Health inspection·February 9, 2026

F740 §483.40 Behavioral health services. Each resident must receive, and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders.

F689 §483.25(d) Accidents. The facility must ensure that - §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. On 9/4/25, an unannounced visit was conducted at the facility to investigate a facility reported incident and complaints regarding a resident (1) who committed suicide in the facility. Resident 1 is a 57-year-old male who was admitted to the facility on 2/11/16 with diagnoses of Paraplegia (partial loss of function on the lower body) and Major Depressive Disorder (mood disorder [mental health condition that primarily affects a person's emotional state] that causes a persistent feeling of sadness and loss of interest). Based on interview and record review, the facility failed to follow the policy and procedure (P&P) on Psychotherapeutic Drug (medication used to treat mental health disorders) Management for one of ten sampled residents (Resident 1) when: 1. Resident 1 was not provided non-pharmacological (without using medications) interventions when Resident 1 verbalized increased sadness. 2. Resident 1 was not monitored every shift for 72 hours after his Lexapro (antidepressant [medication that treat depression]) dosage was increased. 3. The facility failed to have a policy and procedure on doing rounds every two hours when one of ten sampled residents (Resident 1) was not checked for concerns or needs during rounds. These failures resulted in Resident 1 being found with several layers of clear tape (plastic) over his mouth, cloth (cotton fabric) around his neck and ankles, hands were tied together, a white string (multiple strands twisted together) was tied from his hands to his feet, and with no signs of life. Findings: During a review of Resident 1's "Admission Record (AR)," dated 9/4/25, the AR indicated, Resident 1 was admitted to the facility on 2/11/16. The AR indicated, "DIAGNOSIS. . . PARAPLEGIA, INCOMPLETE (partial loss of function on the lower body) . . . MAJOR DEPRESSIVE DISORDER (mood disorder [mental health condition that primarily affects a person's emotional state] that causes a persistent feeling of sadness and loss of interest)." During a review of Resident 1's "Quarterly Minimum Data Set (MDS - an assessment tool)," dated 8/21/25, the MDS indicated on section C (Brief Interview for Mental Status which has a scale with scores ranging from 0 to 15), Resident 1 had a score of 15 (which is the highest score and indicates the resident is cognitively intact [has sufficient mental capacity to think, learn, reason, and solve problems effectively]). The MDS indicated on section D (Mood), Resident 1 had no thoughts he would be better off dead, or of hurting himself in some way. The MDS indicated on section GG (Functional Abilities - capacity of an individual to perform tasks), Resident 1 had functional limitation in range of motion (limited ability to move a joint [part of the body where two or more bones meet to allow movement] that interferes with daily functioning) on both of his legs and was wheelchair bound (person requiring a wheelchair to get around). The MDS indicated, Resident 1 required set up or clean-up (resident completes the activity and staff assists only prior to or following the activity) assistance with lying to sitting on side of the bed, and chair or bed to chair transfer. The MDS indicated, Resident 1 required supervision or touching assistance with rolling left and right on bed and sitting to lying on the bed. The MDS indicated, Resident 1 was unable to stand and walk. During a review of Resident 1's "Documentation Survey Report (DSR - ADL [Activities of Daily Living - basic self-care tasks needed to live independently] flowsheet)," dated September 2025, the DSR indicated, on 9/1/25 night shift, CNA 1 documented Resident did not require assistance with lying to sitting on side of the bed, rolling left and right on bed, and sitting to lying on bed. During a review of Resident 1's "Care Plan (CP - personalized, written document that outlines an individual's specific health conditions, needs, goals, and preferences)," initiated and revised on 5/4/22, the CP indicated, "Problem. . . (Resident 1) prefers to get up late and stay in bed. . . Interventions (any treatment or action that staff perform to enhance resident outcomes) . . . Check with resident for concerns and needs during rounds, med (medication) pass, activities, room visit." The CP indicated, "Problem. . . [Resident 1] has history of unwanted sexual behaviors towards specific staff by exposing himself and touching himself in the presence of female staff. . . Interventions. . . Safety check during care (visualizing residents), rounds, med pass, room visit, activities." The CP indicated, "Problem. . . [Resident 1] has a DX [diagnosis] of Major Depressive Disorder m/b [manifested by] verbalized increased sadness on 8/28/2025. . . Interventions. . . Lexapro. . . Monitor AD [Antidepressant]: SIDE EFFECTS. . . Suicidal Ideations [thoughts of ending one's own life] . . . Monitor behavior m/b verbalization of sadness due to health related issues QS [every shift]." During a review of Resident 1's "Order Summary Report (OSR)," dated 9/4/25, the OSR indicated, "Lexapro Oral Tablet 20 mg (milligrams - unit of measurement) . . . Give 1 tablet by mouth one time a day for M/B verbalization of sadness due to health-related issues related to MAJOR DEPRESSIVE DISORDER. . . Order Date. . . 