**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards. Specifically, the facility failed to: 1) Establish safety measures for proper cigarette disposal and the use of required adaptive devices, identified during smoking safety assessments, for residents who smoke tobacco on the facility's campus for 5 residents (#'s 9, 10, 21, 32, and 47), out of 7 total residents who smoked; 2) Complete annual smoking safety screening assessments for 4 residents (#'s 9, 21, 32, and 47), out of 7 total residents who smoked; 3) Complete smoking safety screening assessments for 3 residents (#'s 12, 25, and 54), out of 3 total residents who used electronic cigarettes (known as vapes); and 4) Secure lighters within the facility for 6 residents (#'s 9, 10, 21, 32, 47, and 53), out of 7 total residents who smoked. These failed practices placed all 9 residents at immediate risk of injury and/or death and placed all residents (based on a census of 60) at immediate risk for exposure to a smoke/fire environment which could have resulted in injury and/or death, which constituted an immediate jeopardy at CFR 483.25(d) Accidents. This situation was brought to the attention of the facility's administration on 3/26/25 at 1:30 PM, at which time the facility was notified of the identified immediate jeopardy. The facility submitted an acceptable removal plan on 3/26/25 at 6:17 PM. The State Agency verified onsite that the immediacy was removed on 3/26/25 at 8:30 PM. Following the removal of the immediacy, noncompliance remained at isolated actual harm that was not immediate. Findings: Campus Layout Observations on 3/23-27/25 revealed the facility campus was situated on a property with maintained grass around the front of the building within 6 feet of the entrances and within 1 foot of the building walls. Further observation revealed a rock border, with planted foliage, was positioned flush against the building's walls, which extended approximately one foot to the grass border and around the grass to the sidewalks that led to the entrances. The facility had two entrances, most often used, at the front of the building: the main entrance (which entered the main lobby of the building) and a secondary entrance (which entered a resident common space and dining room area for the facility). There was a third entrance as well, which lead directly into the hospice wing of the building. Surrounding the property, directly off the paved driveway, parking lot, and sidewalks of the building was tall, dry grass-like foliage and trees that were not maintained. It was observed that, due to the time of the year, this grass-like foliage was last year's growth and was yellow, dry and brittle in appearance. Further observation revealed no designated smoking area with a fire-proof receptable for cigarette butts on campus, nor was there any directly off the campus property. During an interview on 3/24/25 at 10:26 AM, the Director of Nursing (DON) stated the facility was a smoke-free facility and residents were to smoke off property. Facility Smoking Policy Review of the facility-provided smoking policy, received on 3/24/25, revealed: Smoking/Vaping Policy. Maple Springs is a smoke-free and vape-free campus. Smoking and vaping are not permitted on Maple Springs property. Employees and residents who wish to smoke or vape must do so off the property. There are no designated smoking times or locations. During an interview on 3/27/25 at 12:32 PM, the DON stated this smoking policy was signed by all residents upon admission. Tobacco Use During an interview on 3/26/25 at 1:52 PM, the DON stated when a resident was identified as a smoker, a smoking safety screening assessment was completed, and smoking interventions were placed in care plans. The DON further stated smoking safety screening assessments were to be completed annually. Resident #9 Record review on 3/23-27/25 revealed Resident #9 was admitted in the facility with diagnoses that included hemiplegia (paralysis on one side of the body), hemiparesis (weakness on one side of the body), unspecified epilepsy (unprovoked seizures caused by abnormal electrical activity in the brain), GERD (gastric esophagial reflux disease) and major depressive disorder. Review of Resident #9's Smoking - Safety Screen (a screening assessment to determine if a resident was safe to smoke), revealed the resident was last assessed on 12/8/23. Further review revealed the resident had visual and dexterity problems and Resident #9 needed to use adaptive equipment of a smoking apron to smoke safely. An observation on 3/25/25 at 5:33 PM, revealed Resident #9 was smoking by the secondary entrance and was positioned by a handicapped parking space. Further observation revealed the resident was not wearing a smoking apron. Resident #9 was observed extinguishing his/her cigarette on the wheelchair's right wheel [NAME]. He/she discarded the cigarette