**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and video footage review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice by failing to follow the facility's accident policy by moving a resident after a fall and failing to assess 1 (Resident #2) of 2 (Resident #2, #3) residents after a fall. The deficient practice resulted in an Immediate Jeopardy for Resident #2 on 02/14/2024 at approximately 5:35:22 a.m. (per video footage observed) when S3 Van Driver attempted to load Resident #2 on the van lift without following the manufacturer's guidelines for that van lift. S3 Van Driver tried to lift Resident #2's wheelchair over the side of the van lift instead of wheeling Resident #2 on to the front of the lift, as per manufacturer's guidelines. When S3 Van Driver grabbed the front left leg of the wheelchair to get over the side of the van lift, the wheelchair flipped over backwards with Resident #2 in the chair and landed on the concrete. S3 Van Driver called for help and S4 RN (Registered Nurse), S5 LPN (Licensed Practical Nurse), and S6 CNA (Certified Nurse Assistant) came out of the facility to help. S4 RN and S6 CNA then lifted Resident #2's wheelchair with him in it to an upright position. S5 LPN and S6 CNA both lifted the wheelchair over the side of the van lift with Resident #2 in the wheelchair. S3 Van Driver continued to load Resident #2 in the van and then took Resident #2 to his scheduled dialysis. Shortly after Resident #2 arrived at dialysis, the dialysis staff called the facility to let them know Resident #2 complained of severe pain to his neck and dialysis staff called EMS (Emergency Medical Service) who transported Resident #2 to an acute ER (Emergency Room). After arriving at the ER, Resident #2 was found to have a C3 (cervical 3) burst fracture. By the facility failing to implement protective measures, there was a high likelihood that additional severe harm, injury, or death could occur to any of the 66 residents residing in the facility who have the potential for transport in the facility van per the Resident Census and Conditions Report dated 02/19/2024. S1 Administrator was notified of the Immediate Jeopardy on 02/21/2024 at 1:20 p.m. The immediate jeopardy ended on 02/22/2024 at 6:50 p.m. The facility implemented an acceptable Plan of Removal as confirmed through onsite observations, interviews, and record reviews prior to exit. Findings: Review of facility's Policy for Resident Incident and Visitor Accident Report policy (revised 7/23/2018; last reviewed Jan. 2023) revealed in part: Policy The facility will conduct an investigation of all incidents involving residents of the facility. B. Resident Incidents/Accidents: 1. If you witness an incident/accident, you must: immediately summons help; do not move the resident until he/she has been assessed by a licensed nurse; do not leave the resident unattended. 2. Licensed nurse must: a. examine the resident and obtain vital signs b. if the resident hit his/her head or if the incident is unwitnessed initiate neurological checks. c. conduct further assessment as warranted d. render appropriate treatment Review of Resident #2's medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses that included, in part, End Stage Renal disease, dependence of renal dialysis and acquired absences of left leg above knee and right leg above knee. Upon Resident #2's return to the facility on [DATE] the diagnosis of displaced fracture of third cervical vertebra and sprain of ligaments of cervical spine, sequela related to a subsequent encounter for fracture with routine healing was added. Record review of Resident #2's MDS (minimum data set) dated 11/30/2023 revealed, in part, Resident #2 had a BIMS (brief interview of mental status) score of 15 indicating intact cognition. Resident #2 required extensive assistance with bed mobility, transfers, and toilet use. Review of the facility's video record dated 02/14/2024, revealed the following: At 5:31:35 a.m. S3 Van Driver brought Resident #2 outside next to van and locked wheelchair. S3 Van Driver proceeded to get the lift down to ground. At 5:34:30 a.m. S3 Van Driver attempted to put Resident #2 on the lift and was struggling due to the other van that was parked on the other side. At 5:35:22 a.m. S3 Van Driver attempted to raise the front of the wheelchair over the lip of the side of the van lift. S3 Van Driver grabbed the front left side of Resident #2's wheelchair and Resident #2 and the wheelchair flipped over backwards. S3 Van Driver then started knocking on the door to facility trying to get help. At 5:37:31 a.m. S4 RN poked her head out the door and then went back inside. S3 Van Driver stayed with Resident #2. At 5:38:43 a.m. S4 RN came outside. At 5:38:54 a.m. S5 LPN and S6 CNA came out of facility. At 5:39:06 a.m. S4 RN and S6 CNA lifted Resident #2's wheelchair to an upright position with the resident in the chair. At 5:39:50 a.m. S5 LPN and S6 CNA lifted Resident #2's wheelchair onto to the van lift over the lip of the lift. At 5:41:04 a.m. S3 Van Driver loaded Resident #2 into the van and proceeded to take Resident #2 to dialysis. Upon completion of video review by surveyors, the video failed to reveal a head to toe assessment was completed on Resident #2 by S4RN and S5LPN. Record review of Resident #2's hospital records for an admission date of 02/14/2024 revealed the