08/28/2025. . . Start Date. . . 08/29/2025." During a review of Resident 1's "Medication Administration Record (MAR)," dated August 2025, the MAR indicated, Resident 1 was administered Lexapro 15 mg once daily until 8/28/25 and was administered Lexapro 20 mg once daily starting on 8/29/25. The MAR indicated, Resident 1 was monitored for side effects of Lexapro (Dystonia [movement disorder causing the muscles to contract]: torticollis [stiffness of neck], Anti-cholinergic symptoms [dry mouth, blurred vision, constipation, urinary retention] Hypotension [low blood pressure], Sedation or drowsiness, Increased falls or dizziness [feeling faint or weak], Cardiac [referring to the heart] abnormalities, Anxiety [feeling of worry or nervousness] agitation [feeling of irritability], Blurred vision, Sweating/rashes, Headache, Urinary retention [unable to empty all the urine from the bladder] or hesitancy [difficulty urinating], Weakness, Appetite change or weight change, Insomnia [inability to sleep], Confusion, Tardive dyskinesia [Lip smacking or chewing, abnormal tongue movement, involuntary contraction of the arms or legs, rocking or swaying], Suicidal Ideations) every shift and there were no side effects noted for the month of August. The MAR indicated Resident 1 was monitored for episodes of verbalization of sadness and verbalization of nervousness every shift and there were no episodes noted for the month of August. During a review of Resident 1's "Psychiatric (relating to mental illness) Consult (PC)," dated 8/25/25, the PC indicated, Resident 1 was seen by the psychiatrist (medical practitioner specializing in the diagnosis and treatment of mental illness) with the Objective, "Verbal complaints of increased depression and anxiety due to decline in health and environment, keeps to self." Under the Assessment section of the PC, the psychiatrist indicated the resident was "unstable" and recommended to increase Resident 1's Lexapro to 20 mg daily. During a review of Resident 1's "Nurses Notes (NN)," documented by Licensed Vocational Nurse (LVN) 1, dated 9/2/25 indicated, "Notified by CNA (Certified Nursing Assistant) (3) at 0945 that resident (1) was unresponsive (does not respond to sound, touch, or pain). Responded to room resident (1) immediately. Resident (1) not breathing, no respirations (breathing), unresponsive to tactile stimuli (sensory input received through touch). Resident (1) had tape over his mouth and cloth around his neck and ankles. I noticed that his hands were tied together, and a string was tied from his hands to his feet. Called for assistance to room. Current code status (type of emergent treatment a person would or would not receive if their heart or breathing were to stop) DNR (Do Not Resuscitate). RN (Registered Nurse/Director of Nursing [DON]) assessed resident (1). No signs of life, no respirations, no pulse (regular beating of the heart that can be felt by touching certain parts of the body). Current code status DNR. BPD (Bakersfield Police Department) notified. MD (Medical Doctor) notified of resident status. Emergency contact notified. Nephew in Mexico notified of resident status. BPD and Emergency response onsite at 1008. Corners [sic] (an official who investigates violent, sudden, or suspicious deaths) arrived to pick up body at 1256." During a review of Resident 1's "Death Record (DR)," dated 9/2/25, the DR indicated, Resident 1's date and time of death was 9/2/25 at 9:58 a.m. During a review of Resident 1's "Summary of Incident (SI)," documented by Administrator, dated 9/4/25, the SI indicated, "On September 2, 2025, at approximately 9:45 AM, staff (CNA 3) discovered resident (1) unresponsive in his bed. Emergency response protocols were initiated, and 911 (emergency response number) was called. Law enforcement and the coroner's office responded. The coroner ruled the death a suicide (act of intentionally causing one's own death), pending autopsy (medical examination of a body after death to determine the cause of death) results." During a review of Resident 1's "County of Kern Certificate of Death (CKCD)," dated 9/2/25, the CKCD indicated Resident 1's immediate cause of death was "Neck Compressions (occurs when a mechanical force [push or pull that results from the direct physical interaction of objects] was applied to the front or around the neck)." During an interview on 9/4/25 at 3:58 p.m. with DON, DON stated Director of Staff Development (DSD) called her into Resident 1's room on 9/2/25 at around 9:45 a.m. DON stated she saw Resident 1 in bed bound by his wrist, had a tape on his mouth, his face was swollen and had a cloth around his neck. DON stated she removed the tape (DON stated it was a white tape that may have been more than one piece, enough to cover his whole mouth) on Resident 1's mouth and he had gauze inside his mouth, he was not breathing. DON stated she loosened the cloth around Resident 1's neck, and Resident 1 was still not breathing. DON stated the cloth around Resident 1's neck looked like "some type of cut up blanket." DON stated facility staff called 911, and BPD and the homicide team (unit in a police department that investigates deaths) came. During an interview on 9/10/25 at 2:10 p.m. with Treatment Nurse (TN) 1, TN 1 stated the tape on Resident 1's mouth on 9/2/25 was a surgical tape (medical adhesive tape used to attach bandages, gauze, and other dressings to the skin around wounds) but it was thicker, and the facility did not have this kind of tape. TN 1 stated on 9/2/25, Resident 1's both hands and feet were tied with white cloth that looked like a "rolled up sheet." During an interview on 9/10/25 at 2:21 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was the nurse assigned to Resident 1 on 9/2/25 morning shift (6 a.m. to 2 p.m.). LVN 1 stated on 9/2/25, she did her rounds at the beginning of her shift at around 7 a.m. and saw Resident 1 covered with a thick multicolored (blue, green, and red) blanket over his head. LVN 1 stated she did not see anything unusual. LVN 1 stated Resident 1 would normally sleep with his blanket over his head, so LVN 1 assumed Resident 1 was "okay". LVN 1 stated CNA 3 (first person to see Resident 1 on 9/2/25) would normally greet Resident 1 in the morning and when CNA 3 went to Resident 1's room on 9/2/25, CNA 3 found Resident 1 unresponsive at around 9:40 a.m. LVN 1 stated she was called into Resident 1's room and LVN 1 saw Resident 1 with a tape on his mouth (LVN 1 stated it was a clear tape that was about half an inch with a material thinner than a surgical tape), both hands were tied together with a white string that was tied down to his ankles, and both ankles were also tied together. LVN 1 stated Resident 1's blanket had holes at the end with a string tied up to the bed frame at the foot of the bed. LVN 1 stated there was also a white cloth tied around his neck. LVN 1 stated Resident 1 had a white string ("thicker than yarn" with the same thickness of a shoestring) used to tie his hands and feet. LVN 1 stated CNA 2 was the CNA assigned to Resident 1 on 9/2/25 morning shift. LVN 1 stated according to facility policy, the CNAs should do their rounds every two hours to look at the residents and to see if they need any assistance. During an interview on 9/11/25 at 9:50 a.m. with CNA 3, CNA 3 stated she was not the CNA assigned to Resident 1 on 9/2/25 morning shift (6 a.m. to 2 p.m.). CNA 3 stated she went to Resident 1's room on 9/2/25 at around 9:45 a.m. to greet Resident 1. CNA 3 stated, "I see his bed all the way up. He was covered with his blanket. It was so tucked in under his head, arms, legs, body." CNA 3 stated when she tapped Resident 1's right leg, his right leg was hard, and Resident 1 did not respond. CNA 3 stated she had to pull the blanket down hard until his neck area and she saw Resident 1 had tape on his mouth. CNA 3 stated she notified staffing coordinator (SC). CNA 3 stated SC and her pulled Resident 1's blanket lower to Resident 1's feet and saw his hands and ankles were tied up. CNA 3 stated SC called the nurses, DON, and Administrator to come to Resident 1's room. CNA 3 stated when she was assigned to Resident 1, usually every morning Resident 1 would be covered with his blanket up to his head but would move his head when asked if he was "okay". CNA 3 stated Resident 1 would usually lay on his left side but on 9/2/25 she saw Resident 1 lying on his back with his blanket tucked under his body "like a mummy (preserved dead body wrapped in bandages)." During an interview on 9/12/25 at 9:52 a.m. with LVN 2, LVN 2 stated he was the nurse assigned to Resident 1 on 9/1/25 night shift (11 p.m. to 7:30 a.m.). LVN 2 stated the last time he saw Resident 1 alive was on 9/2/25 at 1:30 a.m. when Resident 1 pressed his call light and asked for his urinal to be emptied. LVN 2 stated he called CNA 1 to Resident 1's room to provide Resident 1 with assistance. LVN 2 stated he never saw Resident 1 again after 1:30 a.m. on 9/2/25. LVN 2 stated during change of shift at around 7 a.m., the facility's routine was to do rounds (every change of shift) but not necessarily checking on each resident because the nurses know Resident 1 "very well." LVN 2 stated he was aware Resident 1 was taking antidepressants and Resident 1 was being monitored for side effects of antidepressants including suicidal ideation. LVN 2 stated Resident 1 was a well-known resident with no issues, and they would not look at this kind of resident during change of shift rounds. LVN 2 stated he relied on the CNAs to tell him if there was something unusual about the residents because the CNAs were expected to do their rounds every two hours. LVN 2 stated he was not sure if CNA 1 did her rounds every two hours on 9/1/25 night shift. During an interview on 9/16/25