At Evergreen Lakeport Healthcare, a 90-year-old male resident fell from his wheelchair and hit his head on the floor, causing a significant head wound and profuse bleeding. The Assistant Director of Nursing reported the resident fell when a CNA attempted to tie the resident’s shoes and he stood up and fell forward. Upon investigation, a CNA witness told a much different story. The CNA witness saw a staff person ask the resident if he was ready to go to bed. He replied “no.” The staff person then grabbed the resident by his ankles, against his will, and dragged him and his wheelchair for 20 feet, causing him to fall and hit his head on the ground. (“sounded like a bowling ball hitting concrete”) The resident died three days later. The facility was cited for failure to ensure the resident was treated with dignity and respect and fined $20,000.