by throwing it into the parking space. An observation on 3/25/25 at 4:30 PM, outside, near the secondary entrance, revealed more than 200 cigarette butts, lying 6 feet from the right side of the entrance and 9 feet from the left side of the entrance, scattered on the grass and rock borders of the sidewalk to the entrance. Most of these butts were not flattened, or crushed, to indicate they were not extinguished prior to being discarded on the grass or rocks. Further observation revealed there was no fireproof receptacle in the vicinity to which cigarette butts could be deposited. Further observation revealed there was one non-fireproof trash can, with a lid that had a circular, uncovered hole at its center, with a non-fire proof black, plastic garbage bag in the trash can near the entrance. There was ignitable paper products within this trash can. Further observation revealed a sign on the entrance door Smoking on premises prohibited by law including vapes. Fine $50. Smokefree.alaska.gov AS [Alaska Statute] 18.35.301. During an interview on 3/26/25 at 10:10 AM, Resident #9 stated that he/she smoked nearly every day and that he/she kept his/her supplies (cigarettes and lighters) in the side pouch of his/her wheelchair or in his/her room. He/she stated that he/she usually smoked by the front of the main entrance or in front of the secondary entrance. Resident #9 stated that he/she put out his/her cigarette butts by extinguishing them on the wheelchair's control panel or on the wheelchair's [NAME]. He/she further stated he/she discarded the cigarettes by throwing them into the parking lot or the trash can by the entrances of the facility. Resident #9 stated that he/she had gotten burned before and proceeded to show two burn holes on the left side of the shirt he/she was wearing. He/she further stated that most of his/her clothing had these types of burn holes. Resident #9 further stated that he/she didn't like the apron because it flaps everywhere in the wind outside. Review of Resident #9's Behavior Note, dated 3/26/25 (the day the immediate jeopardy was issued), revealed: .Resident was smoking outside facility and somehow [his/her] fire fell off to [his/her] lap burning a hole in [his/her] jeans through to [his/her] brief and through the brief to [his/her] L [left] side scrotum. Small blister noted to skin, provider made aware as well . as nursing administration. Area dry without noted weeping, cleansed with soap and water LOA [left open to air]. Will evaluate area shift by shift to determine possible tx [treatment] options. Review of Resident #9's care plan, last revised 2/29/24, revealed: .Goal: The resident will not suffer injury from unsafe smoking practices through the review date . Interventions: Observe clothing and skin for signs of cigarette burns . resident safe to smoke without supervision as long as smoking apron is used when smoking. Resident #10 Record review on 3/23-27/25 revealed Resident #10 was admitted to the facility with diagnoses that included left leg below the knee amputation, type 2 diabetes, dementia, COPD (chronic obstructive pulmonary disease - a lung disease that blocks airflow making it difficult to breathe), and kidney disease. Review of Resident #10 Smoking - Safety Screen, dated 10/29/24, revealed the resident needed to use adaptive equipment of a smoking apron to smoke safely. Resident is able to get [himself/herself] outside to smoke on [his/her] own and can light [his/her] own cigarette to smoke. During an interview and concurrent observation on 3/26/25 at 9:25 AM, when asked about smoking, Resident #10 stated, I'm a smoker, and I've smoked here for longer than most people have worked here. I smoke outside and don't go with anyone. I put my cigarette butts in the trash can outside, there are several trash cans for that out there. I've never been told I can't smoke outside, but the staff have asked me to move away from the premises. I've also had problems getting back in the building because nobody would help me. I keep a full pack of cigarettes in my night drawer, but there's no lighter there. The doctor tells me I shouldn't smoke, but that's what I do. A full pack of [NAME] cigarettes was observed in the first drawer of the resident's nightstand. Review of Resident #10's care plan, last revised on 3/23/25, revealed: the resident is a cigarette smoker .will not suffer injury from unsafe smoking practices through the review date .interventions: instruct resident about smoking risks and hazards and about smoking cessation aids that are available; instruct resident about the facility policy on smoking: locations, times, safety concerns; notify charge nurse immediately if it is suspected resident has violated facility smoking policy; observe clothing and skin for cigarette burns; offer/encourage/assist resident with the use of smoking apron while smoking as resident allows; resident