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Bakersfield Post Acute

For profit - Limited Liability company  ·  6212 Tudor Way, Bakersfield, CA 93306  ·  See home’s Medicare page

Affiliated With Windsor
People or companies with an ownership interest in or managerial control of this home, according to CMS data.
3.57
Nurse hours/resident/day
Reported total nurse staffing hours per resident per day.
State Average: 4.4
59.2%
Nurse turnover
The percentage of nursing staff who stopped working at the home over a 12-month period.
State Average: 45.7%
99
Certified beds
Qualifying beds in the certified provider or supplier facility.
93
Average residents/day
Average number of residents based on daily census.
Direct owners are the layer of ownership closest to the nursing home while indirect owners have a stake in the nursing home but are further removed, like a company that owns the direct owner of a home. All owners listed below are people or companies who have at least a 5% stake in the nursing home. Entities with “managerial control” are those who conduct the day-to-day operations of the nursing home.
Direct owners
Windsor Omg Holding Company Ii, Llc (100%)
Indirect owners
Lsf Investments I, Llc
Survivors Trust Under The Samson Family Trust
The C&D Non Exempt Trust
The Eclc Non Exemp Trust
The Lawrence And Simi Feigen Family Trust
Esther Beilis
Chaim Feigen
Lawrence Feigen
Donny Feldman
Lee Samson
Managerial control
S&F Management Company Llc since Apr, 2017
Lawrence Feigen since Apr, 2017
Donny Feldman since Apr, 2017
Lee Samson since Apr, 2017
Managing employee(s)
Gloria Melliti since Apr, 2017

Inspection Reports

78

total deficiencies

4

infection-related deficiencies

This home violated federal standards protecting residents from the spread of infections.

Inspection reports document deficiencies, which are nursing homes’ failures to meet care requirements. The Centers for Medicare and Medicaid Services releases the last three standard inspection reports, as well as the last 36 months of complaint and infection-control reports.
Dec 7, 2023
Complaint report
1 deficiency
E

Nursing and Physician Services Deficiency — F0725
Failure to: Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Nov 7, 2023
Complaint report
5 deficiencies
D

Resident Rights Deficiency — F0558
Failure to: Reasonably accommodate the needs and preferences of each resident.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Resident Rights Deficiency — F0585
Failure to: 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.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Resident Assessment and Care Planning Deficiency — F0656
Failure to: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Resident Assessment and Care Planning Deficiency — F0658
Failure to: Ensure services provided by the nursing facility meet professional standards of quality.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Resident Assessment and Care Planning Deficiency — F0842
Failure to: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Oct 26, 2023
Complaint report
1 deficiency
G

Resident Assessment and Care Planning Deficiency — F0656
Failure to: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Severity
Actual harm that is not immediate jeopardy
Scope
Few people affected
Seriousness
G

Sep 27, 2023
Complaint report
2 deficiencies
D

to E
E

Quality of Life and Care Deficiency — F0677
Failure to: Provide care and assistance to perform activities of daily living for any resident who is unable.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Quality of Life and Care Deficiency — F0688
Failure to: 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.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Aug 24, 2023
Complaint report
5 deficiencies
D

to F
F

Nursing and Physician Services Deficiency — F0725
Failure to: Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Many people affected
Seriousness
F

Nursing and Physician Services Deficiency — F0732
Failure to: Post nurse staffing information every day.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Many people affected
Seriousness
F

Resident Assessment and Care Planning Deficiency — F0658
Failure to: Ensure services provided by the nursing facility meet professional standards of quality.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Quality of Life and Care Deficiency — F0697
Failure to: Provide safe, appropriate pain management for a resident who requires such services.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Resident Assessment and Care Planning Deficiency — F0842
Failure to: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Aug 9, 2023
Complaint report
1 deficiency
D

Quality of Life and Care Deficiency — F0684
Failure to: Provide appropriate treatment and care according to orders, resident's preferences and goals.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

