Height Street Skilled Care
Inspection Findings
F-Tag F0740
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.
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HEIGHT STREET SKILLED CARE in BAKERSFIELD, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in BAKERSFIELD, CA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from HEIGHT STREET SKILLED CARE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.