following, in part: Discharge Summary admission Date 02/14/2024 discharge date [DATE] History of Present Illness- Resident #2 is a [AGE] year old male .status post fall from wheelchair this morning on the way to dialysis. Patient states that he was being loaded in the van and was flipped out of his wheelchair and landed on the posterior aspect of his head. Patient denies any loss of consciousness, numbness/tingling, or upper extremity weakness. Endorses some mild pain in his neck, which prompted Cat-Scan for C (cervical)-Spine. He denied nausea, vomiting, diarrhea or headache. Magnetic Resonance Imaging C-spine: C3 burst fracture with retropulsed fragment and ligamentum flavum hypertrophy result in severe spinal canal stenosis and compression upon the spinal cord. Neurosurgery consulted. Patient admitted to team two. Hospital course: Neurosurgery planning intervention on 02/16/2024. Pain medications to control pain. On morning of surgery (02/16/2024), patient decided against surgical intervention. Neurosurgery was made aware of patient's decision and they are ok with the patient discharging with MJ collar. MJ collar to be worn strictly at all times. Given existing cervical stenosis, patient is high risk for spinal cord injury/paraplegia. Record review of Resident #2's physician orders, dated 02/17/2024, revealed an order for Miami J (MJ) Collar to neck every shift. During an interview on 02/19/2024 at 2:00 p.m., Resident #2 reported S3 Van Driver was trying to load him (Resident #2) on the lift of the van to go to dialysis and there was another van beside the lift. S3 Van Driver tried to get his (Resident #2's) wheelchair loaded on the side of the lift and S3 Van Driver lifted the front wheels of the wheelchair. Resident #2 further reported the wheelchair flipped over backwards and I (Resident #2) hit the concrete. When Resident #2 got to dialysis his neck was hurting bad and dialysis sent him to the emergency room. Resident #2 verified that his neck was broken and a collar was placed on him after he declined having a surgery on his neck. During a telephone interview on 02/20/2024 at 12:35 p.m., S5 LPN indicated on 02/14/2024 she went outside when she was called to help Resident #2 after he fell backwards in wheelchair. S5 LPN then indicated she and S3 Van Driver lifted the wheelchair over the lip of the side of the van lift with S3 Van Driver on the front of the wheelchair and S5LPN on the backside of the wheelchair and they manually lifted the chair on to the van lift and then S3 Van Driver took Resident #2 to the dialysis center. During an interview on 02/20/2024 at 1:36 p.m. S4 RN confirmed she saw Resident #2 lying on his back in the parking lot. S4 RN confirmed she asked Resident #2 if he was okay and he said he wanted to go to dialysis and staff lifted his chair onto the van lift and Resident #2 was transported to dialysis. S4 RN acknowledged she did not do a head to toe assessment on Resident #2 after his fall. During a telephone interview on 02/21/2024 at 11:18 a.m., S8 MD (Medical Doctor) indicated he did not receive a call from the facility on 02/14/2024. S8 MD then indicated he came to the facility on [DATE] and a nurse told him that Resident #2 had a fall and had a neck fracture. S8 MD indicated if the facility had called him when the incident happened he would have told them to not move the resident, call 911 and wait for EMS (Emergency Medical Services) to assess the resident. During a telephone interview on 02/20/2024 at 11:30 a.m., S7 Dialysis Center RN indicated on 02/14/2024, Resident #2 arrived at the dialysis center and he was crying due to pain is his neck. Resident #2 indicated he hit his head during the fall at the facility. S7 Dialysis Center RN indicated Resident #2 should have been sent to the hospital instead of going to dialysis. During an interview on 02/20/2024 at 1:25 p.m. S1 Administrator viewed the video of Resident #2's fall and confirmed S4 RN and S5 LPN were called to the scene and did not assess Resident #2 prior to picking him and his wheelchair up off the ground and should have. S1Administrator acknowledged S4 RN and S5 LPN lifted Resident #2 in his wheelchair onto the van lift and allowed S3 Van Driver to transport Resident #2 to dialysis. S1 Administrator confirmed staff should not have lifted Resident #2 off the ground and EMS (Emergency Medical Services) should have been called. S1 Administrator further verified S4 RN and S5 LPN did not assess Resident #2 prior to picking Resident #2 off the ground. During an interview on 02/20/2024 at 2:05 p.m., S2 Corporate Nurse watched the video of Resident #2 from 02/14/2024 and then verified S4 RN and S5 LPN did not assess Resident #2 prior to and after lifting Resident #2 in his wheelchair off the ground and the staff should have called EMS (911) to send Resident #2 to the ER.