The September 14 incident at Canal View - Houghton County violated the resident's explicit care plan, which required two staff members to remain with him throughout the entire toileting process because he had fallen before.
The 86-year-old resident, who scored zero out of 15 on a cognitive assessment indicating severe dementia, was being assisted to the bathroom by two nursing aides using an EZ Stand device. While standing, he soiled his clothing and was seated on the toilet.
One aide then left the room.
The remaining aide, identified as CNA J, continued helping the resident change his soiled clothing alone. She placed a towel on the floor to prevent slipping. But while she removed clothing from his legs, the resident leaned to the right, lost his balance, and fell.
Another nursing aide found him lying face down on the bathroom floor, bleeding from his head. Staff applied pressure to a laceration on the right side of his head while calling emergency medical services. They couldn't get his blood pressure because of his positioning and because he was crying out in pain.
Hospital scans revealed the extent of his injuries: fractures to the right orbital wall, right zygomatic arch, and right maxillary sinus wall, plus a subdural hematoma. The zygomatic arch forms the lower part of the cheekbone and extends to the temple.
The resident's care plan, initiated in August 2023 and revised in May 2025, contained clear instructions: "DO NOT leave me unattended as I have fallen in the past. Two people must remain with for the entire toileting duration."
Federal inspectors found the facility's own investigation confirmed the violation. "Root cause: Care plan was not followed," the facility wrote in its incident report. "Resident is care planned to have two caregivers present for the entire toileting process."
The resident had been admitted with multiple conditions including Alzheimer's disease, dementia with agitation and anxiety, reduced mobility, and stiffness in both hips and his right knee. His August cognitive assessment showed he couldn't answer basic questions about orientation or memory.
Following the fall, the facility updated his care plan to specify using a commode with two-person assistance for the full toileting duration and contact guard assistance during clothing changes. The aide who left him alone was "re-educated on the importance of adhering to the resident's care plan."
Canal View implemented new protocols requiring staff to remain with residents throughout the entire toileting process and maintain contact guard assistance during clothing changes. The facility planned five weeks of audits to monitor compliance, starting with daily checks for two weeks.
But the damage was already done. The resident who entered the bathroom walking with assistance left in an ambulance with multiple facial fractures and bleeding in his brain.
The facility's investigation summary acknowledged what should have prevented the fall: "Staff members will remain with the residents throughout the entire toileting process. During clothing changes, staff will remain contact guard assist to ensure stability and prevent loss of balance."
These were not new requirements. They were exactly what the resident's care plan had specified for more than two years before CNA J decided to leave him sitting alone on a toilet while she changed his clothes.
The September inspection found Canal View failed to ensure adequate supervision to prevent accidents, resulting in actual harm to the resident. Federal regulators classified the violation as affecting few residents but causing significant injury.
For a man with severe Alzheimer's who couldn't remember where he was or recognize familiar faces, the consequences of one aide's decision to step away extended far beyond the bathroom where he fell. His facial bones would heal, but the brain injury added another layer of damage to a mind already ravaged by dementia.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Canal View - Houghton County from 2025-09-25 including all violations, facility responses, and corrective action plans.