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 Page 1 of 2 555256 555256 11/04/2025 The Rehabilitation Center of Bakersfield 2211 Mount Vernon Avenue Bakersfield, CA 93306

F 0658 Level of Harm - Actual harm Residents Affected - Few going to use the manual blood pressure monitor to check Resident 1's blood pressure because sometimes the vital sign machine's blood pressure cuff would not work. LVN 1 stated she did not notify anyone when the vitals sign machine was not working. LVN 1 stated she did not get the chance to check Resident 1's blood pressure during her shift because Resident 1 became unresponsive when LVN 1 came back from her lunch. LVN 1 stated when she came back from lunch at around 7 p.m. on 10/17/25, she was notified Resident 1 was already unresponsive. LVN 1 stated Resident 1 was pale, cold, and without signs of life. LVN 1 stated Resident 1 was DNR (Do not Resuscitate [if the heart stops beating or if a resident stops breathing, it is the resident's choice to allow a natural death]).During an interview on 12/30/25 at 3:40 p.m. with DON, DON stated if CNA 1 was unable to take Resident 1's vital signs, the nurse should have checked Resident 1's vital signs. DON stated CNA 1 should have also attempted to use the manual blood pressure monitor if CNA 1 was unable to obtain a blood pressure reading using the vital sign machine. DON stated the facility did not get a report of a broken vitals machine tower on 10/17/25 (the day when CNA 1 was unable to obtain Resident 1's blood pressure using the vitals sign machine).During an interview on 1/8/25 at 12:33 p.m. with Maintenance Supervisor (MS), MS stated the facility had eight vitals machine towers. MS stated around the end of December 2025, before he checked the eight vitals machine tower for maintenance, he did not identify any of the towers as broken.During an interview on 2/2/26 at 3:13 p.m. with DON, DON stated if the vitals machine tower showed three horizontal lines, it meant the machine was trying to obtain a blood pressure reading. DON stated if the vitals machine tower showed ERR, it meant error, the blood pressure cuff was not properly attached, and the vitals machine tower was not pumping air into the blood pressure cuff.During a review of the facility's Owner's Manual Touchscreen Vital Signs Monitor (OMTVS), dated February 2024, the OMTVS indicated, EEE905: PRINTER ERROR TROUBLESHOOTING TIPS: DO NOT USE THE MONITOR. CONTACT DIRECT SUPPLY FOR SERVICES. IF THIS ERROR CONTINUES TO APPEAR, PLEASE CONTACT DIRECT SUPPLY WITH THE ERROR YOU ARE SEEING.During a review of the facility's policy and procedure (P&P) titled, Change in Condition, dated 8/25/22, the P&P indicated, 1. It is the responsibility of the person who observes the change to report the change to the Licensed Nurse. 2. The Licensed Nurse will assess the change of condition and determine what nursing interventions are appropriate.During a review of the facility's P&P titled, Obtaining Vital Signs, dated 8/22/19, the P&P indicated, Purpose To take clinical measurements that indicated the state of a resident's basic body functions. Policy Vital signs are obtained as appropriate. Vital signs will include temperature, blood pressure, pulse and respiration rate. Procedure I. Vital signs will be taken with the following frequency but not limited to. When there is a change in the resident's condition. 555256 Page 2 of 2