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interviews, and video review, the facility failed to ensure the residents' environment remains as free of accident hazards as possible for each resident who is transported in the facility's van via wheelchair. The facility's staff failed to follow the guidance of the manufacturer's 'Step by Step Wheelchair Lift Operation Guide' in the loading of wheelchaired residents for 1 (Resident #1) of 2 (Resident #2 and #3) residents reviewed for falls. The deficient practice resulted in an Immediate Jeopardy for Resident #2 on 02/14/2024 at approximately 5:35:22 a.m. (per video footage observed) when S3 Van Driver attempted to load Resident #2 on the van lift without following the manufacturer's guidelines for that van lift. S3 Van Driver tried to lift Resident #2's wheelchair over the side of the van lift instead of wheeling Resident #2 on to the front of the lift, as per manufacturer's guidelines. When S3 Van Driver grabbed the front left leg of the wheelchair to get over the side of the van lift, the wheelchair flipped over backwards with Resident #2 in the chair and landed on the concrete. S3 Van Driver called for help and S4 RN (Registered Nurse), S5 LPN (Licensed Practical Nurse), and S6 CNA (Certified Nurse Assistant) came out of the facility to help. S4 RN and S6 CNA then lifted Resident #2's wheelchair with him in it to an upright position. S5 LPN and S6 CNA both lifted the wheelchair over the side of the van lift with Resident #2 in the wheelchair. S3 Van Driver continued to load Resident #2 in the van and then took Resident #2 to his scheduled dialysis. Shortly after Resident #2 arrived at dialysis, the dialysis staff called the facility to let them know Resident #2 complained of severe pain to his neck and dialysis staff called EMS (Emergency Medical Service) who transported Resident #2 to an acute ER (Emergency Room). After arriving at the ER, Resident #2 was found to have a C3 (cervical 3) burst fracture. By the facility failing to implement protective measures, there was a high likelihood that additional severe harm, injury, or death could occur to any of the 66 residents residing in the facility who have the potential for transport in the facility van per the Resident Census and Conditions Report dated 02/19/2024. S1 Administrator was notified of the Immediate Jeopardy on 02/21/2024 at 1:20 p.m. The immediate jeopardy ended on 02/22/2024 at 6:50 p.m. The facility implemented an acceptable Plan of Removal as confirmed through onsite observations, interviews, and record reviews prior to exit. Findings: Review of facility's Policy for Resident Incident and Visitor Accident Report policy (revised 7/23/2018; last reviewed Jan. 2023) revealed in part: Policy The facility will conduct an investigation of all incidents involving residents of the facility. B. Resident Incidents/Accidents: 1. If you witness an incident/accident, you must: immediately summon help, do not move the resident until he/she has been assessed by a licensed nurse, do not leave the resident unattended. 2. Licensed nurse must: a. examine the resident and obtain vital signs b. if the resident hit his/her head or if the incident is unwitnessed initiate neurological checks. c. conduct further assessment as warranted d. render appropriate treatment Review of facility's Driver and Vehicle Safety Policy (revised 03/2023) revealed in part: Driver Selection: The following criteria are evaluated when selecting individuals to drive on behalf of the company: Demonstration of full understanding of this safety policy during in-servicing prior to driving for the company; Demonstrated ability to safely load and unload residents if the employee will be driving the company vehicle. Review of the manufacturer's guide for How to Operate a Wheelchair Lift, Step by Step Wheelchair Operation Guide, provided by S1 Administrator, included: Loading a passenger- To load a passenger, start with platform at ground level and the outer barrier fully extended. Move the passenger onto lift platform into position within yellow boundaries. Again, lock the wheelchair brakes or turn off wheelchair power . Observation of the van lift on 02/22/2024 at 10:42 a.m. by surveyor revealed the lift had a raised three to four inch lip (approximately) on each side of the lift and a flat ramp on the front of the lift. Review of Resident #2's medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses that included, in part, End Stage Renal disease, dependence of renal dialysis and acquired absences of left leg above knee and right leg above knee. Upon Resident #2's return to the facility on [DATE] the diagnosis of displaced fracture of third cervical vertebra and sprain of ligaments of cervical spine, sequela related to a subsequent encounter for fracture with routine healing was added. Record review of Resident #2's MDS (minimum data set) dated 11/30/2023 revealed, in part, Resident #2 had a BIMS (brief interview of mental status) score of 15 indicating intact cognition. Resident #2 required extensive assistance with bed mobility, transfers, and toilet use. Record review of Resident #2's comprehensive care plans revealed the following, in part: Focus: The resident has had an actual fall, date initiated 02/14/2024. Interventions included- 02/14/2024 witnessed fall with injury. While attempting to load Resident #2, in wheelchair, onto facility van Resident #2's wheelchair flipped backwards. Resident stated, She (S3 Van Driver) dropped me., but was unable to give any other details. S3 Van Driver stated she underestimated maneuvering needed to navigate wheelchair onto van due to limited space. S3 Van driver also stated she prevented resident's head from hitting concrete/ground. Resident #2 refused to return inside facility for further evaluation stating he needed to go to dialysis today. Resident #2 loaded on facility van and transferred to dialysis