interview and record review, the facility failed to notify one of three sampled residents (Resident 4) family members when Resident 4 had a fall incident. This failure had the potential for Resident 4's family member to be unaware of Resident 4's fall.

Inspectors wroteBased on interview and record review, the facility failed to provide care and services for one of three sampled residents (Resident 1) when Charge Nurse intentionally neglected to document, report, and assess Resident 1 after a fall incident. This failure had the potential for delay in care, Resident 1 feeling neglected, and injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a care plan for one of three sampled residents' (Resident 1) fall precaution. This failure had the potential to result injury for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to follow the facility's policy and procedure (P&P) titled, Neurological Evaluation [Neuro check- is a group of questions and tests to check for disorder of the spinal cord and brain], for one of three sampled residents (Resident 1) when Resident 1 had an unwitnessed fall. This failure had the potential for a delay in treatment and care for Resident 1, and had the potential for Resident 1 to suffer adverse health outcomes.

Inspectors wroteBased 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). [...]

Inspectors wroteBased on interview and record review, the facility failed to conduct Medical Doctor (MD) and/or Nurse Practitioner (NP - a registered nurse with a graduate degree who provides advanced healthcare, including diagnosing and treating illnesses, ordering and interpreting tests, and prescribing medication) resident assessments per the facility policy and procedure for seven out of seven residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7). This failure had the potential for residents' medical conditions to change without appropriate interventions by the MD or NP.

Inspectors wroteBased on interview and record review, the facility failed to implement their policy and procedure (P&P) on Abuse Prevention Program - Reporting for two of three sampled residents (Resident 1 and Resident 2) when: 1. The facility did not report an allegation of sexual abuse to the California Department of Public Health (CDPH), the Ombudsman (representatives advocating residents in long-term care facilities) and the local law enforcement (LLE) within 24 hours. 2. The facility did not complete a follow-up investigative report (FIR) within five working days. These failures had the potential to result in continuous sexual abuse and emotional distress for Resident 1 and Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure on narcotic (pain medication) count, narcotic dispensing, and storage for one of three sampled residents (Resident 1). This failure resulted in missing narcotic medications and had the potential to affect Resident 1's pain control. During a review of the facility email (FEM), dated 6/24/25, the FEM indicated Resident 1's narcotic medications (morphine - a narcotic pain medication) were placed into the medication room on 6/11/25 but were not double locked in the narcotics drawer. Licensed Vocational Nurse (LVN) 1 accessed Resident 1's home medications during her evening shift (7 p.m. to 7:30 a.m.) to administer one morphine ER (extended release - medication that is released into the body over a period of time) 15 mg (milligram - a unit of measurement) pill to Resident 1. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure they staffed a Registered Nursed (RN) eight hours a day for seven days a week from 9/2024 to 12/2024. This failure had the potential to affect the quality of care of the residents and put the residents at risk for injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label and store food in a sanitary manner when: 1. Food items were not closed and sealed appropriately in one of one dry storage room. 2. Food items did not have a received by date label in one of one dry storage room. These failures had the potential for Residents eating in the facility to be at risk of acquiring a foodborne illness.

Inspectors wroteThe facility failed to ensure tab alarm orders and informed consents were obtained for two of nine Residents (Resident 45 and Resident 14). 1. Resident 45 had no order and no informed consent for tab alarm. 2. Reisdent 14 had no informed consent for tab alarm. This failure had the potential for staff to be untrained in the proper use of alarms.

Inspectors wroteBased on interview, and record review, the facility failed to document changes and monitor for one of two residents (Resident 22 and Resident 7) when: 1. A resident (Resident 22) had an unwitnessed fall. This failure resulted in Resident 22's fall being undocumented. 2. A resident (Resident 7) had a medical condition not monitored. This failure had the potential for Resident 7 to not have his blood sugars monitored.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure dental needs were met, and followed up for one of two sampled residents (Resident 47). This failure resulted in Resident 47 not recieving dentures, feeling embarrassed, and refusing to socialize with other residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) grievance were investigated and resolved. This failure had the potential for psychosocial distress for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to promote two of three sampled residents (Resident 1 and Resident 2) physical and emotional well-being. This failure resulted in Resident 1 and Resident 2 not to be able to fully take part in activities physically and the freedom to make their own choices.

Inspectors wroteBased 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. These failures resulted in Resident 1 eloping and sustaining a fall outside of the facility which resulted in a fracture (a partial or complete break of the bone) to the left hip requiring surgical intervention.

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient Certified Nursing Assistants (CNA) and Restorative Nursing Assistant's (RNA) to meet the needs for 20 of 31 sampled residents (Resident 3, Resident 4, Resident 5, Resident 6, Resident 8, Resident 10, Resident 11, Resident 13, Resident 15, Resident 16, Resident 17, Resident 19, Resident 21, Resident 22, Resident 23, Resident 26, Resident 29, Resident 30, Resident 40, and Resident 42). This failure had the potential for a decline in residents Range of Motion (ROM) and mobility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one refrigerator and one freezer were monitored for temperature control. This failure had the potential for foodborne illnesses to be spread to residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident (Resident 21) was referred for a Preadmission and Resident Review (PASRR-screening tool used to determine if placement in a nursing facility is appropriate for those with mental illness and makes recommendations for specialized services based on the Level II evaluation) after a change in psychological status. This failure resulted in Resident 21 not receiving recommendations for specialized services to best meet her needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to communicate the weightbearing status to the interdisciplinary team (IDT-group of healthcare professionals from different fields working together) for one of one sampled resident (Resident 13). This failure resulted in a delay of rehabilitative and restorative care to prevent further physical decline.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care for the Foley catheter (tube placed into the bladder to drain urine) to prevent infections and other complications for one of four sampled residents (Resident 33). This failure had the potential to result in infections and injury to the penis or bladder.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Change a physician order, and 2. Communicate the change in the dietary order to provide the dietary preferences for one of three sampled residents (Resident 33). This failure resulted in Resident 33's preferences to not be honored and had the potential to result in further weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store oxygen tubing per policy for two of four sampled residents (Resident 13 and Resident 31). This failure had the potential to result in respiratory infections.