Height Street Skilled Care: Fall Prevention Delays - CA
Height Street Skilled Care admitted one resident with muscle weakness and gait problems who scored 60 on the facility's fall risk assessment. Any score above 45 indicates high fall risk. The facility waited 26 days to create a fall prevention care plan.
A second resident with Alzheimer's disease, muscle weakness, and mobility problems scored 50 on the fall risk assessment. That resident waited seven days for a fall prevention plan.
The Director of Nursing acknowledged both residents were assessed as high fall risk upon admission but confirmed no baseline care plans with fall prevention interventions were developed for them initially.
The facility's own Care Planning policy states that staff "will develop a person-centered Baseline Care Plan for each resident within 48 hours of admission." A separate Fall Management Program policy requires nursing staff to "develop a plan of care specific to the resident's needs with interventions to reduce the risk of fall."
The DON told inspectors that baseline care plans addressing residents' needs should be created within 72 hours of admission. This contradicts the facility's written 48-hour policy.
Federal inspectors cited the facility for failing to create immediate care plans for residents' most pressing needs. The violation affected few residents but carried potential for actual harm.
The first resident's admission record showed diagnoses of muscle weakness and abnormalities of gait and mobility. These conditions, combined with the high fall risk score, should have triggered immediate fall prevention planning under both federal regulations and facility policy.
The second resident's multiple risk factors included Alzheimer's disease alongside the same mobility and muscle weakness issues. Memory loss combined with physical instability creates compounded fall risks that typically require immediate intervention strategies.
Inspection records show the facility conducted fall risk assessments promptly after admission for both residents. The assessments correctly identified high fall risk. But translating those assessments into protective care plans took far longer than policy allowed.
The 26-day delay for the first resident represents nearly a month without documented fall prevention interventions. During this period, the resident remained at high risk for falls and potential injury without formal protective measures in place.
The seven-day delay for the second resident, while shorter, still exceeded facility policy by more than three times. For residents with Alzheimer's disease and mobility problems, even a week without fall prevention planning can pose significant safety risks.
The Director of Nursing's statement during the inspection confirmed the facility recognized both residents as high fall risk immediately upon admission. This makes the delays in developing protective care plans more concerning, as staff understood the risks but failed to implement timely safeguards.
Federal regulations require nursing homes to develop comprehensive care plans that address residents' highest priority needs within specific timeframes. Fall prevention ranks among the most critical safety concerns for elderly residents, particularly those with documented mobility issues and cognitive impairment.
The facility's Fall Management Program policy acknowledges this priority by requiring individualized fall prevention plans. However, the inspection revealed a gap between written policy and actual practice in implementing these protective measures.
Both residents carried multiple diagnoses that compound fall risks. Muscle weakness affects balance and stability. Gait abnormalities increase stumble risks. Alzheimer's disease impairs judgment about safety hazards. These combined factors demanded immediate protective planning.
The inspection found the facility capable of conducting proper fall risk assessments but struggling to translate those assessments into timely protective action. This pattern suggests systemic issues in care plan development rather than isolated oversights.
Height Street Skilled Care's admission records documented the necessary clinical information to identify fall risks. The facility possessed policies requiring prompt care plan development. Staff acknowledged understanding residents' high-risk status. Yet the protective plans materialized days and weeks late.
The violation received a "minimal harm" designation, indicating inspectors found potential rather than actual injury. However, fall prevention delays create windows of vulnerability where serious injuries can occur without warning.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Height Street Skilled Care from 2025-09-03 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
HEIGHT STREET SKILLED CARE in BAKERSFIELD, CA was cited for violations during a health inspection on September 3, 2025.
Height Street Skilled Care admitted one resident with muscle weakness and gait problems who scored 60 on the facility's fall risk assessment.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.