Health inspection·September 16, 2025

F 0740 Level of Harm - Actual harm Residents Affected - Few 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. The PC indicated the psychiatrist increased Resident 1's Lexapro to 20 mg once daily. The PC indicated Resident 1 had no suicidal ideation.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 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555902 If continuation sheet Page 2 of 5 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 555902 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Height Street Skilled Care 1611 Height Street Bakersfield, CA 93305 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)

F 0740 Level of Harm - Actual harm Residents Affected - Few 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 [NAME] 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 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555902 If continuation sheet Page 3 of 5 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 555902 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Height Street Skilled Care 1611 Height Street Bakersfield, CA 93305 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)

F 0740 Level of Harm - Actual harm Residents Affected - Few 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 at 10:20 a.m. with DSD, DSD stated CNAs were expected to do rounds for all the residents every two hours unless there was an order for hourly monitoring. DSD stated, If the resident is independent, (CNAs) are still supposed to check on the residents visually and make sure the residents are there and make sure they are alive and breathing. DSD stated the CNAs do not document their rounds every two hours.During an interview on 9/16/25 at 10:56 a.m. with CNA 2, CNA 2 stated she was the CNA assigned to Resident 1 on 9/2/25 morning shift (6 a.m. to 2 p.m.). CNA 2 stated she went to Resident 1's room on 9/2/25 at around 6:25 a.m. and saw Resident 1 lying in bed covered with an animal-designed blanket from head to toe. CNA 2 stated at around 9 a.m. she went to Resident 1's room to give a shower to his roommate but she did not look at Resident 1. CNA 2 stated she emptied Resident 1's trash a few minutes after 9 a.m. and saw Resident 1 was still covered with a blanket from head to toe, his bed was a little higher, and the head of the bed was flat. CNA 2 stated Resident 1's bed was not that high and it was normal for him. CNA 2 stated she left Resident 1's room on 9/2/25 at 9:25 a.m. then SC called CNA 2 to Resident 1's room and told her Resident 1 had passed away at around 9 something. CNA 2 stated she was supposed to check on all the residents assigned to her every two hours, even if the resident was alert with a BIMS of 15, to see if they were doing okay and to check if they were breathing.During an interview on 9/17/25 at 3:28 p.m. with CNA 1, CNA 1 stated she was the CNA assigned to Resident 1 on 9/1/25 night shift (10 p.m. to 6 a.m.). CNA 1 stated the last time she talked to Resident 1 was on 9/1/25 at around 10 p.m. when she asked him if he needed some ice. CNA 1 stated she emptied Resident 1's urinal between 1:30 a.m. to 2 a.m. and Resident 1 was asleep in bed. CNA 1 stated when she was doing her rounds at around 2:35 a.m., Resident 1 was still asleep with a thin plain white sheet covering his chest down. CNA 1 stated she looked at Resident 1 briefly at around 3:45 a.m. but did not see his face and she was not sure if he was still breathing because the room was dark. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555902 If continuation sheet Page 4 of 5 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 555902 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Height Street Skilled Care 1611 Height Street Bakersfield, CA 93305 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)

F 0740 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete CNA 1 stated she went to Resident 1's room at around 5:45 a.m. but did not see Resident 1 because his curtain was drawn. CNA 1 stated on 9/1/25 night shift, Resident 1 had the thin plain white sheet on him and had no other blankets on his bed. CNA 1 stated she would only go to Resident 1 when he presses his call light to ask for help. CNA 1 stated she only did rounds every two hours for those who are not alert, with behaviors, or unable to use call lights. (Based on staff interviews, CNA 1's description of Resident 1's blanket was different from LVN 1 and CNA 2's description).During a concurrent interview and record review on 12/10/25 at 3 p.m. with DON, Resident 1's CP, dated 8/28/25, the CP indicated, Problem. (Resident 1) is on antidepressant medication (Lexapro). Resident verbalized increased sadness on 8/28/2025. Interventions. NON-PHARMACOLOGICAL INTERVENTION for BEHAVIOR MANAGEMENT prior to give psychotropic meds: 1) 1:1 (one on one resident supervision); 2) Activity; 3) Adjust room temperature; 4) Backrub; 5) Change position; 6) Give fluids; 7) Give food; 8) Redirect; 9) Refer to nurse's notes; 10) Remove resident from environment; 11) Return to room; 12) Toilet; 13) Provide medication(s) as ordered; 14) Other. DON stated the licensed nurses were supposed to provide Resident 1 non-pharmacological interventions for behavior management on 8/28/25 when Resident 1 verbalized increased sadness.During a concurrent interview and record review on 12/10/25 at 3 p.m. with DON, Resident 1's MAR, dated August 2025 was reviewed. The MAR indicated, NON-PHARMACOLOGICAL INTERVENTION for BEHAVIOR MANAGEMENT R/t on psychotropic meds: 1) 1:1 (one on one resident supervision); 2) Activity; 3) Adjust room temperature; 4) Backrub/Massage; 5) Change position; 6) Give fluids; 7) Give food; 8) Redirect; 9) Refer to nurse's notes; 10) Remove resident from environment; 11) Return to room; 12) Toilet; 13) Music, Radio, TV; 14) Other. The MAR indicated, on 8/28/25, the licensed nurses documented 15 for day, evening, and night shift. The MAR indicated, on 8/28/25, there was no non-pharmacological intervention for behavior management provided. DON stated the licensed nurses were supposed to document codes 1-14 corresponding to the non-pharmacological intervention indicated on the physician's order. DON stated the licensed nurses were supposed to provide Resident 1 non-pharmacological interventions for behavior management on 8/28/25 when Resident 1 verbalized increased sadness.During a concurrent interview and record review on 12/10/25 at 3 p.m. with DON, Resident 1's Nurses Notes (NN), dated 8/28/25-9/1/25, the NN indicated, on 8/29/25 day and evening shift, Resident 1 was on 72-hour monitoring for the new physician's order to increase his Lexapro's dose from 15 mg to 20 mg due to increased verbalization of sadness. The NN indicated no documentation of 72-hour monitoring on 8/28/25 day, evening, and night shift, 8/29/25 night shift, and 9/1/25 day, evening, and night shift. DON stated the licensed nurses were supposed to monitor Resident 1 every shift for 72 hours (8/28/25 evening shift until 9/1/25 night shift). DON stated the licensed nurses were supposed to look at Resident 1 to check for any adverse effects from Lexapro including suicidal ideation, and to provide any intervention as needed.During a review of the facility's policy and procedure (P&P) titled, Psychotherapeutic Drug Management, dated 5/19/25, the P&P indicated, To ensure residents only receive psychotherapeutic medications when other nonpharmacological interventions are clinically contraindicated and that residents only remain on psychotherapeutic medications when a gradual dose reduction and behavioral interventions have been attempted and/or deemed clinically contraindicated. Nursing Responsibility. Monitoring should also include evaluation of the effectiveness of non-pharmacological approaches prior to administering PRN (as needed) medications. Implements and updates the care plan as indicated. Event ID: Facility ID: 555902 If continuation sheet Page 5 of 5