clinic for scheduled dialysis at 5:45 a.m. At 6:39 a.m. dialysis nurse notified facility that Resident #2 was sent out to an acute ED (emergency department) for evaluation and treatment due to complaint of neck pain. New order 02/17/2024 Miami J Collar in place to neck every shift; PT (physical therapy) consult for strength and mobility; Monitor/document/report as needed every 72 hours to MD (medical doctor) for signs and symptoms of pain, bruises, change in mental status, new onset confusion, sleepiness, inability to maintain posture, agitation . Review of the facility's video record dated 02/14/2024, revealed the following: At 5:31:35 a.m. S3 Van Driver brought Resident #2 outside next to van and locked wheelchair. S3 Van Driver proceeded to get the lift down to ground. At 5:34:30 a.m. S3 Van Driver attempted to put Resident #2 on the lift and was struggling due to the other van that was parked on the other side. At 5:35:22 a.m. S3 Van Driver attempted to raise the front of the wheelchair over the lip of the side of the van lift. S3 Van Driver grabbed the front left side of Resident #2's wheelchair and Resident #2 and the wheelchair flipped over backwards. S3 Van Driver then started knocking on the door to facility trying to get help. At 5:37:31 a.m. S4 RN poked her head out the door and then went back inside. S3 Van Driver stayed with Resident #2. At 5:38:43 a.m. S4 RN came outside. At 5:38:54 a.m. S5 LPN and S6 CNA came out of facility. At 5:39:06 a.m. S4 RN and S6 CNA lifted Resident #2's wheelchair to an upright position with the resident in the chair. At 5:39:50 a.m. S5 LPN and S6 CNA lifted Resident #2's wheelchair onto to the van lift over the lip of the lift. At 5:41:04 a.m. S3 Van Driver loaded Resident #2 into the van and proceeded to take Resident #2 to dialysis. Record review of Resident #2's nurse's notes revealed the following, in part: Note on 02/14/2024 by S5 LPN created 08:05:55 a.m. - Writer (S5 LPN) was called outside per east hall nurse at 5:24 a.m. Upon exiting the writer observed Resident #2 flipped over backward in his wheelchair. Resident #2 wasn't able to explain exactly what happened. Resident #2 just stated she (S3 Van Driver) dropped me. Resident #2 examined and assisted off the ground per three staff. Vital signs collected. Writer (S5 LPN) asked Resident #2 to come back inside. Resident #2 said no he needed his dialysis today. Writer (S5 LPN) said ok and notified dialysis of the situation. Writer (S5 LPN) spoke with S7 Dialysis RN at Dialysis at 5:40 a.m. Resident #2 left the facility at 5:45 a.m. in stable condition. Note on 02/14/2024 by S5 LPN- Staff from dialysis called at 6:39 a.m. to report Resident #2 was being sent to ER for evaluation and treatment due to neck pain. Record review of Resident #2's hospital records for an admission date of 02/14/2024 revealed the following, in part: Discharge Summary admission Date 02/14/2024 discharge date [DATE] History of Present Illness- Resident #2 is a [AGE] year old male .status post fall from wheelchair this morning on the way to dialysis. Patient states that he was being loaded in the van and was flipped out of his wheelchair and landed on the posterior aspect of his head. Patient denies any loss of consciousness, numbness/tingling, or upper extremity weakness. Endorses some mild pain in his neck, which prompted Cat-Scan for C (cervical)-Spine. He denied nausea, vomiting, diarrhea or headache. Magnetic Resonance Imaging C-spine: C3 burst fracture with retropulsed fragment and ligamentum flavum hypertrophy result in severe spinal canal stenosis and compression upon the spinal cord. Neurosurgery consulted. Patient admitted to team two. Hospital course: Neurosurgery planning intervention on 02/16/2024. Pain medications to control pain. On morning of surgery (02/16/2024), patient decided against surgical intervention. Neurosurgery was made aware of patient's decision and they are ok with the patient discharging with MJ collar. MJ collar to be worn strictly at all times. Given existing cervical stenosis, patient is high risk for spinal cord injury/paraplegia. Record review of Resident #2's physician orders, dated 02/17/2024, revealed an order for Miami J (MJ) Collar to neck every shift. During an interview on 02/19/2024 at 2:00 p.m., Resident #2 reported S3 Van Driver was trying to load him on the lift of the van to go to dialysis on 02/14/2024 and there was another van beside the lift. S3 Van Driver tried to get his wheelchair loaded on the side of the lift and she S3 Van Driver lifted the front wheels of the wheelchair. Resident #2 further reported the wheelchair flipped over backwards and I (Resident #2) hit the concrete. When Resident #2 got to dialysis his neck was hurting bad and dialysis sent him to the emergency room. Resident #2 verified that his neck was broken and a collar was placed on him after he declined having a surgery on his neck. During an interview on 02/20/2024 at 1:15 p.m., S3 Van Driver indicated she was loading up Resident #2 on the van lift on 02/14/2024. The van on the other side was blocking the lift to be able to put the resident on the lift. S3 Van Driver then proceeded to attempt to lift the front of the wheelchair over the side lip of the lift and the wheelchair flipped over backwards. S3 Van Driver indicated she kept the resident's head from hitting the ground. S3 Van Driver then tried