May 17, 2023
Complaint report
2 deficiencies
D

Quality of Life and Care Deficiency — F0684
Failure to: Provide appropriate treatment and care according to orders, resident's preferences and goals.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Resident Assessment and Care Planning Deficiency — F0842
Failure to: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

May 15, 2023
Complaint report
1 deficiency
D

Quality of Life and Care Deficiency — F0689
Failure to: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

May 4, 2023
Complaint report
1 deficiency
D

Freedom from Abuse, Neglect, and Exploitation Deficiency — F0609
Failure to: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Mar 2, 2023
Standard report
21 deficiencies
(1 infection)

This report includes a citation for violating federal standards protecting residents from the spread of infections.

$5,000 Fine
D

to F
F

Nutrition and Dietary Deficiency — F0801
Failure to: Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Many people affected
Seriousness
F

Freedom from Abuse, Neglect, and Exploitation Deficiency — F0943
Failure to: Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Many people affected
Seriousness
F

Resident Rights Deficiency — F0558
Failure to: Reasonably accommodate the needs and preferences of each resident.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Resident Rights Deficiency — F0578
Failure to: Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Quality of Life and Care Deficiency — F0677
Failure to: Provide care and assistance to perform activities of daily living for any resident who is unable.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Quality of Life and Care Deficiency — F0684
Failure to: Provide appropriate treatment and care according to orders, resident's preferences and goals.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Quality of Life and Care Deficiency — F0688
Failure to: 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.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Quality of Life and Care Deficiency — F0698
Failure to: Provide safe, appropriate dialysis care/services for a resident who requires such services.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Nursing and Physician Services Deficiency — F0725
Failure to: Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Nursing and Physician Services Deficiency — F0726
Failure to: 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.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Pharmacy Service Deficiency — F0759
Failure to: Ensure medication error rates are not 5 percent or greater.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Pharmacy Service Deficiency — F0761
Failure to: 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.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Nutrition and Dietary Deficiency — F0804
Failure to: Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Nutrition and Dietary Deficiency — F0805
Failure to: Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Nutrition and Dietary Deficiency — F0807
Failure to: Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Infection Control Deficiency — F0880
Failure to: Provide and implement an infection prevention and control program.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Environmental Deficiency — F0921
Failure to: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Resident Rights Deficiency — F0567
Failure to: Honor the resident's right to manage his or her financial affairs.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Resident Rights Deficiency — F0623
Failure to: Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Resident Assessment and Care Planning Deficiency — F0641
Failure to: Ensure each resident receives an accurate assessment.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Resident Assessment and Care Planning Deficiency — F0657
Failure to: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Jan 25, 2023
Complaint report
1 deficiency
(1 infection)

This report includes a citation for violating federal standards protecting residents from the spread of infections.

E

Infection Control Deficiency — F0880
Failure to: Provide and implement an infection prevention and control program.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Dec 16, 2022
Complaint report
1 deficiency
D

Resident Assessment and Care Planning Deficiency — F0658
Failure to: Ensure services provided by the nursing facility meet professional standards of quality.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Sep 13, 2022
Complaint report
3 deficiencies
D

Resident Assessment and Care Planning Deficiency — F0655
Failure to: Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Resident Assessment and Care Planning Deficiency — F0656
Failure to: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Quality of Life and Care Deficiency — F0697
Failure to: Provide safe, appropriate pain management for a resident who requires such services.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Aug 9, 2022
Complaint report
1 deficiency
D

Resident Assessment and Care Planning Deficiency — F0658
Failure to: Ensure services provided by the nursing facility meet professional standards of quality.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Jul 15, 2022
Complaint report
1 deficiency
D

Resident Rights Deficiency — F0580
Failure to: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Apr 14, 2022
Complaint report
2 deficiencies
D

Resident Assessment and Care Planning Deficiency — F0656
Failure to: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Resident Assessment and Care Planning Deficiency — F0658
Failure to: Ensure services provided by the nursing facility meet professional standards of quality.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Apr 13, 2022
Complaint report
1 deficiency
D

