Lakewood Healthcare Center: Fall After Staff Error - CA
The fall happened on December 22, 2025. The resident, identified in inspection records only as Resident 6, had a documented history of anxiety with activity, self-limiting behavior, and a specific mobility requirement: supervision or touching assistance for every step she took. According to a physical therapy treatment note from December 17, five days before the fall, she could walk ten feet and required either physical contact or verbal cues the entire time.
The nursing assistant, identified as CNA 4, told inspectors she had been watching the resident from a chair positioned outside the room because the resident was restless and trying to get out of bed. When Resident 6 stood up, CNA 4 approached and asked if she needed the restroom. The resident did not like to be touched or held.
So CNA 4 walked in front of her.
She led the way toward the restroom, reached for the door, turned around, and Resident 6 was already falling. CNA 4 told inspectors that because she was walking ahead of the resident, she could not see how the resident lost her balance, and she could not catch her.
The facility's Director of Rehabilitation reviewed the physical therapy notes with inspectors on December 31 and was direct about what the documentation required. Supervision or touching assistance, the director explained, meant physical or verbal cues for safety throughout ambulation. Optimal safety precautions required the staff member to walk next to or slightly behind the resident, the director said, so that if the resident became unsteady, the staff member could react immediately.
The Director of Nursing said the same thing in a separate interview the same morning. When a resident needs supervision or touch assistance, the staff member is responsible for cueing, guiding, and redirecting. CNA 4 should have been walking next to Resident 6, the director said. Walking next to her would have provided visual supervision and could have minimized or prevented the injury entirely.
The facility's own ambulation policy, last revised in January 2012, described the correct technique: stand on the resident's weakest side, slightly behind, with one hand available to support the shoulder or hip if needed.
CNA 4 was not beside Resident 6. She was in front of her, reaching for a door.
What the inspection report does not answer is how a nursing assistant assigned to a resident with documented fall risk and a specific ambulation protocol ended up leading that resident down a hallway the wrong way. CNA 4's account suggests she understood the resident's aversion to being touched, but the inspection record contains no finding that anyone had trained her on what supervision or touching assistance actually required, or that anyone had verified she understood the physical therapy notes before that morning.
The inspection was classified as a complaint investigation. The level of harm was listed as minimal harm or potential for actual harm. Few residents were noted as affected.
Seven sutures is the only number in the record that describes what actually happened to Resident 6.
She had been restless, trying to get out of bed, and the aide watching her from the hallway had improvised a solution: sit outside the door, wait, and lead the way. It was the leading that failed her. The resident who did not like to be touched walked to the bathroom behind someone who could not see her, and when she lost her balance there was no one close enough to catch her.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lakewood Healthcare Center from 2025-12-31 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
LAKEWOOD HEALTHCARE CENTER in DOWNEY, CA was cited for violations during a health inspection on December 31, 2025.
The fall happened on December 22, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.