Height Street Skilled Care

In the surveyor’s words

From the most serious findings on record at Height Street Skilled Care, in the surveyor’s own words.

• Actual harm, isolatedF740Sep 16, 2025

  Based on interview and record review, the facility failed to follow the policy and procedure (P&P) on Psychotherapeutic Drug (medication used to treat mental health disorders) Management for one of ten sampled residents (Resident 1) when Resident 1:1. Was not provided non-pharmacological (without using medications) interventions when Resident 1 verbalized increased sadness.2. Was not monitored every shift for 72 hours after his Lexapro (antidepressant [medication that treat depression [persistent feeling of sadness and loss of interest]-Lexapro black box warning, which is the U.S. [United States] Food and Drug Administration [FDA] most serious warning for prescription drugs. […]

• Actual harm, isolatedF684Apr 1, 2025

  Based on interview and record review, the facility failed to ensure one of 11 sampled residents (Resident 1) received quality care when the facility failed to: 1. Implement their policy and procedure on a change of condition (an important change in a resident ' s baseline condition which includes physical, mental, emotional or functional changes that require a change in treatment to address) for one of 11 sampled residents (Resident 1). 2. Ensure the MDS assessment (Minimum Data Set - an assessment tool) was accurate for one of 11 sampled residents (Resident 1) when contractures (when your skin, muscles, tendons [tough, ropelike cords that connect muscles to bones, enabling movement], or ligaments [tough tissues that act like ropes or bands connecting bones to other bones providing… […]

• Actual harm, isolatedF825Apr 1, 2025

  Based on interview and record review, the facility failed to provide and accurately document physical therapy (PT - branch of healthcare for the treatment of disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise), occupational therapy (OT -branch of healthcare that helps people adapt to challenges in their daily lives, like getting dressed, eating, or working, by improving their ability to perform those activities) services and speech therapy (branch of healthcare that helps people with difficulties talking, understanding language, or swallowing) services, when the facility therapy staff inaccurately documented the time spent providing therapy to 11 of 11 sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6,… […]

• Actual harm, isolatedF689Feb 28, 2025

  Based on observation, interview, and record review, the facility failed to implement the care plan (comprehensive documents outlining the care and services to be provided by the facility to residents) intervention of providing supervision during toilet transfers for one of three sampled residents (Resident 1), who had generalized muscle weakness, a history of falls, was at risk for falls, and had Alzheimer's Disease (memory loss), when Resident 1 got up unsupervised to use the toilet and fell in her room. […]

• No harm, potential for more than minimal, widespreadF812Apr 28, 2022

  Based on observation, interview, and record review, the facility failed to ensure safe food handling and sanitation were implemented when: 1. Two of two nourishment refrigerator's temperatures were not maintained at safe temperature for food storage. 2. The ice machine was not sanitized in accordance with manufacturer's guidelines. These failures had the potential to cause food borne illness. Findings: 1. During a concurrent observation and interview on 4/25/22, at 10:12 AM, with Licensed Vocational Nurse (LVN) 6, the Nurses' Station 2's medication room, the residents' food storage refrigerator was observed. LVN 6 opened up the refrigerator used for residents' foods brought in from the outside. […]