Height Street Skilled Care: Fall Risk Bed Violations - CA
The resident, identified as Resident 4 in the inspection report, had a fall risk assessment score of 50. Scores of 45 or higher indicate high fall risk.
Resident 4 was admitted with diagnoses including Alzheimer's disease, muscle weakness, abnormalities of gait and mobility, and pain. The resident's care plan specifically stated the need for "a safe environment with the bed in the low position."
When inspectors visited Resident 4's room on the morning of their inspection, they found the resident lying in what should have been a specialty low bed designed to lower close to the floor to reduce injury risk from falls. Instead, the bed was positioned at the height of a regular bed.
A family member was present during the inspection visit. The family member told inspectors they were concerned about Resident 4 falling from the bed because the resident attempted to get out of bed unassisted.
The licensed nurse on duty confirmed the problem immediately. When inspectors pointed out the bed height issue, the nurse acknowledged that Resident 4's bed was not in the low position and proceeded to lower it at least one foot closer to the floor.
"Resident 4 was at risk for falls and his bed should always be kept in the low position," the licensed nurse told inspectors.
The Director of Nursing confirmed this understanding during a separate interview that afternoon, stating that Resident 4's bed should be kept at the low position according to his fall prevention care plan.
The facility's own written policy reinforced these requirements. The Fall Management Program policy, which outlines "Universal Fall Prevention Measures for all Residents," specifically instructs staff to "place bed in lowest position."
Low beds are specialty equipment used specifically for residents at high risk of falling. They are designed to lower close to the floor with the express purpose of reducing the risk of injury should a resident fall from the bed.
The violation represents a failure to implement a basic fall prevention intervention for a particularly vulnerable resident. Resident 4's combination of Alzheimer's disease, muscle weakness, gait abnormalities, and documented attempts to get out of bed unassisted created multiple risk factors that the facility's own assessment had identified.
Federal inspectors determined the facility failed to ensure the nursing home area was free from accident hazards and failed to provide adequate supervision to prevent accidents. The violation was classified as having minimal harm or potential for actual harm, affecting few residents.
The inspection was conducted in response to a complaint. The facility had established the appropriate care plan and possessed the correct equipment, but staff failed to follow through on the most basic requirement of the fall prevention protocol.
For families of residents with dementia and fall risk, the case illustrates how even well-documented care plans can fail at the point of daily implementation. Resident 4's family member was present to witness the bed at the wrong height and express concerns about fall risk, yet the problem persisted until inspectors arrived.
The licensed nurse's immediate recognition of the error and ability to correct it within minutes suggested the failure was not due to lack of knowledge or equipment malfunction, but rather inadequate attention to following established protocols for high-risk residents.
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.
The resident, identified as Resident 4 in the inspection report, had a fall risk assessment score of 50.
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.