Inspection visit
Health inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
Based on observation, interview, and record review, the facility failed to implement the care plan (is a
comprehensive, personalized document that outlines the specific needs of an individual requiring care,
detailing the type of support, how it will be provided, and the goals of the care) for two of three sampled
residents (Resident 1 and Resident 2) when: 1.Resident 1 was not repositioned every two hours. This
failure had the potential for Resident 1 to develop pressure injury (localized damage to the skin and
underlying soft tissue usually over a bony prominence). 2.Resident 2 was not supervised during a meal.
This failure had the potential for Resident 2 not to consume the proper nutrition and had the potential for
choking. Findings: 1.During a review of Resident 1's Care Plan (CP), dated 6/28/25, the CP indicated,
[Resident 1] has altered skin integrity related to pressure injury/wound (localized damage to the skin and
underlying soft tissue usually over a bony prominence) Contributory factors: admitted with pressure injury
Re-opened pressure injury to sacrococcyx [end of spine, tailbone-two set of bone that form the tailbone]
extending to left and right buttock, turn and reposition every 2 hours and PRN (as needed).During an
observation on 7/21/25 at 10:46 a.m. at the nurses' station 1, Resident 1 was observed in his wheelchair
sitting flat on his buttocks at a 45-degree angle (position of resident lies on the back with pressure is
concentrated on the buttocks because the resident's weight is shifted onto their tailbone and buttock
regions).During a concurrent observation and interview, on 7/21/25 at 1:32 p.m. in Resident 1's room, with
Certified Nursing Assistant (CNA) 2, Resident 1 was observed sitting flat on his buttocks in his wheelchair
at a 45-degree angle. CNA 2 stated Resident 1 had previously had a pressure injury and had to be
repositioned every two hours. CNA 2 stated she has had Resident 1 since 11a.m. CNA 2 stated Resident 1
was still in the same position sitting in wheelchair.During a review of Resident 1's Minimum Data Set
(MDS-comprehensive assessment tool), dated 5/29/25, the MDS indicated Resident 1 is dependent (staff
does all the effort) with transfers and mobility. During a concurrent interview and record review, on 7/21/25
at 2:37 p.m. with Director of Nursing (DON). Resident 1's CP dated 6/28/25, was reviewed. DON stated
Resident 1 had a history of pressure injury and the CP indicated Resident 1 was to be turned and
reposition every two hours. 2. During a review of Resident 2's CP dated 6/15/25, the CP indicated,
Nutritional Problems, [Resident 2] required supervision and assistance with all meals. During a review of
Resident 2's CP dated 1/23/25, the CP indicated, [Resident 2] has behavior of feeding other resident's [sic],
Assign a staff member to be present during mealtimes to offer redirection if the patient attempts to feed
others.During an observation on 7/21/25 at 12:21p.m. in Resident 2 and Resident 3's room, Resident 3 was
sitting up on bed eating, with meal tray at her bedside table. Resident 2 was sitting on the side of her bed
eating her meal, there were no staff were present in the room to monitor Resident 2.During a concurrent
observation and interview, on 7/21/25 at 12:42 p.m. in Resident 2's room with CNA 1, Resident 2 was
eating by herself in her room. CNA 1 stated Resident 2 needed encouragement and cues to focus on
eating. CNA 1 stated there were no
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 4
Event ID:
555902
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555902
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/06/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Height Street Skilled Care
1611 Height Street
Bakersfield, CA 93305
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
staff present in Resident 2 and Resident 3's room, and Resident 2 still had her meal tray on her bedside
table and was still eating her meal. CNA 1 stated she was not sure if Resident 2 was supervised for her
meal. CNA 1 stated usually the CNA on the floor should help. During an interview on 7/21/25 at 2:12 p.m.
with DON, DON stated Resident 2 likes to feed people and for residents with swallowing problems, this
could be a safety issue.During a review of the facility's Policy and Procedure (P&P) titled, Care Planning,
dated 10/24/22, the P&P indicated, II. The Care Plan serves as a course of action where the resident
(resident's family and or guardian or other legally authorized representative). Resident's Attending
Physician, and IDT (Interdisciplinary Team- team of healthcare professionals with various areas of expertise
who work together to improve patient safety and outcomes) work to help the resident move toward resident
-specific goals that address the resident's medical, nursing, mental and psychosocial needs. IX. Each
resident Comprehensive Care Plan will describe the following: A. Service that are to be furnished to attain
or maintain the resident's highest practicable physical, mental and psychosocial well-being.