can smoke unsupervised; the resident is able to light own cigarette safely. Resident #21 Record review on 3/23-27/25 revealed Resident #21 was admitted to the facility with diagnoses that included hemiplegia and hemiparesis following a cerebral infarction (stroke that is caused by lack of blood flow to the brain) that affected the left non-dominant side, left above the knee amputation, and mild cognitive impairment. Review of Resident #21's Smoking - Safety Screen, revealed the resident was last assessed on 1/2/24. Further review revealed the resident had cognitive loss and Resident #21 needed to use adaptive equipment of a smoking apron to smoke safely. During an interview on 3/27/25 at 11:57 AM, the DON stated that all smokers in the facility should have a Smoking-Safety Screen completed annually. When asked if Resident #21's 2025 annual Smoking-Safety Screen was completed, the DON stated it was not. Resident #32 Record review on 3/23-27/25 revealed Resident #32 was admitted to the facility with diagnoses that included nontraumatic chronic subdural hemorrhage (a slow-developing collection of blood beneath the dura mater, the outermost layer of the brain's covering), dysphagia (difficulty swallowing), acute kidney failure, and repeated falls. Review of Resident #32's Smoking - Safety Screen, revealed the resident was last assessed on 1/2/24. Further review revealed the assessment indicated the resident was able to smoke safely independently. During an interview on 3/26/25 at 8:53 AM, Resident #32 stated he/she had been at the facility for about 5 years. He/she stated he/she smoked daily for the last 2 years here at the facility. Resident #32 stated he/she smoked outside by the handicap parking on the sidewalk in front of the building. Resident #32 stated staff have never told him/her he/she couldn't smoke on the facility's property. When asked how he/she deposited his/her cigarette butts, Resident #32 stated he/she crushed the butt and threw it into the trash can by the entrances to the building. Resident #32 further stated that other residents throw their butts all over the ground and residents have complained repeatedly to leadership about this and asked for a cigarette butt canister with sand in it. When asked how leadership had responded, Resident #32 stated leadership would not do it. An observation on 3/25/25 at 4:40 PM, outside near the main entrance, revealed more than 150 cigarette butts, lying 6 feet 8 inches from the right side of the entrance and 5 feet from the left side of the entrance, scattered on the grass and rock borders of the sidewalk to the entrance. Most of these butts were not flattened, or crushed, to indicate they were not extinguished prior to being discarded on the grass or rocks. Further observation revealed there was no fireproof receptacle in the vicinity to which cigarette butts could be deposited. Further observation revealed there was one non-fireproof trash bin, with a lid that had a circular, uncovered hole at its center, with a non-fire proof, black plastic garbage bag in the trash can. There was ignitable paper products within this trash can. Further observation revealed a sign on the entrance door Smoking on premises prohibited by law including vapes. Fine $50. Smokefree.alaska.gov AS 18.35.301. Resident #47 Record review on 3/23-27/25 revealed Resident #47 was admitted to the facility with diagnoses that included quadriplegia (paralysis of all four limbs), orthopedic aftercare following surgical amputation, stage 4 (deep wound that may impact muscle, tendons, ligaments and bone) pressure ulcer of the sacral region, unspecified neuromuscular dysfunction of the bladder, and GERD. Review of Resident #47's Smoking - Safety Screen, revealed the resident was last assessed on 1/19/24. Further review revealed the assessment indicated the resident had dexterity problems and Resident #47 needed to use adaptive equipment of a smoking apron and cigarette holder to smoke safely. Resident wears smoking apron and able to light up [his/her] cigarette independently and hold [his/her] cigarette his own as well . Resident is able to use electric wheelchair to ambulate outside and able to use holder to hold cigarette and light up cigarette [himself/herself]. An observation on 3/23/25 at 8:26 AM, as the survey team was entering the facility to initiate the survey, revealed Resident #47 sitting in his/her wheelchair approximately 15 feet from the main entrance of the building smoking a cigarette. Further observation revealed the resident had the cigarette between the tines of a plastic fork taped to the resident's hand brace. Further observation revealed no smoking apron was used. An observation on 3/25/25 at 4:40 PM, as surveyors were exiting the main entrance, revealed Resident #47 smoking approximately 20 feet directly in front of the entrance. Cigarette smoke entered the building on an incoming