The August 5 incident at Oakwood Heights Village left the resident with a significant forehead laceration and what CT scan results described as "acute very low volume bilateral intraventricular hemorrhage." The resident was on comfort measures only, meaning family had decided against aggressive medical intervention.
Agency CNA Employee E1 was positioned between the resident's bed and their roommate's bed when attempting to roll Resident R1. According to the nursing assistant's own written statement, "as he/she was turning Resident R1 his/her head hit the other bed because it was so close, and nobody told him/her that Resident R1 was so stiff."
The agency worker's account continued: "Resident R1 hit his/her head on the edge of the bed and agency Employee E1 called for help."
But another staff member who responded to sounds from the room described a more disturbing scene. CNA Employee E4 was assisting another resident when "he/she heard several bangs coming from Resident R1's room." Upon investigation, Employee E4 found "the agency CNA Employee E1 was sitting on Resident R1's bed facing the windows with Resident R1 laying across his/her lap."
The positioning was awkward and dangerous. "Resident R1's upper half was laying on the bed, his/her mid-section was on the agency CNA Employee E1's lap, and his/her legs were out of the bed towards the roommate's bed."
When Employee E4 arrived, the agency nursing assistant claimed "that Resident R1 fell out of bed." Employee E4 left to call the registered nurse, and when returning found "Resident R1 was completely in bed bleeding from his/her forehead."
RN Employee E2 responded to the call and found Resident R1 "laying supine in his/her bed with a significant laceration on his/her right forehead." When the RN asked what happened, agency CNA Employee E1 explained "that he/she was standing between Resident R1's bed and his/her roommates' bed and when agency Employee E1 went to roll Resident R1 towards him/her he/she did not realize how stiff Resident R1 was and Resident R1's torso rolled out of the bed and struck his/her forehead on the bed frame of the roommates' bed."
The facility immediately removed the agency worker. "Agency Employee E1 was asked to wait at the nurse's station at that time, and he/she was relieved of his/her duties and left the building."
Hospital staff contacted the facility about CT scan results the same day. A physician's assistant explained the scan "showed a small hemorrhage" and that "normally they would send resident to larger hospital for observation and consult with neurosurgery, but due to CMO (Comfort Measures Only) status residents family does not want him/her sent and that resident would be sent back to facility for us to monitor and keep comfortable as needed."
The medical imaging, completed at 1:50 p.m. on August 5, revealed the full extent of the injury caused by the fall.
Every staff member interviewed by federal inspectors confirmed the same critical fact about Resident R1's care requirements. During October 21 interviews, "RN Employees E2 and E9, LPN Employees E3, E5, and E6, and CNA Employees E7 and E8, all confirmed that Resident R1 was always an assist of two for transfers/bed mobility rolling side to side and the information could be found under the task orders."
The two-person requirement wasn't hidden or unclear. It was documented in the resident's care plan and task orders, accessible to any staff member providing care.
Director of Nursing confirmed during an October 21 interview that "the agency CNA Employee E1 did not ask for assistance, did not follow the task orders, and did not follow the care plan which indicated Resident R1 required two staff for bed mobility/rolling side to side and attempted to roll Resident R1 independently causing harm to Resident R1."
The agency nursing assistant had signed orientation policies about abuse and neglect prevention on September 7, 2024, nearly a year before the incident. The orientation was specifically designed "to ensure safe care of all residents."
Resident R1 could not provide any account of what happened. Federal inspectors noted the resident "is non-verbal and could not provide a statement or any details related to the incident."
The facility's investigation moved quickly. Documentation dated August 5 showed "that the facility initiated an investigation and the agency CNA Employee E1 was asked to leave the facility immediately and would not be returning."
But the damage was done. A resident who required careful, two-person assistance for basic bed mobility had been handled alone by someone who admitted not understanding the person's physical condition. The result was a traumatic fall that caused bleeding in the brain.
The incident highlighted the risks of agency staffing in nursing homes, where temporary workers may not fully understand residents' specific care needs. Despite signing abuse and neglect prevention policies, the agency nursing assistant proceeded without following established safety protocols.
Federal inspectors determined the facility "failed to ensure that Resident R1 was free from neglect resulting in actual harm of a laceration to the right forehead and an intraventricular hemorrhage."
The brain hemorrhage was classified as "acute," meaning it was new and directly related to the trauma from striking the bed frame. For a resident already on comfort measures, the additional injury represented a particularly tragic outcome of what should have been routine care.
The resident's family had already made the difficult decision to focus on comfort rather than aggressive medical intervention. Instead of peaceful care, their loved one suffered a preventable brain injury because one worker chose to ignore safety requirements that every other staff member understood and followed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Oakwood Heights Village from 2025-10-22 including all violations, facility responses, and corrective action plans.