Health inspection·November 4, 2025

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Actual harm Based on interview and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 1 obtained complete vital signs (heart rate, temperature, respiration [breathing] rate, and blood pressure [force of blood on the walls of the blood vessels as the heart pumps blood around the body] that indicate a person's essential body functions) for one of three sampled residents (Resident 1) when Certified Nursing Assistant (CNA) 1 was unable to obtain viable vital signs after four attempts. This failure resulted in delay in care and resulted in Resident 1 being found unresponsive (medical emergency in which a patient does not respond to activity, touch, sound, other stimulation).Findings:During a review of Resident 1's admission Record (AR), dated 11/6/25, the AR indicated Resident 1 had diagnoses of Essential (Primary) Hypertension (elevated blood pressure, normal blood pressure is less than 120/80 mmHg [millimeters of mercury - measures the force of blood against the blood vessel]), and Atherosclerotic Heart Disease of Native Coronary Artery (build-up of fat inside the native coronary artery [original, natural blood vessel that supplies oxygen-rich blood to the heart muscle]) without Angina Pectoris (chest pain). The AR indicated, Resident 1 was DNR [Do not Resuscitate - healthcare providers will not perform Cardiopulmonary Resuscitation (chest compressions) or other life-saving measures if a patient's breathing or hear stops].During a review of Resident 1's Care Plan (CP), dated 7/20/24, the CP indicated, Focus. The resident has coronary artery disease [a condition where plaque buildup narrows or blocks blood vessels supplying oxygen-rich blood to the heart] . Interventions. Monitor blood pressure. Notify physician of any abnormal readings.During a review of the facility's Vital Sign Tower Preventative Maintenance (VSTPM quarterly [every three months] inspection log), dated 10/17/25, the VSTPM indicated, the facility's vitals machine towers were last inspected on 10/17/25.During a review of Resident 1's Alert Note (AN), dated 10/17/25, the AN indicated, 7:15 [10/17/25] pm resident [1] was found unresponsive [not responding to verbal, touch, or pain] in bed. DON [Director of Nursing] and MD [Medical Doctor] notified. Family notified [LVN 1 notified the DON, MD, and Resident 1's family].During a review of Resident 1's Weights and Vitals Summary (WVS), (This document is used by CNAs to document the vital signs of the residents) dated 1/23/26, the WVS indicated, Resident 1's last vital signs were taken on 10/10/25.During an interview on 11/4/25 at 2:47 p.m. with CNA 1, CNA 1 stated on 10/17/25 at 3 p.m. she attempted to check Resident 1's blood pressure four times using the vitals machine tower, but there was no reading. CNA 1 stated the vital machines tower was showing three horizontal lines on her first two attempts, and then ERR (error) on her third and fourth attempt. CNA 1 stated at 5:30 p.m., she notified Licensed Vocational Nurse (LVN) 1, CNA 1 was unable to get Resident 1's blood pressure using the vital sign machine. CNA 1 stated she did not attempt to use a manual blood pressure monitor. CNA 1 stated at around 6:30 p.m. on 10/17/25, she went into Resident 1's room and saw Resident 1 unresponsive. CNA 1 notified LVN 1 Resident 1 was unresponsive.During an interview on 11/4/25 at 3:04 p.m. with LVN 1, LVN 1 stated CNA 1 told her CNA 1 was unable to obtain a blood pressure reading on Resident 1 on 10/17/25. LVN 1 stated she was Residents Affected - Few (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 555256 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555256 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Rehabilitation Center of Bakersfield 2211 Mount Vernon Avenue Bakersfield, CA 93306 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)