Lakewood Healthcare Center
LAKEWOOD HEALTHCARE CENTER in DOWNEY, CA — inspection on December 31, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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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