current of air from the outside as the sliding doors opened. Further observation revealed Resident #47 had the cigarette between the tines of a plastic fork taped to the resident's hand brace. Further observation revealed no smoking apron was used. An observation on 3/25/25 at 8:05 AM revealed Resident #47 was smoking by the facility's emergency generator located off to the side of the secondary entrance. Further observation revealed the resident's cigarette was skewered on one of the tines of the plastic fork. He/she stated that he/she utilized the fork to keep the cigarette stable which was taped onto a small grey Velcro hand brace. Further observation revealed no smoking apron was used. Resident #47 further stated he/she declined using the smoking apron because the apron flaps in the wind. Resident #47 further stated it was very windy all the time. An observation on 3/26/25 at 8:20 AM, revealed Resident #47 was smoking by the facility's emergency generator located off to the side of the secondary entrance. Resident #47 was not wearing an apron, and the cigarette was lodged in the space between the tines of the plastic fork. During an interview on 3/25/25 at 3:15 PM, Resident #47 stated that he/she smoked daily. During a follow-up interview on 3/26/25 at 8:22 AM, Resident #47 stated that he/she kept his/her supplies in his/her own room by his/her nightstand. He/she stated he/she usually smoked by the front of the main entrance or by the secondary entrance where the generators were located. He/she extinguished and disposed of the cigarettes in his/her own ashtray that was located on the left side of his/her wheelchair. Resident #47 denied any injuries from smoking but further added due to his/her diagnoses, he/she waited on the wind to blow the cigarette ash away when it fell on his/her clothing. Review of Resident #47's care plan, last revised on 3/23/25, revealed: .Goal: The resident will not suffer injury from unsafe smoking practices through the review date . Interventions: .resident safe to smoke without supervision as long as smoking apron and cigarette holder is used when smoking . Smoking Aprons During an interview with a concurrent observation, on 3/26/25 at 2:52 PM, when asked how a resident could obtain a smoking apron, the MDS Nurse pulled a smoking apron from her desk drawer and stated residents would need to come to her office and ask for one. The MDS Nurse's office was in the main dining plaza area (by the secondary entrance). During an interview with a concurrent observation, on 3/26/25 at 2:57 PM, the receptionist stated she would be able to provide a smoking apron if a resident asked for one. The receptionist stated they were kept behind the receptionist's desk. She also stated if a resident from the second floor wanted to grab one on the way down, they could grab one from a drawer in the main plaza area by the elevator. Vapes Resident #12 Record review on 3/23-27/25 revealed Resident #12 was admitted to the facility with diagnoses that included type 2 diabetes, depression, chronic pain, atrial fibrillation (irregular heart rhythm), hepatic encephalopathy (brain dysfunction from liver failure) and alcoholic cirrhosis of the liver with ascites (liver scarring from alcohol with fluid buildup). During an interview on 3/26/25 at 9:08 AM, when asked about smoking, Resident #12 stated, I'd vape, but they (the facility) put me on a patch and weaned me off. I'd rather smoke indoors, but they won't let you. He/she said, Currently, I don't go out to smoke, but I have used the ashtrays by the front desk and another by the side door (referring to the trash cans outside). They just told me I had to stay away from the door. Resident #12 also stated that when he/she needed help getting back inside, he/she had to wait by the door (it locks if you go out). Otherwise, you just sit there and freeze in the winter. This happened to me about three or four months ago. Resident #12 also stated he/she does not currently have a vape in his/her room. Resident #12 stated that he/she vaped but no longer kept the vape in his/her room. He/she mentioned the doctor recently prescribed patches to help with smoking cessation, then discontinued the patch altogether. The resident further stated he/she, does not remember signing any waivers for smoking in the facility. Review of Resident #12's medical record revealed no smoking safety screening assessment. Review of Resident #12's care plan, last revised on 3/23/25, revealed: the resident is at risk for nicotine dependence r/t [related to] nicotine vape use. The resident will not suffer injury from unsafe vaping practices through the review date . interventions: instruct resident about smoking/vaping and hazards and about nicotine cessation aids that are available; instruct resident about the facility policy on smoking/vaping: locations, times, safety concerns; monitor oral