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F0689
D

Improper Transfer Method Used for Resident with Amputation

Black River Falls, Wisconsin Survey Completed on 12-03-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident with a right below the knee amputation, who was care planned for transfer with a full body mechanical lift and assistance of two staff, was instead transferred using a sit-to-stand mechanical lift. The facility's policy specifies that residents who cannot sit, stand, or bear weight should not be lifted manually and require a mechanical assist. Despite this, a Certified Nursing Assistant (CNA) used a sit-to-stand lift for the transfer, contrary to the resident's care plan and facility policy. This action was confirmed through interviews with the CNA and the Nursing Home Administrator, as well as review of the resident's care plan and facility policy.

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