Event ID:
Facility ID:
555902
If continuation sheet
Page 2 of 4
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555902
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/06/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Height Street Skilled Care
1611 Height Street
Bakersfield, CA 93305
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0658
Ensure services provided by the nursing facility meet professional standards of quality.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review, the facility failed to notify the physician of a change in condition and
administer medication according to the physician's order for one of three sampled residents (Resident 1)
when Resident 1 was having continuous loose stools/diarrhea. This failure had the potential for Resident 1
losing three lbs. (pounds-weight measurement) weight in one week and potential for adverse health
outcomes.Findings:During a review of Resident 1's Plan of Care (PC-is a comprehensive, personalized
document that outlines the specific needs of an individual requiring care, detailing the type of support, how
it will be provided, and the goals of the care), dated 6/13/25, the PC indicated, [Resident1] has dehydration
or potential fluid deficit r/t (related to) new GT (gastrostomy tube feeding- where nutrition and/or fluids are
delivered directly into the stomach through a tube inserted into the abdomen) feeding and GI infection
(gastrointestinal infection - is an inflammation or irritation of the digestive tract, often caused by bacteria,
viruses, or parasites. Administer medications as ordered. Monitor/document for side effects and
effectiveness. Notify physician if persistent symptoms of diarrhea, nausea/vomiting unresolved past 48
hours.During a review of Resident 1's PC dated 6/30/25, the PC indicated, The resident [1] has diarrhea r/t
[related to] x [times] 4 loose stools with foul odor. Intervention: Give anti -diarrheal medications as ordered.
Monitor intake and output.During a review of Resident 1's Medication Administration Record (MAR),dated
June 2025, the MAR indicated, Imodium A-D Oral Tablet 2 MG (Milligram- unit of measure) . Give 2 mg via
G-Tube every 6 hours as needed for loose stools -Start Date- 06/30/2025 2100 [9 p.m.]-D/C [discontinued]
Date- 07/1/2025 1023 [10:23 a.m.] The MAR indicated there was no Imodium administered on
6/30/25.During a review of Resident 1's Documentation Survey Report (DSR), dated July 2025, the DSR
indicated the following:On 7/1/25 for the day shift, Resident 1 had a medium loose/diarrhea stool.On 7/1/25
for the evening shift, Resident 1 had a large loose/diarrhea stool.On 7/1/25 for the night shift, Resident 1
had a medium loose/diarrhea stool.On 7/2/25 for the evening shift, Resident 1 had a medium
loose/diarrhea stool.On 7/2/25 for the evening shift, Resident 1 had a medium loose/diarrhea stool.On
7/2/25 for the night shift, Resident 1 had a large loose/diarrhea stool.On 7/3/25 for the night shift, Resident
1 had a large loose/diarrhea stool.On 7/4/25 for the evening shift, Resident 1 had a large loose/diarrhea
stool.On 7/5/25 for the day shift, Resident 1 had a large sized loose/diarrhea stool.On 7/5/25 for the
evening shift, Resident 1 had a large loose/diarrhea stool.On 7/5/25 for the night shift, Resident 1 had a
large loose/diarrhea stool.On 7/6/25 for the evening shift, Resident 1 had a large loose/diarrhea stool.On
7/7/25 for the evening shift, Resident 1 had a large loose/diarrhea stool.On 7/7/25 for the evening shift,
Resident 1 had a large loose/diarrhea stool.On 7/7/25 for the evening shift, Resident 1 had a large
loose/diarrhea stool.On 7/8/25 for the evening shift, Resident 1 had a large loose/diarrhea stool.On 7/8/25
for the night shift, Resident 1 had a large loose/diarrhea stool.On 7/8/25 for the night shift, Resident 1 had a
small loose/diarrhea stool.On 7/10/25 for the evening shift, Resident 1 had a large loose/diarrhea stool.On
7/10/25 for the evening shift, Resident 1 had a medium loose/diarrhea stool.On 7/11/25 for the day shift,
Resident 1 had a medium loose/diarrhea stool.On 7/12/25 for the day shift, Resident 1 had a large
loose/diarrhea stool.On 7/12/25 for the evening shift, Resident 1 had a large loose/diarrhea stool.On
7/12/25 for the night shift, Resident 1 had a large loose/diarrhea stool.On 7/13/25 for the night shift,
Resident 1 had a large loose/diarrhea stool.On 7/14/25 for the evening shift, Resident 1 had a large
loose/diarrhea stool.On 7/14/25 for the night shift, Resident 1 had a large loose/diarrhea stool.On 7/16/25
