Both the State of California and the Centers for Medicare and Medicaid Services (CMS) conduct routine investigations, surveys and inspections of every nursing facility statewide. The results of their inspections often help identify serious safety concerns, health violations, and deficiencies. When the Center is found to be deficient and violating state and federal nursing home regulations, they are required to make prompt changes to the level of care they provide residents and revise their policies and procedures that reflect compliance with the law.
Unfortunately, some nursing home facilities are unwilling or unable to make necessary corrections and changes. In these cases, nursing home regulators will designate the Center a Special Focus Facility (SFF) and add the Home to the federal Medicare watch list. Additionally, the nursing facility must undergo many more inspections than normal. If the nursing home remains out of compliance, the owners can be forced to sell their operation to another company in good standing or lose their contract with Medicare and Medicaid to provide services to federally-funded patients.
In 2015, state and federal nursing home regulators designated Bakersfield Healthcare Center a Special Focus Facility and placed the Home on the national Medicare watch list. Since then, the facility has shown some improvement in the level of care they provide and the enforcement of acceptable policies and procedures. Some serious violations and deficiencies involving this facility are listed below.
This Facility is a “for-profit” Center providing cares and services to the residents of Bakersfield and Kern County, California. The 150-certified bed Long-Term Care Home is located at:
730 34th St.
Bakersfield, CA 93301
(661) 327-7687
In addition to providing around-the-clock skilled nursing care, the facility also offers memory care, rehabilitation, independent living, system living, Montessori memory care, and short-term stays.
The federal and state government gives Medicare and Medicaid regulators the authority to issue monetary penalties against any nursing facility identify with serious deficiencies and violations. Within the last three years, Bakersfield Healthcare Center has received more than $100,000 in monetary penalties including a $66,300 fine on March 2, 2015, and a $35,700 fine on January 25, 2016.
During that same time, Medicare refused a request for payment from the facility due to identified substandard care. These denials came on March 2, 2015, January 25, 2016, and May 5, 2016. Also, there were 18 filed formal complaints during the same time that resulted in citations and 18 facility-reported issues that resulted in citations.
Potential residents and family members of any nursing facility in the United States can find publicly available information on incident inquiries, dangerous hazards, filed complaints, health violations, safety concerns, and opened investigations at Medicare.gov. This website also offers a star rating summary system to quickly identify nursing facilities in the local community that provide the worst and best care.
Currently, Bakersfield Healthcare Center maintains an overall below average two out of five stars ranking compared to all other facilities nationwide. This ranking includes one out of five stars for health inspections, four out of five stars for staffing, and two out of five stars for quality measures. Some of the serious violations, health concerns and deficiencies involving this facility are listed below.
Failure to Provide a Safe Environment and Accurately Assess the Resident’s Needs by Qualified Health Professional
In a summary statement of deficiencies dated February 6, 2017, the state investigator noted the facility had failed to “re-assess [a female resident’s] ability to smoke independently, which resulted in [the resident] catching on fire while smoking and then being transferred to a hospital for severe burns.” The resident’s Admission Record dated March 6, 2014, reveals that the female resident has a medical condition that “frequently affects the feet and hands causing weakness, loss of sensation, pins and needles sensations or burning pain, [along with a] nicotine dependents.”
A review of the resident’s January 8, 2017, at 10:14 AM Change of Condition reveal that the resident “was smoking outside when [a Certified Nursing Assistant (CNA)] heard the resident yell for help.” The CNA “was with another patient in their room and saw the resident catch on fire through the patio door [and] entered the patio door immediately to help the resident while yelling for help.”
A Licensed Nurse responded to the CNA’s “yells and helped put the fire out while [another Certified Nursing Assistant] help remove the patient clothes.” The patient stated that “sparks of her cigarette were blown by the wind on her sweater causing the fire. 911 was called, and the Fire Department and ambulance responded [and transported] the patient to the local acute hospital burn unit.”
The investigator interviewed the second Certified Nursing Assistant who stated that “on Sunday, January 8, 2017, at approximately 10:00 PM, she was in the hallway when she heard a loud voice yelling for help.” That CNA responded and went to the outside smoking patio and saw the fire on [the resident’s] jacket.” The CNA stated that “it’s so bad; is like you see in the movie.”
To help the resident, the Certified Nursing Assistant began taking the resident’s “jacket off the resident’s right arm; the fire moved to the left arm. While another Licensed Nurse was reaching over from the resident’s back and was also helping and removing [the resident’s] jacket.” However, that nurse “realized that the fire was so bad [they] took the water hose and put out the fire.”
That Certified Nursing Assistant said that the resident “was smoking independently, but she always felt [that resident] needed supervision when smoking.” There was a concern “because [the resident] was paralyzed on the left side of her body [and that the resident] smoked in the smoking patio all day long (every day) and was [responsible for] keeping her …cigarettes and lighters.”
Failure to Ensure That Residents with Reduced Range of Motion Are Provided Proper Treatment and Services to Increase the Range of Motion
In a summary statement of deficiencies dated August 10, 2017, the state investigator noted the facility’s failure “to implement an intervention for [one resident] with contractures. This [deficiency] had the potential to result in further limitations in range of motion for [the] resident.”
Observation of the resident was made on the morning of August 7, 2017, while the resident “was awake and seated in a wheelchair. Her lower extremities were covered from her lap down her feet with a blanket.” A Certified Nursing Assistant (CNA) providing her care “lifted the blanket and found [the resident’s] knees flexed and her feet behind a Velcro leg rest support. Her feet were also not on the footrest [but] resting on the floor.” The CNA stated that the resident’s “feet should always be on the wheelchair’s footrest and in front of the leg rest support.”
