Lakewood Healthcare Center
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
indicated on 12/23/2025 at 6:10 a.m., Resident 6 was readmitted to the facility. The Progress Notes indicated Resident 6 had a laceration on her right forehead with intact sutures and without bleeding or swelling. During a review of Resident 6's Skin Check, dated 12/23/2025, the Skin Check indicated Resident 6 had seven sutures .During an interview on 12/30/2025 at 1:29 p.m., with CNA 4, CNA 4 stated, on 12/22/2025, Resident 6 was very restless and tried to get up out of bed. CNA 4 stated she placed her chair outside of Resident 6's room to monitor and assist the resident if she tried to get out of bed. CNA 4 stated when she saw Resident 6 get out of bed, she approached the resident and asked her if she needed to use
the restroom. CNA 4 stated Resident 6 did not like to be touched or held. CNA 4 stated she walked in front of Resident 6 while leading the way to the restroom. CNA 4 stated she reached for the door to the restroom and when she turned around Resident 6 lost her balance and was unable to catch her. CNA 4 stated because she was walking in front of Resident 6, she was unsure how the resident lost her balance and fell.
During a concurrent interview on 12/31/2025 at 10:14 a.m., with the Director of Rehab (DOR), Resident 6's Physical Therapy (PT) Treatment Note, dated 12/17/2025, was reviewed. The PT Treatment Note indicated Resident 6 exhibited self-limiting behavior and required encouragement to participate and exhibited anxiety (feeling of unease, fear, or dread) with activity. The PT Treatment Note indicated supervision or touching assistance was required when Resident 6 walked ten feet. The DOR stated Resident 6 required supervision or touching assistance when ambulating (walking) which meant Resident 6 required physical or verbal cues for safety. The DOR stated optimal safety precautions required the staff member to walk next to or slightly behind Resident 6 when ambulating. The DOR stated this precaution would allow the staff member to quickly react and assist Resident 6 if she became unsteady.During an interview on 12/31/2025 at 11:45 a.m., with the Director of Nursing (DON), the DON stated when a resident needs supervision or touch assistance, the staff member was responsible for cueing, guiding, and redirecting, if needed. The DON stated when CNA 4 assisted Resident 6, CNA 4 should have been walking next to Resident 6. The DON stated walking next to Resident 6 would have provided visual supervision to steady Resident 6 when she became unbalanced and could have minimized Resident 6's injury and/or prevented Resident 6's fall.
During a review of the facility's Policy and Procedure (P&P) titled, Ambulation, revised 1/1/2012, the P&P indicated, Ambulation techniques are utilized to increase safety for the resident and staff. The P&P indicated to ensure safety during ambulation, the staff member had to observe correct guarding or spotting by standing on the weakest side and just a little behind and to use their other hand to support the resident's shoulder or hip, if needed.
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LAKEWOOD HEALTHCARE CENTER in DOWNEY, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in DOWNEY, CA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from LAKEWOOD HEALTHCARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.