Height Street Skilled Care: Missed Skin Treatments - CA
The resident, identified in inspection records only as Resident 6, had a Braden Skin Risk Score of 13 as of late February 2026. The Braden scale is used to assess how likely a resident is to develop a pressure ulcer, the kind of wound that forms when sustained pressure cuts off circulation to skin over a bony area. A score of 13 or 14 places a resident in the moderate-risk category.
Because of that risk, a physician ordered Calmoseptine ointment, a product used to protect and heal irritated skin, to be applied to Resident 6's left and right buttocks and perineum every two hours for skin maintenance. Every two hours. The order was active as of April 23, 2026, when inspectors reviewed it.
What the records showed for April 14 was a different picture entirely.
When inspectors sat down with the facility's treatment nurse that morning and pulled up Resident 6's Treatment Administration Record for April, four time slots were blank: noon, 2 p.m., 8 p.m., and 10 p.m. No documentation that the ointment was applied. The treatment nurse did not suggest the entries might have been missed by accident or recorded elsewhere. She said directly that if there was no documentation on the record, the Calmoseptine was not administered. Then she said something else: if it wasn't administered as the physician ordered, it would put Resident 6 at risk for skin breakdown.
That is not an inspector's conclusion. That is the treating nurse's own assessment of what the missed applications meant for this specific resident.
Four days later, on April 27, inspectors returned and reviewed the situation with the Director of Nursing. They went through the facility's own Wound Management policy together, a document dated January 1, 2026, which states that residents with wounds will receive necessary treatment and services to promote healing, prevent infection, and prevent new pressure ulcers from developing, and that wound treatment will be implemented per physician's order.
The Director of Nursing said the policy was not followed.
The inspection, a complaint survey, identified the violation as causing minimal harm or the potential for actual harm, and noted that few residents were affected. One resident in a sample of three. But the framing of "minimal harm" sits uneasily next to what the treatment nurse spelled out: a resident already identified as moderate risk, a physician who determined that ointment every two hours was medically necessary, and four gaps in a single day when that order went unfulfilled.
Pressure ulcers are not abstract risks. They begin as redness and irritation and can progress, in vulnerable patients, to wounds that reach muscle and bone. They are painful, difficult to treat, and in elderly or medically compromised residents, can become life-threatening. The every-two-hour frequency of the order is itself a signal of how seriously the physician weighed the risk.
What the records do not show is whether anyone noticed the missed doses on April 14, whether a supervisor reviewed the treatment record that day, or whether Resident 6 experienced any skin changes as a result. The inspection report does not say. What it does say is that on the day inspectors looked, the blanks were there, the nurse confirmed what they meant, and the director of nursing confirmed the policy had not been followed.
Resident 6 was still a patient at the facility when inspectors conducted their review.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Height Street Skilled Care from 2026-04-27 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 April 27, 2026.
The resident, identified in inspection records only as Resident 6, had a Braden Skin Risk Score of 13 as of late February 2026.
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.