CNA #5 attempted to move Resident #2 from bed to wheelchair alone, even though the resident's care plan had been revised to require two-person transfers after a fall. The assistant had no knowledge of the updated requirement.
"The resident looked wobbly and weak, so she attempted to sit Resident #2 on the bed," CNA #5 told inspectors during a January interview. "She said the resident was seated on the edge and had to be assisted to the ground."
The resident was wearing non-slip socks and a gait belt during the transfer attempt. CNA #5 said Resident #2 "usually required one-person staff assistance to transfer," unaware that protocols had changed.
The breakdown occurred because updated care plan interventions were never transcribed to CNA tasks. Staff remained uninformed of critical safety changes implemented after the resident's previous fall.
The Director of Nursing confirmed the communication failure during multiple interviews with inspectors. "CNA #5 did not know Resident #2 became a two-person assist with transfers," the DON said. "The new intervention that was implemented after Resident #2's fall of the resident becoming a two person transfer was not transcribed onto the CNA tasks, which led to CNA #5's lack of knowledge of the resident's current transfer status."
Federal inspectors found the facility failed to ensure proper implementation of fall prevention interventions. The care plan revision requiring two-person assistance had been initiated following the resident's previous fall, but critical information never reached direct care staff.
The DON described proper fall response protocols during her interview. "When a fall was sustained by a resident, the staff should try to determine the root cause of the fall with an IDT approach," she said. "The initial response should include making sure the resident was safe and could access their call light."
She acknowledged that care plans should be updated when new interventions are implemented. After Resident #2's fall, the facility revised the fall care plan with new interventions, including the two-person transfer requirement.
However, the DON was unable to determine whether a two-person transfer had occurred at the time of the fall that prompted the care plan revision.
The inspection revealed a systematic communication breakdown between clinical decision-making and direct care implementation. While administrators updated care plans with appropriate safety interventions, they failed to ensure frontline staff received the information necessary to carry out those interventions.
CNA #5's description of the transfer attempt highlighted the resident's physical instability. The assistant recognized the resident appeared "wobbly and weak" but proceeded with a single-person transfer, unaware that facility protocols now required additional assistance.
The resident ultimately had to be "assisted to the ground" during the failed transfer attempt, despite wearing appropriate safety equipment including non-slip socks and a gait belt.
Federal regulations require nursing homes to implement care plan interventions designed to prevent avoidable accidents and maintain resident safety. The failure to communicate updated transfer requirements to direct care staff undermined these safety measures.
The inspection found that some residents were affected by the facility's failure to properly implement two-person assistance for transfers. The violation carried a determination of minimal harm or potential for actual harm.
South Valley Post Acute Rehabilitation's breakdown in communication left vulnerable residents at risk during transfers, with nursing assistants operating under outdated protocols while administrators believed new safety measures were in place.
The facility's inability to bridge the gap between care plan revisions and daily care tasks exposed residents to preventable risks during routine activities like transfers from bed to wheelchair.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for South Valley Post Acute Rehabilitation from 2026-01-29 including all violations, facility responses, and corrective action plans.