hygiene; notify charge nurse immediately if it is suspected resident has violated facility smoking/vaping policy. Resident #25 Record review on 3/23-27/25 revealed Resident #25 was admitted to the facility with diagnoses that included paraplegia (paralysis of the lower half of the body), cellulitis of the lower limb (potentially serious bacterial skin infection), orthopedic aftercare following surgical amputation, and neuromuscular dysfunction of bladder (a condition where the bladder's ability to store and empty urine is impaired due to nerve damage or dysfunction). During an interview on 3/26/25 at 8:50 AM, Resident #25 stated that he/she quit smoking when he/she was admitted and switched to vape products. The resident stated that he/she usually went with his/her sister to the smoke shop to smoke. The resident further stated that he/she did not smoke while in the facility. The resident further added that his/her vaping products were kept near his/her nightstand. Review of Resident #25's medical record revealed no smoking safety screen assessment. Review of Resident #25's care plan, last reviewed 3/23/25, revealed: .Goal: The resident will not suffer injury from unsafe vaping practices through the review date .Interventions . Instruct resident about smoking/vaping risks and hazards and about smoking/nicotine cessations aids that are available . Instruct resident about the facility policy on smoking/vaping: locations, times, safety concerns . Notify charge nurse immediately if it is suspected resident has violated facility smoking/vaping policy. Review of the Food and Drug Administration article, Tips to Help Avoid Vape Battery Fires or Explosions, dated 4/12/23, at https://www.fda.gov/tobacco-products/products-ingredients-components/tips-help-avoid-vape-battery-fires-or-explosions, revealed: You may have heard that e-cigarettes, or vapes, can catch on fire or explode and seriously hurt people. Although these incidents are uncommon, vape fires and explosions are dangerous to the person using the vape product and others around them . The exact causes of fires or explosions are not yet clear, but some evidence suggests that battery-related issues may be a cause . Until all vapes and vape batteries conform to strong and consistent safety standards, your best protection against vape battery fires or explosions may be knowing as much as possible about your device and how to properly handle and charge its batteries . Charge your vape on a clean, flat surface, away from anything that can easily catch fire and someplace you can clearly see it - not on a couch or pillow where it may more easily overheat or get turned on accidentally . Protect your vape from extreme temperatures by not leaving it in direct sunlight . Don't vape around flammable gasses or liquids, such as oxygen . Make sure you know how to safely dispose of e-cigarettes . Resident #54 Record review on 3/23-27/25 revealed Resident #54 was admitted to the facility with diagnoses that included anoxic brain damage (damage to the brain caused by a complete lack of oxygen, which may lead to serious and permanent neurological problems), unspecified convulsions (sudden, involuntary muscle contractions or movements of unknown cause or type), alcoholic cirrhosis of the liver without ascites (chronic liver disease caused by excessive alcohol use where the liver becomes scarred and impairs liver function), and pulmonary hypertension (high blood pressure in the artery of the lungs that makes the heart work harder to pump blood and can lead to heart failure). Review of Resident's #54's care plan, last revised on 3/23/25, revealed: Focus .The resident is at risk for nicotine dependence r/t [related to] nicotine vape use .Goal .The resident will not suffer injury from unsafe vaping practices through the review date .Interventions . Instruct resident about smoking/vaping risks and hazards and about smoking/nicotine cessations aids that are available . Instruct resident about the facility policy on smoking/vaping: locations, times, safety concerns . Notify charge nurse immediately if it is suspected resident has violated facility smoking/vaping policy. Review of Resident #54's medical record revealed no smoking safety screening assessment. Review of Resident #54's Plan of Care Note, a late entry note effective 12/20/24 at 3:20 PM, but was created on 3/26/25 at 3:25 PM, revealed: CNA [Certified Nursing Assistant] brought to this writer's attention that Resident frequently goes outside with significant other to use [his/her] nicotine vape. This writer had discussion with resident and provided to education to resident about the risks of nicotine dependence and the option for nicotine cessation if [he/she] would like. Resident declines nicotine cessation at this time. During an interview on 3/26/25 at 1:26 PM, the DON stated that residents who vape should have smoking safety assessments