Height Street Skilled Care: Fall Prevention Failure - CA
The resident is identified in inspection records only as Resident 4, an individual living at Height Street Skilled Care on Height Street in Bakersfield. He has Alzheimer's disease, muscle weakness, and abnormalities of gait and mobility. His fall risk assessment score was 50. Scores of 45 or higher indicate high fall risk.
His care plan was direct: the bed should be kept in the low position.
The bed he was lying in is a specialty low bed, a piece of equipment designed to sit close to the floor specifically to reduce the chance of serious injury if a resident falls out. That morning, it wasn't close to the floor. It was raised to the height of a standard bed.
The family member, identified in the report as Family Member 4, was in the room during the inspection visit on September 3, 2025. He said he was concerned about Resident 4 falling because the resident attempted to get out of bed without assistance. The concern wasn't hypothetical. The equipment meant to protect him was defeating its own purpose.
A licensed nurse, identified as LN C, was also present. She confirmed the bed was not in the low position. Then she lowered it, at least one foot closer to the floor, while the inspector watched.
LN C said Resident 4 was at risk for falls and that his bed should always be kept in the low position.
The Director of Nursing said the same thing that afternoon. Resident 4's bed should be kept at the low position, the Director of Nursing said, according to his fall prevention care plan.
The facility's own Fall Management Program policy lists placing the bed in the lowest position as a universal fall prevention measure for all residents, not just those with documented high risk. Resident 4 had both the universal policy and a specific, individualized care plan instruction applying that measure to him directly.
Neither was being followed when the inspector walked in at 10:15 in the morning.
CMS inspectors rated the level of harm as minimal harm or potential for actual harm, the lower end of the deficiency scale. The violation affected few residents. In the calculus of federal nursing home enforcement, this registers as a relatively minor finding.
But the gap between what the record required and what the inspector found was not subtle. The care plan said low position. The bed was a foot higher than it should have been. The nurse who lowered it on the spot didn't dispute that it was wrong. The Director of Nursing didn't dispute it either.
What the inspection doesn't answer is how long the bed had been in the raised position that morning, or whether this was the first time. The report documents one observation, at one moment, in one resident's room. It doesn't say whether anyone checked the bed the night before, or the morning before that.
Family Member 4 was there. He had already noticed. He was already worried.
Resident 4 has Alzheimer's disease. He tries to get out of bed without help. He has a fall risk score that places him firmly in the high-risk category, and he has a piece of equipment in his room specifically designed to make a fall less catastrophic. That morning, the equipment wasn't doing what it was supposed to do.
A nurse lowered it when asked. The question the inspection record leaves open is who would have lowered it if no one had asked.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
HEIGHT STREET SKILLED CARE in BAKERSFIELD, CA was cited for violations during a health inspection on September 3, 2025.
The resident is identified in inspection records only as Resident 4, an individual living at Height Street Skilled Care on Height Street in Bakersfield.
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.