Inspection citations
11’21
5’23
42’24
31’25
2’26
91 shown
| Date | Severity | What inspectors found | Visit |
|---|---|---|---|
| Apr 29, 2026 | D · potential | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Complaint |
| Apr 29, 2026 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Jul 28, 2025 | D · potential | Ensure that residents are fully informed and understand their health status, care and treatments. | Complaint |
| Jul 28, 2025 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Complaint |
| Jul 28, 2025 | D · potential | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Complaint |
| Jul 28, 2025 | D · potential | Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Complaint |
| May 16, 2025 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| May 15, 2025 | D · potential | Ensure that residents are fully informed and understand their health status, care and treatments. | Complaint |
| May 15, 2025 | D · potential | Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Complaint |
| Apr 24, 2025 | F · potential | Ensure that residents are fully informed and understand their health status, care and treatments. | Routine |
| Apr 24, 2025 | D · potential | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Routine |
| Apr 24, 2025 | D · potential | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Routine |
| Apr 24, 2025 | D · potential | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Routine |
| Apr 24, 2025 | E · potential | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Routine |
| Apr 24, 2025 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Routine |
| Apr 24, 2025 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Routine |
| Apr 24, 2025 | D · potential | Provide care and assistance to perform activities of daily living for any resident who is unable. | Routine |
| Apr 24, 2025 | D · potential | Provide activities to meet all resident's needs. | Routine |
| Apr 24, 2025 | D · potential | Provide appropriate foot care. | Routine |
| Apr 24, 2025 | D · potential | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Routine |
| Apr 24, 2025 | D · potential | Provide safe, appropriate dialysis care/services for a resident who requires such services. | Routine |
| Apr 24, 2025 | F · potential | Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Routine |
| Apr 24, 2025 | E · potential | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Routine |
| Apr 24, 2025 | D · potential | Provide routine and 24-hour emergency dental care for each resident. | Routine |
| Apr 24, 2025 | D · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Routine |
| Apr 24, 2025 | D · potential | Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Routine |
| Apr 24, 2025 | E · potential | Hire a qualified full-time social worker in a facility with more than 120 beds. | Routine |
| Apr 24, 2025 | E · potential | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Routine |
| Apr 24, 2025 | E · potential | Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Routine |
| Apr 24, 2025 | F · potential | Provide and implement an infection prevention and control program. | Routine |
| Apr 24, 2025 | F · potential | Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Routine |
| Feb 25, 2025 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Feb 25, 2025 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Complaint |
| Dec 31, 2024 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Dec 9, 2024 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Dec 5, 2024 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| Sep 5, 2024 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| Aug 22, 2024 | D · potential | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Complaint |
| Aug 22, 2024 | D · potential | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Complaint |
| Aug 22, 2024 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Complaint |
| Aug 22, 2024 | D · potential | Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Complaint |
| Aug 2, 2024 | D · potential | Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Complaint |
| Jul 31, 2024 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Complaint |
| Jul 23, 2024 | D · potential | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Complaint |
| Jul 23, 2024 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| Jul 23, 2024 | D · potential | Provide safe, appropriate dialysis care/services for a resident who requires such services. | Complaint |
| Jul 16, 2024 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Jul 9, 2024 | D · potential | Reasonably accommodate the needs and preferences of each resident. | Complaint |
| Jun 28, 2024 | D · potential | Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Complaint |
| Jun 25, 2024 | D · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Complaint |
| May 16, 2024 | D · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Complaint |
| May 16, 2024 | D · potential | Allow residents to self-administer drugs if determined clinically appropriate. | Complaint |
| May 16, 2024 | D · potential | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Complaint |
| May 16, 2024 | D · potential | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Complaint |
| May 16, 2024 | D · potential | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Complaint |
| May 16, 2024 | D · potential | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Complaint |
| May 16, 2024 | D · potential | PASARR screening for Mental disorders or Intellectual Disabilities | Complaint |
| May 16, 2024 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| May 16, 2024 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Complaint |
| May 16, 2024 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| May 16, 2024 | D · potential | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Complaint |
| May 16, 2024 | E · potential | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Complaint |
| May 16, 2024 | D · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Complaint |
| May 16, 2024 | D · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Complaint |
| May 16, 2024 | D · potential | Provide and implement an infection prevention and control program. | Complaint |
| Apr 16, 2024 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Complaint |
| Apr 9, 2024 | D · potential | Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. | Complaint |
| Mar 17, 2024 | D · potential | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Complaint |
| Feb 26, 2024 | D · potential | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Complaint |
| Feb 8, 2024 | D · potential | Reasonably accommodate the needs and preferences of each resident. | Complaint |
| Feb 8, 2024 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Complaint |
| Feb 8, 2024 | D · potential | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Complaint |
| Feb 8, 2024 | D · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Complaint |
| Jan 10, 2024 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| Jan 5, 2024 | F · potential | Employ staff that are licensed, certified, or registered in accordance with state laws. | Complaint |
| Dec 7, 2023 | G · harm | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Dec 7, 2023 | E · potential | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Complaint |
| Dec 7, 2023 | E · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| Dec 7, 2023 | D · potential | Respond appropriately to all alleged violations. | Complaint |
| Dec 7, 2023 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| May 13, 2021 | D · potential | Allow residents to self-administer drugs if determined clinically appropriate. | Routine |
| May 13, 2021 | D · potential | Reasonably accommodate the needs and preferences of each resident. | Routine |
| May 13, 2021 | D · potential | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Routine |
| May 13, 2021 | E · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Routine |
| May 13, 2021 | D · potential | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Routine |
| May 13, 2021 | E · potential | Provide enough food/fluids to maintain a resident's health. | Routine |
| May 13, 2021 | D · potential | Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Routine |
| May 13, 2021 | E · potential | Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Routine |
| May 13, 2021 | D · potential | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Routine |
| May 13, 2021 | E · potential | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Routine |
| May 13, 2021 | E · potential | Provide and implement an infection prevention and control program. | Routine |
Medicare's severity letters: A–C minimal harm, D–F potential for more than minimal harm, G–L actual harm or immediate danger. Source: CMS health deficiencies file, processed October 1, 2026.
Questions to ask on a visit
Kern River Transitional Care
5151 Knudsen Drive, Bakersfield, CA 93308 · (661) 325-9900
Visit date: ____________ Spoke with: ______________________
Record on file
- Certification
- Medicare and Medi-Cal certified skilled nursing facility
- Medicare number (CCN)
- 555912
- Certified beds
- 140
- Legal owner
- Bakersfieldidence Opco LLC
- Part of
- Pacs Group
Full profile on Medicare's Care Compare. Source: CMS, processed October 1, 2026.
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