performed. During an interview on 3/26/25 at 4:05 PM, the DON stated Resident #54 did not smoke or vape on admission. Resident #54 was observed on 12/20/24 to have family putting a cigarette to his/her lips during visits outside. During an interview on 3/27/25 at 11:36 AM, the DON stated Resident #54 should have had a smoking safety assessment performed earlier. Lighters in the Building During an interview on 3/26/25 at 1:52 PM, the DON stated that resident lighters were allowed to stay with the residents who smoked cigarettes. The DON stated the facility did not maintain accountability of these lighters because the facility was a smoke-free campus. Resident #9 Review of Resident #9's Smoking - Safety Screen, dated 12/8/23, revealed: . Does resident need facility to store lighter and cigarettes? Answer: No. During an interview on 3/26/25 at 10:11 AM, Resident #9 stated that his/her cigarettes and lighters were all self-purchased. He/she further stated that these were typically stored in the side pouch of his/her wheelchair and proceeded to show the pouch containing his/her cigarettes and 4 pocket style BiC (brand name) lighters. He/she also stated that there were extra lighters stored in his/her room. Resident #10 Review of Resident #10 Smoking - Safety Screen, dated 10/29/24, revealed: . Does resident need facility to store lighter and cigarettes? Answer: No. Resident #21 Review of Resident #21's Smoking - Safety Screen, dated 1/2/24, revealed: . Does resident need facility to store lighter and cigarettes? Answer: No. Resident #32 Review of Resident #32's Smoking - Safety Screen, dated 1/19/24, revealed: . Does resident need facility to store lighter and cigarettes? Answer: No. During an interview on 3/26/25 at 8:53 AM, Resident #32 stated he/she purchased his/her own cigarettes and lighters and has them hidden in his/her bedroom. Resident #47 Review of Resident #47's Smoking - Safety Screen, dated 1/19/24, revealed: . Does resident need facility to store lighter and cigarettes? Answer: No. An observation on 3/25/25 at 3:15 PM, revealed Resident #47's electric arc lighter and cigarettes were unsecured on his/her nightstand. During an interview on 3/25/25 at 3:16 PM, Resident #47 stated his/her cigarettes and lighters were all self-purchased. He/she further added these were usually stored by his/her nightstand or by the wheelchair for ease of access as he/she smoked daily. Resident #53 Review of Resident #53's Smoking - Safety Screen, dated 2/19/25, revealed: . Does resident need facility to store lighter and cigarettes? Answer: No. During an interview and concurrent observation on 3/26/25 at 9:27 AM, revealed Resident #53 indicated he/she kept his/her cigarette and lighters in his/her coat pocket. Resident #53 also indicated to the surveyor that he/she kept his/her coat in his/her wardrobe. While talking with Resident #53 an empty [NAME] cigarette pack was lying on the floor of Resident #53's room. Observations on 3/23-27/25 revealed the facility had 69 resident rooms. These rooms were unsecure an often the bedroom doors were left open and accessible to all current 60 residents of the facility. Resident room doors were left open when the residents who resided in them were elsewhere in the facility. Review of the MDS Resident Matrix (a form used to identify pertinent care categories during a survey), completed by the facility on 3/23/25, revealed 17 residents in the facility had some form of Alzheimer's or dementia (increasing the risk of exposure to unsecure lighters and introducing a smoke/fire environment within the facility). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, interview, and observation the facility failed to identify and implement safe application, as well as, education and training for staff on appropriate utilization of a seatbelt securement system used for securing wheelchair bound residents during transport in the facility van and/or bus. This failed practice led to 1 resident (#1) obtaining a significant injury, specifically, a compound fracture of the lower leg after sliding out of his/her wheelchair. This failure placed 3 resident's (#'s 2;3;4) who were observed using the facility transportation on 2/14/23 and 9 resident's (#s' 5; 6; 7; 8; 9; 10; 11; 12; 13) scheduled to use the van and/or bus transportation during the week of 2/14/23, including wheelchair-bound residents using the facility transportation for activities, at immediate risk for serious harm and or injury from possible ejection, dislodgment, or injury during a sudden stop and/or accident while riding in the facility vehicle. Findings: Record review on 2/14/23 revealed Resident #1 had diagnoses that included osteoarthritis, depression, and anxiety. Review of Nurses Notes, dated 1/25/23 at 1:55 PM, revealed Facility transportation staff called the facility to let them know the res [Resident #1] slid forward when [he/she] stopped and [his/her] ankle is injured. [He/she] had already pulled over and called 911. This RN [Registered Nurse] notified [Resident Representative] via phone at 1328 [1:28 PM]. Notified [him/her] that the res has an injury to [his/her] ankle and an ambulance was on their way to pick [his/her] up and would be taking [him/her] to [hospital emergency room]. During an interview on 2/14/23 at 10:19 AM, the Administrator stated the facility provided a shuttle bus and a [NAME] van to transport residents to appointments. The Administrator stated Resident #1 was riding in the [NAME] van and was injured when the driver came to an abrupt stop at a red light. Further stating Resident #1 had slid out of the seatbelt and ended up sitting on the pedals of the wheelchair. He stated the Resident was admitted to the hospital for an open fracture of the right leg and other injuries. The Administrator stated Resident #1 had not returned to the facility after admission to the hospital. Observations of the [NAME] van, with the Administrator, revealed the backseats of the van were removed and there was enough space to accommodate 2 wheelchairs. The Administrator demonstrated how the wheelchairs were secured using the Q'Straint Securement System and further explained the process that a resident in a wheelchair is brought into the van, and the brakes on the wheelchair are locked. The wheelchair is then secured to the floor using 4 tie-downs with the Q'Straint system. The 2 tie-downs for the rear of the wheelchair had a lap belt that is to be placed through the armrests and over the resident and connected in front of the resident. When asked about the seatbelts observed hanging on the left side of the van wall, the Administrator stated the one pre-installed by the manufacturer was not used and the other seatbelt, a Q'Straint shoulder belt was not used. During an observation on 2/14/23 at 11:00 AM, Driver #2 pushed Resident #2 out to the [NAME] van in his/her wheelchair. The Driver pushed the wheelchair up the ramp and secured the wheelchair in the van using the Q'Straint tie-downs. Driver #2 then pulled the lap belt over the top of the wheelchair armrests and snapped the buckle in front of the Resident. A gap between the resident and the lap belt was observed. A shoulder strap was not used. During a second interview on 2/14/23 at 12:35 PM, the Administrator was asked for the manufacturer's instructions or education on the use of the Q'Straint Securement System. The Administrator stated he would have to check, when asked if he knew of any Q'Straint training videos, he stated that he had never seen them. No information on the manufacturer's instructions or education was provided by the facility prior to the survey exit on 2/14/23 at 5:00 PM. During an interview on 2/14/23 at 12:35 PM, Driver #1 stated he/she drove Resident #1 to an appointment when the incident occurred. He/she stated he/she used both the [NAME] van and the facility bus when transporting residents. When asked what training the facility had provided, he/she stated Driver #3 trained him/her by demonstrating how to secure the residents in the vehicles. Driver #1 stated he had also shadowed Driver #3 and did ride-alongs for a couple of days. Driver #1 further stated that on 1/25/23 he/she loaded Resident #1 in the van as usual. The Resident was seated in a wheelchair and positioned on a blue sling and the resident was leaning to one side. Driver #1 stated he/she locked the wheels of the chair, attached the tie-downs to the front and back wheels and positioned the lap belt over Resident #1. The Driver stated because of the Resident's larger size, there was no room to run the lap belt between the arm rest and the back of the wheelchair. While driving he/she looked back and asked the Resident if he/she was okay, to which the Resident replied, Yeah. Driver #1 further stated he/she had come to an abrupt stop at a red light, he/she looked back and saw that Resident #1 had slid out of the wheelchair and was sitting on the foot pedals of the wheelchair and the lap belt was up around the Resident's chin. He/she pulled over and removed the strap from around the Resident's neck. The Resident was unable to get up or move, at which point the Driver noticed the Resident's right leg was bleeding. Driver #1 stated he/she called 911, then the Administrator of the facility. During an observation on 2/14/23 at 12:52 PM, Driver #1 demonstrated, using the wheelchair, used by Resident #1, how he/she had locked the wheels, tied down the wheelchair and had placed the lapbelt between the back of the wheelchair and the armrests and in front of the resident. The wheelchair was large and had a blue nylon cushion in the seat. During an interview on 2/14/23 at 1:22 PM, Driver #3 stated he/she had been training facility staff on how to secure and transport the residents in the facility van. When asked