The December 22 incident at Lakewood Healthcare Center occurred when CNA 4 was escorting Resident 6 to the restroom. The nursing aide positioned herself ahead of the resident instead of beside her, violating the facility's own safety protocols and the resident's documented care requirements.
Resident 6 had been readmitted to the facility on December 23 at 6:10 a.m. with intact sutures on her right forehead, showing no bleeding or swelling. Her skin check documented seven sutures from the injury.
The resident's physical therapy notes from December 17 painted a clear picture of her vulnerabilities. She exhibited anxiety with activity and required encouragement to participate in treatment. Most critically, supervision or touching assistance was required when she walked even ten feet.
CNA 4 described the events leading to the fall during an interview with inspectors. She said Resident 6 was restless on December 22 and kept trying to get out of bed. The aide placed her chair outside the resident's room to monitor and assist if needed.
When Resident 6 got out of bed, CNA 4 approached and asked if she needed the restroom. The aide knew the resident "did not like to be touched or held" and decided to walk in front of her while leading the way to the bathroom.
"She reached for the door to the restroom and when she turned around Resident 6 lost her balance and was unable to catch her," according to the inspection report. Because she was walking ahead of the resident, CNA 4 couldn't see how Resident 6 lost her balance.
The facility's Director of Rehab explained that supervision or touching assistance meant Resident 6 required physical or verbal cues for safety when walking. Optimal safety precautions required staff to walk next to or slightly behind the resident, not in front.
"This precaution would allow the staff member to quickly react and assist Resident 6 if she became unsteady," the director told inspectors.
The Director of Nursing confirmed that when residents need supervision or touch assistance, staff are responsible for cueing, guiding, and redirecting as needed. She said CNA 4 should have walked next to Resident 6, which would have provided visual supervision to steady the resident when she became unbalanced.
Walking beside the resident "could have minimized Resident 6's injury and/or prevented Resident 6's fall," the nursing director acknowledged.
The facility's own ambulation policy, revised in 2012, explicitly required staff to observe correct guarding by standing on the resident's weakest side and just slightly behind. Staff were instructed to use their other hand to support the resident's shoulder or hip if needed.
The policy stated that proper ambulation techniques "are utilized to increase safety for the resident and staff."
Federal inspectors found the facility failed to ensure residents received adequate supervision and assistive devices to prevent accidents. The violation affected few residents but created minimal harm or potential for actual harm.
The incident highlighted a fundamental breakdown in following established safety protocols. Despite clear documentation that Resident 6 required touch assistance when walking, and despite facility policies mandating proper positioning during ambulation, the nursing assistant chose to walk ahead of the vulnerable resident.
Resident 6's physical therapy records showed she had exhibited self-limiting behavior and anxiety with activity just five days before the fall. The combination of her documented need for assistance and her psychological state made proper positioning by staff even more critical.
The nursing assistant's decision to walk in front of the resident, rather than beside or slightly behind her, eliminated any chance of preventing the fall once Resident 6 became unsteady. By the time CNA 4 turned around at the restroom door, the resident was already losing her balance.
The seven sutures required to close the forehead laceration served as a visible reminder of what happens when staff fail to follow basic safety protocols designed to protect vulnerable residents.
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.