The resident hit her head and tore skin on her right elbow during the January 7 fall at Village at Victory Lakes. She was transported to a local emergency room, where she underwent X-rays of her knee, hip and spine, plus head scans. She never returned to the facility.
The injured resident had undergone artificial hip replacement surgery and suffered from difficulty walking and hip osteoarthritis. Her care plan, initiated December 17, identified her as a fall risk due to unsteady gait, balance problems, and decreased strength and endurance. Staff were supposed to keep her personal items within easy reach and provide safety instructions.
Certified nursing assistant V4 was drying the resident's legs and back when the woman mentioned wanting lotion applied. V4 had placed the resident's personal items on top of the heater in the bathroom.
"She turned her back to R1 and went to get her wheelchair to bring it closer," according to the inspection report of V4's account. "The next thing she knew the shower chair moved and R1 fell out onto the floor."
The resident required partial to moderate assistance for showers, dressing, and transfers.
V4 acknowledged her mistake during the October 28 inspection interview. She said she should have handed the resident the lotion or positioned her closer to the items "so she did not have to reach for them."
The nursing assistant also explained that shower chairs at the facility sometimes move unexpectedly. "R1 was a tall lady so with her having her feet on the floor she thinks that maybe why the chair suddenly moved," V4 told inspectors.
The fall left the resident "very upset," according to the incident report completed by licensed practical nurse V3. The resident subsequently refused to let V4 provide her care.
A registered nurse who responded to assist after the fall confirmed the shower equipment's instability. V6 told inspectors that "the shower chair can still move at times depending on the resident position," and for that reason, "she would not walk away from a resident or turn their back to them in the shower room."
Hospital records show the resident arrived at the emergency room complaining of head and back pain from the facility fall. Medical tests found no acute injuries, and she was discharged the following day on January 8.
The facility's Fall Prevention and Management Program policy, last revised January 23, states that all staff are responsible for preventing resident falls. The policy specifically requires following care plan interventions, including keeping personal items within reach to minimize fall risk.
But V4 had done the opposite. She placed the resident's items out of reach on the heater, then turned away to retrieve equipment, leaving the woman alone in an unstable shower chair.
The inspection found the facility failed to ensure the resident was free from injury during her shower. Federal investigators cited the nursing home for failing to provide adequate supervision to prevent accidents.
The resident's care plan had been updated December 18 with specific interventions to prevent falls, including the requirement to keep personal items accessible. Those safety measures were in place for less than three weeks before V4's actions led to the bathroom fall.
V4's admission that she "should have handed R1 the lotion" revealed her awareness of safer alternatives that would have kept the resident secure in the shower chair. Instead, her decision to leave the woman unattended while retrieving a wheelchair created the conditions for injury.
The facility policy held all staff responsible for fall prevention, but V4's actions directly contradicted established safety protocols. Her placement of personal items out of reach and decision to turn away from a resident in an unstable shower chair violated the care plan designed specifically to protect this woman from falls.
The registered nurse's statement that she would never turn her back on a resident in the shower room highlighted how V4's actions departed from accepted safety practices at the facility.
The resident's refusal to allow V4 to provide further care demonstrated the lasting impact of the incident beyond the physical injuries that required emergency room treatment.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Village At Victory Lakes, The from 2025-10-28 including all violations, facility responses, and corrective action plans.
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