to get help from staff in the facility and the nurses came out to help her. During a telephone interview on 02/20/2024 at 12:35 p.m., S5 LPN indicated on 02/14/2024 she went outside when she was called to help Resident #2 after he fell backwards in wheelchair. S5 LPN indicated Resident #2 was shook up and said he hit his head during the fall and there was a hematoma on the back of his head. S5 LPN indicated she completed an assessment and got Resident #2 back up in his wheelchair. S5 LPN told Resident #2 we needed to go back inside the facility and Resident #2 said he had to go to dialysis and he was persistent about going. S5 LPN then indicated she and S3 Van Driver lifted the wheelchair over the lip of the side of the van lift with S3 Van Driver on the front of the wheelchair and S5 LPN on the backside of the wheelchair and they manually lifted the chair on to the van lift and then S3 Van Driver took Resident #2 to the dialysis center. S5 LPN indicated she called the dialysis center to let them know what happened and then after Resident #2 got to the dialysis center, the dialysis nurse called and said his neck was hurting and they were going to send him to the hospital. During an interview on 02/20/2024 at 1:36 p.m. S4 RN confirmed on 02/14/2024 she saw Resident #2 lying on his back in the parking lot. S4 RN confirmed she asked Resident #2 if he was okay and he said he wanted to go to dialysis and staff lifted his chair onto the van lift and Resident #2 was transported to dialysis. S4 RN acknowledged she did not do a head to toe assessment on Resident #2 after his fall. During a telephone interview on 02/21/2024 at 11:18 a.m., S8 MD (Medical Doctor) indicated he did not receive a call from the facility on 02/14/2024. S8 MD then indicated he came to the facility on [DATE] and a nurse told him that Resident #2 had a fall and had a neck fracture. S8 MD indicated if the facility had called him when the incident happened he would have told them to not move the resident, call 911 and wait for EMS to assess the resident. During an interview on 02/19/2024 at 9:20 a.m., S1 Administrator indicated facility had a new van driver who was fully trained (S3Van Driver). S1 Administrator reported on 02/14/2024, S3 Van Driver was trying to load Resident #2 on to the lift from behind the van. Another transport van was behind the lift of the van that she was trying to get Resident #2 in. Since the lift was blocked from the back where you normally load residents on the van, S3 Van Driver attempted to put the wheelchair on the side of the lift. When S3 Van Driver lifted the front of the wheelchair, it flipped over backwards. This caused Resident #2 to fall to the concrete and Resident #2 suffered a C3 fracture. During a telephone interview on 02/20/2024 at 11:30 a.m., S7 Dialysis Center RN indicated on 02/14/2024, the nursing home staff called letting her know that Resident #2 had a fall when attempting to be loaded on the facility van. S3 Van Driver came into the clinic and asked for help unloading Resident #2. When she (S7 Dialysis Center RN) went to help the driver, Resident #2 was crying in pain of the due to neck pain. Resident #2 indicated to her that he hit his head during the fall. S3 Van Driver said she caught his head and his head didn't hit the ground. S7 Dialysis Center RN indicated Resident #2 should have been sent to the hospital instead of going to dialysis. During an interview on 02/20/2024 at 1:25 p.m. S1 Administrator viewed the video footage from 02/14/2024 and acknowledged Resident #2 was not loaded onto the van by S3 Van Driver appropriately leading to Resident #2 being dropped onto his back in the facility parking lot. During an interview on 02/20/24 at 1:29 p.m., S3 Van Driver watched the video from 02/14/2024 of the incident of Resident #2 flipping over in wheelchair and she reported, Well I guess I didn't catch him from falling. I thought I did. During an interview on 02/20/2024 at 2:05 p.m., after S2 Corporate Nurse watched the video of Resident #2's fall on 02/14/2024 while trying to be lifted on the van, S2 Corporate Nurse indicated that staff should have moved the van so Resident #2 could safely be put on the van lift. S2 Corporate Nurse confirmed S4 RN and S5 LPN did not assess Resident #2 prior to and after lifting Resident #2 in his wheelchair of the ground and they should have. During an interview on 02/22/2024 at 9:00 a.m., S1 Administrator reviewed S3 Van Driver's training and verified S3 Van Driver did not complete watching an online video that is required for safety for lift and tie downs on her checklist sheet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews and video footage review, the facility failed to ensure the van driver possessed the competency to load a resident on to the facility van correctly and nursing staff possessed the competency to assess residents after a fall for 1 (Resident #2) of 2 (Resident #2 and #3) residents reviewed for falls. The deficient practice resulted in an Immediate Jeopardy for Resident #2 on 02/14/2024 at approximately 5:35:22 a.m. (per video footage observed) when S3 Van Driver attempted to load Resident #2 on the van lift without following the manufacturer's guidelines for that van lift. S3 Van Driver tried to lift Resident #2's wheelchair over the side of the van lift instead of wheeling Resident #2 on to the front of the lift, as