The following morning at 8:10 AM, an observation was made of the resident with a different Certified Nursing Assistant while a resident was “seated in her wheelchair and her feet were [strapped] on the Velcro leg support.” That CNA “stated that she was not informed or trained [how] to apply the Velcro leg rest support on the resident’s wheelchair.
The investigator interviewed the facility’s RNA (Restorative Nursing Assistant) that same morning at 10:20 AM. The RNA stated that Restorative Nursing Assistants providing care at the facility “were providing exercises to [the resident] for both lower extremities daily [and] stated she was not informed [how] to apply the Velcro leg rest support on the resident’s wheelchair.”
The investigator reviewed the resident’s Clinical Record, specifically the Joint Mobility Assessment that indicated that the resident “had moderate limitations of movement on the right and left knees.” The physician’s orders and physical therapy note indicated “the use of bilateral leg rests with support to control knee flexion response and sitting.” The investigator noted that there “was no documented evidence in [the resident’s] Restorative Nursing Record or Restorative Treatment Plan for the use of a Velcro leg support.
Failure to Ensure a Resident’s Drug Regimen Is Free from Unnecessary Medications
In a summary statement of deficiencies dated August 10, 2017, the state investigator noted the facility’s failure “to monitor and document behavior for [one resident receiving antidepressant medications].” The deficiency by the nursing staff “had the potential to result in the administration of unnecessary medications, provide the physician with incorrect information, and potential to adversely affect the resident’s well-being.”
As a part of the findings, the state investigator interviewed the resident on August 7, 2017, who “was in her room, she was in bed awake with the head slightly elevated.” The resident stated that “she was transferred to the hospital a month ago because of internal bleeding (G.I.; gastrointestinal). [The resident also stated] she is worried about her medical condition.”
The state investigator interviewed the facility’s Licensed Vocational Nurse (LVN) on the morning of August 9, 2017, who was providing the resident care. The LVN stated that “he was not monitoring [the resident’s] behaviors, but he would ask the resident how she had felt during [the medication administration] times.” The Licensed Vocational Nurse also stated that “they were not using non-pharmacological behavior intervention for [this resident].”
A review of the resident’s June 18, 2017, Depression Care Plan indicated that “staff was to monitor mood and behaviors to evaluate the effectiveness of interventions. There is no documentation information and [the resident’s] clinical record (Medication Administration Record), and her behavior for depression was monitored from June 2017 to August 8, 2017.”
However, the investigator noticed that “there was also …documented information in [the resident’s] clinical record that non-pharmacological behavior interventions were implemented.” As a part of the investigation, the Register Nurse Supervisor was informed on August 10, 2017, that the resident’s “behavior was not monitored by staff from June 2017 through August 8, 2017.”
The facility was reminded of their Behavior Management and Documentation policy and procedure that reads in part:
“Licensed nursing staff shall assess the behavioral symptoms to determine possible causal factors and implement non-drug interventions to attempt to alleviate the symptoms prior to initiating psychotherapeutic agents. Residents with prescribed psychotherapeutic agents will have behaviors monitored and documented every shift in the Medication Administration Record…”
Failure to Review or Revise a Resident’s Care Plan after a Major Change Has Occurred in Their Physical or Mental Health
In a summary statement of deficiencies dated August 10, 2017, the state investigator noted the facility’s failure “to do a reassessment for [one resident for] a significant change in the status of locomotion in activities of daily living. This [deficiency] had the potential to result in unmet care needs.”
A resident was observed on the morning of August 7, 2017, who “was in her room… awake [and] lying flat in bed.” The resident “stated she could go to the bathroom by herself with some minimal help from the staff.” The investigator interviewed a Certified Nursing Assistant (CNA) that same morning. The CNA stated that the resident “had improved from her abilities to do things for herself [and] required extensive to total assistance in most areas of her activities of daily living (ADL) [when admitted on April 8, 2017].” The CNA stated that the resident “could do things for herself independently now with minimal assistance.”
The investigator reviewed the resident’s MDS (Minimum Data Set and Quarterly Assessment that identified the resident as having “an improvement in transfers, locomotion on and off the unit, dressing, personal hygiene, and bathing.” Because of that, the investigator interviewed the Minimum Data Set Coordinator on the afternoon of August 7, 2017, who stated that she “reviewed the clinical record for [the resident] and was unable to locate a significant change of condition assessment.”
The facility was reminded of their Long-term Care Facility Resident Assessment Instrument User’s Manual involving the Significant Change in Status Assessment that reads in part:
If you been injured, abused, mistreated or neglected at the Bakersfield Healthcare Center, or any other nursing facility in California, you might want to file a nursing home neglect compensation claim. Contact us today! An attorney working on your behalf can file all the necessary documentation in the right courthouse before the California statute of limitations expires.
Most personal injury attorneys who handle wrongful death lawsuits and nursing home neglect cases will postpone accepting payment for their services until the case is resolved through a contingency fee arrangement. This agreement allows you to have immediate legal representation so your lawyer can build your case, file the paperwork, negotiate a settlement, and present evidence in front of judge and jury in a neglect or abuse lawsuit if necessary.
For more information on nursing home negligence lawsuits in California, please visit the pages below:
Attorney Anthony Lanzone
Licensed in California
Kern County Nursing Home Injury Attorney Nursing Home Law Center LLC Home