what training had been provided and utilized, the Driver stated his/her training consisted of verbal instruction and shadowing another driver. Driver #3 stated the facility started conducting audits after the incident with Resident #1. When asked about specific training on the Q'Straint system, the Driver stated he/she had not reviewed any Q'Straint videos, and his/her training had been verbal. Observation on 2/14/23 at 1:39 PM revealed Resident #3 arrived in the van with Driver #2 driving. When the door opened, the Resident was observed seated in a wheelchair in the van. The wheelchair was anchored to the floor with the Q'Straint anchor straps, and the lap belt came up from the two back anchors, between the seat and the wheels and around the outside of the armrest panel. The seat belt was buckled in the front and was not touching the Resident, leaving a large gap between the resident's abdomen and the lapbelt. The shoulder strap was not attached to the seatbelt system. During an interview on 2/14/23 at 2:00 PM, Occupational Therapist and the Physical Therapist (PT) stated the facility had not asked their department to review the seatbelt securement system since the incident with Resident #1. Further stating they had not been involved in the facility investigation nor trainings with securement systems. During an interview on 2/14/23 at 3:35 PM, when asked about his/her van ride, Resident #3 stated the drivers have straps everywhere with one over his/her lap. The Resident stated they did not use a shoulder strap. Resident #3 stated he/she feels like he/she is going to fall out of the wheelchair at times. An observation on 2/14/23 at 4:10 PM, revealed Driver #2 returned to the facility with Resident #4. During an interview at 4:20 PM, when asked about the use of the lap belt and the shoulder harness, Driver #2 stated he/she was unsure how it attached and stated he/she had never used the shoulder harness. Review of the transport schedule on 2/14/23 revealed 9 residents were scheduled to use the facility transportation from 2/15-17/23, for activities. Review on 2/14/23 of a facility Follow-up Investigation report, dated 1/30/23, revealed secured resident in the van and departed to [his/her] doctor's visit. While the van was breaking routinely for a traffic light, the Resident slid from [his/her] seat twisting [his/her] right ankle and becoming stuck on the seatbelt. Driver then pulled over, removed seatbelt, and called 911 for assistance. if Systemic actions . While our investigation did not find abuse or neglect, increased training and oversight will be implemented to ensure the safe transport of our residents. Non-emergency braking procedures will be reviewed with all transport drivers. Proper securing of residents being transported will also be reviewed with all transport drivers. Spot audits will be conducted within the next 60 days to ensure that residents or property secured when being transported in a Maple vehicle. Review of employee training records on 2/14 /23 revealed that Drivers #'s 1; 2; 3; 4 and the Administrator had no documented training on how to utilize the Q'Straint Securement Systems for securing wheelchair bound residents in the facility provided van and/or bus. Review of the Transportation Safety Competency Checklist for Driver #3, dated 1/27/23, signed off by the Director of Nursing (DON), revealed Pre-Transport Checklist .6. Resident's seatbelt is appropriately fastened, positioned and tight prior to departure. Review of the Transportation Safety Competency Checklist for Driver #1, dated 1/27/23, signed off by Driver #3 and the DON revealed Pre-Transport Checklist .6. Resident's seatbelt is appropriately fastened, positioned and tight prior to departure. Review of the Transportation Safety Competency Checklist for Driver #2, dated 1/27/23, signed off by Driver #3 and the DON revealed Pre-Transport Checklist .6. Resident's seatbelt is appropriately fastened, positioned and tight prior to departure. Review of the Transportation Safety Competency Checklist for Driver #4, dated 1/27/23, signed off by Driver #3 and the DON revealed Pre-Transport Checklist .6. Resident's seatbelt is appropriately fastened, positioned and tight prior to departure. Review of the Administrator's training record revealed there was not a Transportation Safety Competency Checklist or information about the use of the Q'Straint Securement System. The review of the checklist's revealed there was no information specific to the Q'straint securement system for the wheelchairs. Review of the facility Driver Safety Policy -General Industry policy, effective 4/26/2019, revealed Basic Vehicle Operation Guidelines: Employees are required to adhere to the following basic vehicle operation principles: Always use seat belts. There was no manufacturer information about the use of the Q'Straint Securement System and employee education. .