per manufacturer's guidelines. When S3 Van Driver grabbed the front left leg of the wheelchair to get over the side of the van lift, the wheelchair flipped over backwards with Resident #2 in the chair and landed on the concrete. Did you observe hiS3 Van Driver called for help and S4 RN (Registered Nurse), S5 LPN (Licensed Practical Nurse), and S6 CNA (Certified Nurse Assistant) came out of the facility to help. S4 RN and S6 CNA then lifted Resident #2's wheelchair with him in it to an upright position. S5 LPN and S6 CNA both lifted the wheelchair over the side of the van lift with Resident #2 in the wheelchair. S3 Van Driver continued to load Resident #2 in the van and then took Resident #2 to his scheduled dialysis. Shortly after Resident #2 arrived at dialysis, the dialysis staff called the facility to let them know Resident #2 complained of severe pain to his neck and dialysis staff called EMS (Emergency Medical Service) who transported Resident #2 to an acute ER (Emergency Room). After arriving at the ER, Resident #2 was found to have a C3 (cervical 3) burst fracture. By the facility failing to implement protective measures, there was a high likelihood that additional severe harm, injury, or death could occur to any of the 66 residents residing in the facility who have the potential for transport in the facility van per the Resident Census and Conditions Report dated 02/19/2024. S1 Administrator was notified of the Immediate Jeopardy on 02/21/2024 at 1:20 p.m. The Immediate Jeopardy ended on 02/22/2024 at 6:50 p.m. The facility implemented an acceptable Plan of Removal as confirmed through onsite observations, interviews, and record reviews prior to exit. Findings: Review of facility's Driver and Vehicle Safety Policy (revised 03/2023) revealed in part: Driver Selection: The following criteria are evaluated when selecting individuals to drive on behalf of the company . Demonstration of full understanding of this safety policy during in servicing prior to driving for the company; Demonstrated ability to safely load and unload residents if the employee will be driving the company vehicle What to do in the event of an Emergency or Accident: In the event of an emergency while transporting residents, employees should follow the established policies and procedures of the company as if in the facility. Following are guidelines for the driver in the event of an accident: At the scene of the accident: Always stop if involved in an accident, call or have another party call 911 to summons an ambulance and/or police, and do not drive a resident or employee to the hospital. Wait for an ambulance to transport injured parties. Review of facility's Resident Incident and Visitor Accident Report policy (last reviewed 01/2023) revealed in part: Policy: The facility will conduct an investigation of all incidents involving residents of the facility. B. Resident Incidents/Accidents: 1. If you witness an incident/accident, you must: immediately summons help; do not move the resident until he/she has been assessed by a licensed nurse; do not leave the resident unattended. 2. Licensed nurse must: a. examine the resident and obtain vital signs b. if the resident hit his/her head or if the incident is unwitnessed initiate neurological checks. c. conduct further assessment as warranted d. render appropriate treatment Review of Resident #2's medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses that included, in part, End Stage Renal disease, dependence of renal dialysis and acquired absences of left leg above knee and right leg above knee. Upon Resident #2's return to the facility on [DATE] the diagnosis of displaced fracture of third cervical vertebra and sprain of ligaments of cervical spine, sequela related to a subsequent encounter for fracture with routine healing was added. Record review of Resident #2's MDS (minimum data set) dated 11/30/2023 revealed in part, Resident #2 had a BIMS (brief interview of mental status) score of 15 indicating intact cognition. Resident #2 required extensive assistance with bed mobility, transfers, and toilet use. Review of the facility's video record dated 02/14/2024, revealed the following: At 5:31:35 a.m. S3 Van Driver brought Resident #2 outside next to van and locked wheelchair. S3 Van Driver proceeded to get the lift down to ground. At 5:34:30 a.m. S3 Van Driver attempted to put Resident #2 on the lift and was struggling due to the other van that was parked on the other side. At 5:35:22 a.m. S3 Van Driver attempted to raise the front of the wheelchair over the lip of the side of the van lift. S3 Van Driver grabbed the front left side of Resident #2's wheelchair and Resident #2 and the wheelchair flipped over backwards. S3 Van Driver then started knocking on the door to facility trying to get help. At 5:37:31 a.m. S4 RN poked her head out the door and then went back inside. S3 Van Driver stayed with Resident #2. At 5:38:43 a.m. S4 RN came outside. At 5:38:54 a.m. S5 LPN and S6 CNA came out of facility. At 5:39:06 a.m. S4 RN and S6 CNA lifted Resident #2's wheelchair to an upright position with the resident in the chair. At 5:39:50 a.m. S5 LPN and S6 CNA lifted Resident #2's wheelchair onto to the van lift over the lip of the lift. At 5:41:04 a.m. S3 Van Driver loaded Resident #2 into the van and proceeded to take Resident #2 to dialysis. Upon completion of video