Resident Rights Deficiency — F0585
Failure to: 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.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Mar 17, 2022
Complaint report
2 deficiencies
D

Quality of Life and Care Deficiency — F0684
Failure to: Provide appropriate treatment and care according to orders, resident's preferences and goals.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Quality of Life and Care Deficiency — F0686
Failure to: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Mar 16, 2022
Complaint report
1 deficiency
D

Pharmacy Service Deficiency — F0755
Failure to: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Mar 15, 2022
Complaint report
1 deficiency
D

Quality of Life and Care Deficiency — F0677
Failure to: Provide care and assistance to perform activities of daily living for any resident who is unable.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Feb 23, 2022
Complaint report
1 deficiency
$35,734 Fine
G

Quality of Life and Care Deficiency — F0689
Failure to: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity
Actual harm that is not immediate jeopardy
Scope
Few people affected
Seriousness
G

Dec 20, 2021
Complaint report
1 deficiency
D

Resident Assessment and Care Planning Deficiency — F0658
Failure to: Ensure services provided by the nursing facility meet professional standards of quality.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Jul 19, 2021
Complaint report
1 deficiency
D

Resident Rights Deficiency — F0626
Failure to: Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Dec 12, 2019
Standard report
12 deficiencies
(1 infection)

This report includes a citation for violating federal standards protecting residents from the spread of infections.

D

to E
E

Nursing and Physician Services Deficiency — F0732
Failure to: Post nurse staffing information every day.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Nutrition and Dietary Deficiency — F0803
Failure to: Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Nutrition and Dietary Deficiency — F0812
Failure to: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Infection Control Deficiency — F0880
Failure to: Provide and implement an infection prevention and control program.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Environmental Deficiency — F0908
Failure to: Keep all essential equipment working safely.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Resident Rights Deficiency — F0550
Failure to: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Resident Assessment and Care Planning Deficiency — F0655
Failure to: Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Resident Assessment and Care Planning Deficiency — F0656
Failure to: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Resident Assessment and Care Planning Deficiency — F0658
Failure to: Ensure services provided by the nursing facility meet professional standards of quality.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Quality of Life and Care Deficiency — F0692
Failure to: Provide enough food/fluids to maintain a resident's health.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Nutrition and Dietary Deficiency — F0806
Failure to: Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Nutrition and Dietary Deficiency — F0807
Failure to: Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Jan 18, 2019
Standard report
9 deficiencies
(1 infection)

This report includes a citation for violating federal standards protecting residents from the spread of infections.

D

to F
F

Nutrition and Dietary Deficiency — F0812
Failure to: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Many people affected
Seriousness
F

Infection Control Deficiency — F0880
Failure to: Provide and implement an infection prevention and control program.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Many people affected
Seriousness
F

Environmental Deficiency — F0921
Failure to: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Many people affected
Seriousness
F

Pharmacy Service Deficiency — F0761
Failure to: 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.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Resident Rights Deficiency — F0553
Failure to: Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Resident Assessment and Care Planning Deficiency — F0655
Failure to: Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Resident Assessment and Care Planning Deficiency — F0657
Failure to: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Quality of Life and Care Deficiency — F0698
Failure to: Provide safe, appropriate dialysis care/services for a resident who requires such services.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Nutrition and Dietary Deficiency — F0803
Failure to: Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Penalties

$41.4K

total fines

A nursing home receives a penalty, either a fine or payment suspensions, when it has a serious health citation or fails to fix a citation. Fines may be imposed once per citation or regularly until the nursing home corrects the citation. Fines not associated with inspection reports can include fines for not reporting COVID-19 data or not complying with infection-control requirements. Payment suspensions are when the government stops payments to the nursing home until an issue is fixed. The Centers for Medicare and Medicaid Services releases the last three years of penalty information.
Mar 2, 2023
Feb 23, 2022
Aug 16, 2021
$655 fine
No corresponding inspection report.