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Operation Guardians Reports

Bakersfield Healthcare Center – Bakersfield


“The chaos in facility operation was apparent…The number of residents transferred to acute care hospitals are excessive, likely because of the deficient nursing care in many instances.” Inspectors noticed an extremely foul odor in a resident’s room. A CNA was asked whether the resident’s diaper possibly needed to be changed. The CNA assured staff that the resident would inform her when toileting was required. When the resident was turned on her side, inspectors observed liquid fecal matter in the diaper and on the bed that apparently had been stagnant for “some time.” A resident speaking anonymously admitted that staff members refuse to change her diaper at night because “there are not enough diapers to fit her.”

Inspectors also observed that the amount of water a resident was to ingest daily via feeding tube had been cut in half a month prior to the inspection date by the staff dietician. The order had no apparent medical purpose and ultimately the resident suffered severe dehydration requiring hospitalization.

In addition, the physician notes in patient charts at this facility are either “illegible, devoid of any meaningful information, or both.” Both the male and female shower rooms contain fecal matter on the floors and shower chairs. “Overall, the condition of the building was deplorable.”