review by surveyors, the video failed to reveal a head to toe assessment was completed on Resident #2 by S4RN and S5LPN. During an interview on 02/19/2024 at 2:00 p.m., Resident #2 reported S3 Van Driver was trying to load him on the lift of the van to go to dialysis on 02/14/2024 and there was another van beside the lift. S3 Van Driver tried to get his wheelchair loaded on the side of the lift and S3 Van Driver lifted the front wheels of the wheelchair. Resident #2 further reported the wheelchair flipped over backwards and I (Resident #2) hit the concrete. When Resident #2 got to dialysis his neck was hurting bad and dialysis sent him to the emergency room. Resident #2 verified that his neck was broken and a collar was placed on him after he declined having a surgery on his neck. During an interview on 02/20/2024 at 1:15 p.m., S3 Van Driver indicated she was loading up Resident #2 on the van lift on 02/14/2024. The van on the other side was blocking the lift to be able to put the resident on the lift. S3 Van Driver then proceeded to attempt to lift the front of the wheelchair over the side lip of the lift and the wheelchair flipped over backwards. S3 Van Driver acknowledged she did not follow proper protocol when loading Resident #2 on to the van lift. S3 Van Driver confirmed Resident #2 should have been loaded going forward on to the lift and not lifted over the side. During a telephone interview on 02/20/2024 at 12:35 p.m., S5 LPN indicated on 02/14/2024 she went outside when she was called to help Resident #2 after he fell backwards in wheelchair. S5 LPN indicated Resident #2 was shook up and said he hit his head during the fall and there was a hematoma on the back of his head. S5 LPN indicated she completed an assessment and got Resident #2 back up in his wheelchair. S5 LPN told Resident #2 we needed to go back inside the facility and Resident #2 said he had to go to dialysis and he was persistent about going. S5 LPN then indicated she and S3 Van Driver lifted the wheelchair over the lip of the side of the van lift with S3 Van Driver on the front of the wheelchair and S5LPN on the backside of the wheelchair and they manually lifted the chair on to the van lift and then S3 Van Driver took Resident #2 to the dialysis center. S5 LPN indicated she called the dialysis center to let them know what happened. During an interview on 02/20/2024 at 1:36 p.m., S4 RN confirmed on 02/14/2024 she saw Resident #2 lying on his back in the parking lot. S4 RN confirmed she asked Resident #2 if he was okay and he said he wanted to go to dialysis and staff lifted his chair onto the van lift and Resident #2 was transported to dialysis. S4 RN acknowledged she did not do a head to toe assessment on Resident #2 after his fall. During a telephone interview on 02/21/2024 at 11:18 a.m., S8 MD (Medical Doctor) indicated he did not receive a call from the facility on 02/14/2024 regarding Resident #2's fall. S8 MD reported if the facility had called him he would have instructed staff to not move the resident, call 911 and wait for EMS to assess the resident. S8 MD acknowledged Resident #2 should not have been moved by staff and loaded on to the facility van for transport to dialysis. During an interview on 02/19/2024 at 9:20 a.m., S1 Administrator indicated facility had a new van driver (S3 Van Driver). S1 Administrator reported on 02/14/2024, S3 Van Driver was trying to load Resident #2 on to the lift from behind the van. Another transport van was behind the lift of the van that she was trying to get Resident #2 in. Since the lift was blocked from the back where you normally load residents on the van, S3 Van Driver attempted to put the wheelchair on the side of the lift. When S3 Van Driver lifted the front of the wheelchair, it flipped over backwards. This caused Resident #2 to fall to the concrete and Resident #2 suffered a C3 (cervical 3) fracture. During a telephone interview on 02/20/2024 at 11:30 a.m., S7 Dialysis Center RN indicated on 02/14/2024, the nursing home staff called letting her know that Resident #2 had a fall when attempting to be loaded on van. S3 Van Driver came into the clinic and asked for help unloading Resident #2. When she (S7 Dialysis Center RN) went to help the driver, Resident #2 was crying in pain of the neck. Resident #2 indicated to her that he hit his head during the fall. S7 Dialysis Center RN indicated Resident #2 should have been sent to the hospital instead of going to dialysis. During an interview on 02/20/2024 at 1:25 p.m., S1 Administrator viewed the video footage from 02/14/2024 with surveyors and acknowledged Resident #2 was not loaded onto the van by S3 Van Driver appropriately leading to Resident #2 being dropped onto his back in the facility parking lot. S1 Administrator confirmed S4 RN and S5 LPN were called to the scene and did not assess Resident #2 prior to picking him and his wheelchair up off the ground and should have. S1Administrator acknowledged S4 RN and S5 LPN lifted Resident #2 in his wheelchair onto the van lift and allowed S3 Van Driver to transport Resident #2 to dialysis. S1 Administrator confirmed staff should not have lifted Resident #2 off the ground and EMS (Emergency Medical Services) should have been called. During an interview on 02/20/2024 at 2:05 p.m., after S2 Corporate Nurse watched the video of Resident #2's fall while trying to be lifted on the van, S2 Corporate Nurse indicated S3 Van Driver should have moved the van so Resident #2 could safely be put on the van lift. S2 Corporate Nurse verified S4 RN and S5 LPN did not do an assessment after Resident#2 fell backwards in wheelchair and should have. S2 Corporate Nurse further indicated when Resident #2 had the fall; staff should have called EMS and sent Resident #2 to ER for evaluation. During an interview on 02/22/2024 at 9:00 a.m., S1 Administrator reviewed S3 Van Driver's training and verified S3 Van Driver did not complete watching an on line training video, required for safety for lift and tie downs and should have.

