Height Street Skilled Care

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.

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