Certified Nurse Aide #10 admitted to federal inspectors they had previously rolled Resident #1 in bed by themselves, even though they were aware the patient required two-person assistance for safe positioning.
On May 30, 2025, the aide was changing the resident's brief when they positioned the patient on their left side and noticed a stain on the draw sheet. Instead of rolling the resident back or getting help, the aide left the patient positioned on their side and walked to the foot of the bed to retrieve a clean sheet.
The resident rolled off the bed and hit the floor.
"At that time, they saw the resident roll off the bed and to the floor," inspectors documented. "The resident had blood on their head."
Hospital records from the emergency admission showed the resident suffered a scalp laceration near their brain shunt with bleeding and reported back pain. X-rays revealed acute fractures in the L1 and L2 transverse process of the spine. Medical notes indicated the resident's condition was so severe that examination was "limited due to resident wincing if moved from side to side."
Licensed Practical Nurse #12 responded to the aide's call for help and found the resident "lying on their back and bleeding from their head." The nurse called the supervisor, then 911.
When questioned about the incident, the aide told the nurse they "thought" the resident required two-person assistance but could not explain why they had worked alone.
"They further asked Certified Nurse Aide #10 why they were turning the resident on their own and did not receive an answer," the inspection report stated.
Multiple staff members confirmed the fall was preventable. Physician #2 told inspectors the incident "could have been avoided if there was assistance of two certified nurse aides."
Licensed Practical Nurse Unit Manager #3 was more direct: "This incident could have been prevented and Certified Nurse Aide #10 was not thinking."
The unit manager explained that Resident #1 "was very stiff and needed two people to turn them. It would be very hard to do with one person." They told inspectors they "could not understand why or how it happened."
Registered Nurse Supervisor #9 said the aide "should have looked at the record to see if the resident required staff assistance of one or two staff prior to starting cares."
Licensed Practical Nurse #12 explained that while aides were expected to help each other and organize themselves to be available for two-person assists, Certified Nurse Aide #10 never asked for help that night.
The facility's administrator confirmed that the aide "did not follow the care plan and get help for the two-person assist." The administrator noted that Certified Nurse Aide #10 had been at the facility for only a short time and had just completed training before the incident occurred.
The aide was terminated following the fall.
Federal inspectors determined the facility failed to ensure residents received proper care and services to prevent accidents, citing the incident as causing actual harm to the resident. The violation occurred despite clear documentation in the resident's care plan requiring two-person assistance for positioning and turning.
The inspection found that staff knew the safety requirements but failed to follow them, resulting in preventable injuries to a vulnerable resident who required specialized care due to their medical condition and mobility limitations.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sky View Rehabilitation & Health Care Center L L C from 2025-10-10 including all violations, facility responses, and corrective action plans.
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