Based on record review, interview and video footage review, the facility failed to be administered in a manner that enabled its resources to be used effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being for 1 (Resident #2) of 2 (Resident #2 and #3) residents after a fall: 1. by failing to ensure a system was in place to safely transport Resident #2 in the facility van; 2. by failing to ensure the van driver possessed the competency to load a resident on to the facility van correctly and nursing staff possessed the competency to assess residents after a fall; and 3. by failing to ensure a system was in place to provide necessary care and treatment in accordance with professional standards of practice to Resident #2 after an incident on 02/14/2024. The lack of administrative oversight resulted in an Immediate Jeopardy for Resident #2 on 02/14/2024 at approximately 5:35:22 a.m. (per video footage observed) when S3 Van Driver attempted to load Resident #2 on the van lift without following the manufacturer's guidelines for that van lift. S3 Van Driver tried to lift Resident #2's wheelchair over the side of the van lift instead of wheeling Resident #2 on to the front of the lift, as per manufacturer's guidelines. When S3 Van Driver grabbed the front left leg of the wheelchair to get over the side of the van lift, the wheelchair flipped over backwards with Resident #2 in the chair and landed on the concrete. S3 Van Driver called for help and S4 RN (Registered Nurse), S5 LPN (Licensed Practical Nurse), and S6 CNA (Certified Nurse Assistant) came out of the facility to help. S4 RN and S6 CNA then lifted Resident #2's wheelchair with him in it to an upright position. S5 LPN and S6 CNA both lifted the wheelchair over the side of the van lift with Resident #2 in the wheelchair. S3 Van Driver continued to load Resident #2 in the van and then took Resident #2 to his scheduled dialysis. Shortly after Resident #2 arrived at dialysis, the dialysis staff called the facility to let them know Resident #2 complained of severe pain to his neck and dialysis staff called EMS (Emergency Medical Service) who transported Resident #2 to an acute ER (Emergency Room). After arriving at the ER, Resident #2 was found to have a C3 (cervical 3) burst fracture. By the facility failing to implement protective measures, there was a high likelihood that additional severe harm, injury, or death could occur to any of the 66 residents residing in the facility who have the potential for transport in the facility van per the Resident Census and Conditions Report dated 02/19/2024. S1 Administrator was notified of the Immediate Jeopardy on 02/21/2024 at 1:20 p.m. The immediate jeopardy ended on 02/22/2024 at 6:50 p.m. The facility implemented an acceptable Plan of Removal as confirmed through onsite observations, interviews, and record reviews prior to exit. Findings: Cross Reference F689, F726, F684 During an interview on 02/20/2024 at 1:25 p.m., S1 Administrator viewed the video footage from 02/14/2024 with surveyors and acknowledged Resident #2 was not loaded onto the van by S3 Van Driver appropriately leading to Resident #2 being dropped onto his back in the facility parking lot. S1 Administrator confirmed S4 RN and S5 LPN were called to the scene and did not assess Resident #2 prior to picking him and his wheelchair up off the ground and should have. S1Administrator acknowledged S4 RN and S5 LPN lifted Resident #2 in his wheelchair onto the van lift and allowed S3 Van Driver to transport Resident #2 to dialysis. S1 Administrator confirmed staff should not have lifted Resident #2 off the ground and EMS (Emergency Medical Services) should have been called. During an interview on 02/20/2024 at 2:05 p.m., after S2 Corporate Nurse watched the video of Resident #2's fall while trying to be lifted on the van, S2 Corporate Nurse indicated S3 Van Driver should have moved the van so Resident #2 could safely be put on the van lift. S2 Corporate Nurse verified S4 RN and S5 LPN did not do an assessment after Resident#2 fell backwards in wheelchair and should have. S2 Corporate Nurse further indicated when Resident #2 had the fall; staff should have called EMS and sent Resident #2 to ER for evaluation. During an interview on 02/22/2024 at 9:00 a.m., S1 Administrator reviewed S3 Van Driver's training and verified S3 Van Driver did not complete watching an on line training video, required for safety for lift and tie downs and should have. During an interview on 02/22/2024 at 3:10 p.m., S1 Administrator verified she was the person that was ultimately responsible for what happened in the facility. S1Administrator further verified the facility did not identify areas of concern and they should have been aware.