for the night shift, Resident 1 had a small loose/diarrhea stool. On 7/17/25 for the evening shift, Resident 1
had a large loose/diarrhea stool.On 7/17/25 for the evening shift, the DRS indicated Resident 1 had a
Residents Affected - Few
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555902
If continuation sheet
Page 3 of 4
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555902
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/06/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Height Street Skilled Care
1611 Height Street
Bakersfield, CA 93305
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0658
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
medium loose/diarrhea stool.On 7/17/25 for the night shift, the DRS indicated Resident 1 had a large
loose/diarrhea stool.On 7/18/25 for the evening shift, Resident 1 had a large loose/diarrhea stool.On
7/18/25 for the night shift, Resident 1 had a large loose/diarrhea stool.On 7/19/25 for the evening shift,
Resident 1 had a medium loose/diarrhea stool.On 7/19/25 for the night shift, Resident 1 had a large
loose/diarrhea stool.On 7/20/25 for the day shift, Resident 1 had a small loose/diarrhea stool.On 7/20/25 for
the evening shift, Resident 1 had a large loose/diarrhea stool.During a review of Resident 1's Weight
Summary (WS), dated July of 2025, the WS indicated Resident 1 weighted 135 pounds on 7/1/25 and 132
pounds on 7/8/25 (three pound weight loss in one week).During a review of Resident 1's Change of
Condition (COC), dated 7/9/25, the COC indicated, On g-tube feeding, frequently has diarrhea . Resident
has lost 3 lbs a weekDuring a review of Resident 1's PC dated 7/9/25, the PC indicated, (Resident 1) has
weight loss of 3 lbs in one week. During an interview on 8/6/25 at 11:44 a.m. with Licensed Vocational
Nurse (LVN) 1, LVN 1 stated after a change of condition the facility monitors the resident for three days but
if the symptoms do not improve, she calls the physician and communicates the situation, follows up on
orders, and continues to monitor. During a concurrent interview and record review, on 8/6/25 at 11:52 a.m.
with Director of Nursing (DON), Resident 1's COC, dated 6/30/25. DON stated Resident 1 had diarrhea and
the physician ordered Imodium every 6 hours as needed for loose stool on 6/30/25. Resident 1's DSR,
dated July 2025, was reviewed. DON stated Resident 1 had 18 loose stools between 7/1/25 and 7/9/25.
Resident 1's MAR, dated July 2025 was reviewed. DON stated Imodium was not given according to
physician's order. Resident 1's COC, dated 7/9/25, was reviewed. DON stated Resident 1 had a 3-pound
weight loss in one week. DON stated she sees a correlation between Resident 1's weight loss and
Resident 1's loose stools/diarrhea. Resident 1's medical record was reviewed. DON stated there was no
physician notification regarding Resident 1's continued loose stool/diarrhea. DON stated, I am not sure if
the nurses were not documenting the PRN antidiarrhea and if so, they should have notified the physician if
the medication was ineffective.During a review of the facility's policy and procedure (P&P) titled Nutrition &
Weight Variance Committee, revised 6/1/17, the P&P indicated, To ensure that each resident maintains
acceptable parameters of weight and nutritional status, such as body weight . To ensure that a resident
receives a therapeutic diet when there is a nutritional problem. II. Prior to each meeting, the Director of
Nursing Services or designee will compile a list of residents who are at risk for, or in need of, weight
change. Residents that meet the following criteria may be included on the list for discussion: . B. 2% weight
change in 1 week . V. Objectives of the Nutrition &Weight Variance Committee may include, but not limited
to: A. Identifying medical or pharmacological conditions, which may be affecting weight changes for the
identified residents.
Event ID:
Facility ID:
555902
If continuation sheet
Page 4 of 4
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Back to topCitations
2 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F658 - Comprehensive Care Plans
Ensure services provided by the nursing facility meet professional standards of quality.
FAQ · About this visit
Common questions about this visit
What happened during the August 6, 2025 survey of HEIGHT STREET SKILLED CARE?
This was a inspection survey of HEIGHT STREET SKILLED CARE on August 6, 2025. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at HEIGHT STREET SKILLED CARE on August 6, 2025?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be ..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.