**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from neglect when the facility failed to obtain immediate medical assistance for Resident #1 who sustained a fall from a wheelchair in the facility van. Resident #1 was transported back to the facility while lying on the floor of the facility van and was not assessed by licensed personal for approximately thirty (30) minutes during transport for one (1) of four (4) sampled residents (Resident #1). On [DATE] Resident #1 was transported to an appointment by the Administrator in a wheelchair at 1:06 PM without assistance from a nurse or Certified Nursing Assistant (CNA). At 1:49 PM on [DATE] the Administrator called Licensed Practical Nurse (LPN)#1 to inform her that Resident#1 had slipped from the wheelchair, but he stated she was not injured and was on the way back to the facility with the resident. Resident #1 was transported back to the facility while lying on the floor of the facility van for approximately 42 miles and arrived back at the facility at 2:40 PM. The facility's failure to ensure Resident #1 was properly secured and transported safely, under trained supervision, resulted in her fall from a wheelchair in the facility van. Resident #1 was transported back to the facility while lying on the floor of the facility van for approximately thirty minutes. This failure and a lack of immediate assessment by licensed personnel placed the resident in a situation that was likely to cause serious injury, serious harm, serious impairment, or death. The situation was determined to be Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), which began on [DATE], when Resident #1 sustained a fall from a wheelchair in the facility van and was not assessed by licensed personal for approximately thirty (30) minutes during transport. The State Agency (SA) notified the Administrator of the IJ on [DATE] at 04:20 PM and provided an IJ Template. The SA validated the Removal Plan on [DATE], and determined that the IJ was removed on [DATE], prior to SA exit. Therefore, the scope and severity for CFR §483.12 Freedom from Abuse, Neglect, and Exploitation - F600 was lowered from a J to a D while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: A review of the facility's policy, Transportation Assistant Document, dated Copyright 2024, revealed, Position Purpose; Provides transport assistive services to assigned residents in accordance with care plans, facility policies and procedures and at the direction of supervisor(s); Required Qualifications . Certified Nursing Assistant in good standing with the state . Current CPR/BLS (Cardiopulmonary Resuscitation/Basic Life Support) certifications. A review of the facility's policy, Transporting a Resident (Facility Van), dated Copyright 2025, revealed, .It is the policy of this facility to provide residents safe, non-emergency transportation to doctor's appointments . 3.Facility will ensure that residents who require an escort to appointments due to cognitive or physical limitations have arrangements made ahead of time .6.Each resident will be secured in a seat with a seatbelt or in their wheelchair secured with wheelchair tie downs . Record review of the incident report dated [DATE] revealed Resident arrived at facility in facility van accompanied by facility employee. Resident positioned on buttocks, resting on bilateral footrests. Resident WC (wheelchair) foot pedals resting on van floor. WC secured with four floor harnesses. Tilted forward slightly. Lap seat belt buckled but not tightened across resident abdominal area. Pressure cushion tilted forward slightly and down towards floors at front edge of WC seat, resting against mid-thoracic region of back. Resident's left foot extended straight beneath back bench seat, sock intact. Right lower extremity extended forward slightly with knee flexed and right foot resting in front of pelvic region. Sock is intact to right foot. Does not recall how she came to be seated on bilateral WC footrests on van floor. On [DATE] at 3:49 PM, during an interview with the Resident Representative (RR) for Resident #1, she explained that the Director of Nursing Services (DNS) informed them that Resident #1 had fallen out of her wheelchair in the van during transport and was returned to the facility unsecured on the floor. She stated that the Administrator should have contacted emergency services and not transported the resident alone. She confirmed Resident #1 was admitted to a medical center on [DATE] due to Congestive Heart Failure, Urinary Tract Infection, and Septicemia. On [DATE] at 4:15 PM, during an interview with the Administrator, he explained he transported Resident #1 alone to an appointment approximately thirty-five (35) miles away. He stated the resident began scooting forward, fell to the floor of the van, and did not verbally respond after the fall. He confirmed he did not seek emergency assistance and drove back to the facility with the resident lying on the floor between the back of a van seat and the wheelchair. On [DATE] at 11:15 AM, during an interview with the Director of Nursing Services (DNS), she explained she was unaware that the Administrator transported Resident #1 alone and did not call emergency services after the fall. She described the resident's position as lodged between the wheelchair and van seat, with her legs extended and the seatbelt loose. Emergency services were contacted at 2:43 PM and arrived at 2:50 PM. The DNS confirmed the Administrator had not contacted them during the return transport. On [DATE] at 3:00 PM, during an observation, the Administrator demonstrated the resident's position on the van floor, confirming the resident was lodged between the wheelchair and a van seat with her legs extended and unrestrained. A record review of Resident #1's admission Record revealed an admission date of [DATE] with diagnoses including Major Depressive Disorder, Dementia, Lung Cancer, Panic Disorder, and Difficulty Walking. A record review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of six (6), indicating severely impaired cognition. The MDS identified Resident #1 as non-ambulatory and dependent on a wheelchair for mobility. The facility implemented the following plan to remove the Immediate Jeopardy: Incident on [DATE] Resident #1 was transported to an appointment by the Administrator in a wheelchair at 1:06pm with no assistance from nurse or certified nursing assistant(CNA). At 1:49 pm on [DATE] the Administrator called Licensed Practical Nurse (LPN)#1 to inform her that Resident#1 had slipped from wheelchair, but he stated she was not injured and was on the way back to the facility with the resident. Director of Nursing(DON) was notified by LPN#1 that the Administrator was on the way back to the facility with the resident in the transportation van. At 2:40 pm on [DATE], the Administrator arrived and DON, Assistant Director of Nursing(ADON), Quality Assurance(Q/A) nurse and LPN#1 went out to the van to assess the resident. Resident #1 was on the floor of the van with the wheelchair at her back. DON and ADON assessed Resident#1 without moving resident with no apparent injuries noted. Resident#1 rated pain 0 using a 0-10 pain scale. Ambulance service was notified at 2:43pm by the Charge Nurse. The van doors were shut and air turned up with DON and ADON at her side to ensure she was safe until the ambulance arrived. At approximately 2:50pm two ambulances arrived along with the fire department. Using three(3) person total assistance, the wheelchair was unlocked from its 4-point harness. Leg rests were moved outward and folded from the sides of the wheelchair. Wheelchair was gently moved backwards from the Resident#1. Resident#1 verbally stated she was okay. Emergency Medical Services(EMS) personnel transferred Resident#1 onto a sheet from the floor of the van with 4-person total manual lift. Resident#1 was brought to the local hospital and was evaluated by the emergency department provider. Resident#1 arrived back at the facility at 6:46 pm by ambulance with no further orders at the time. Upon resident's arrival it was noted x-rays were not obtained at the emergency department. Medical Doctor(MD) was notified and x-rays were ordered for 23 views. Portable x-ray performed the x-rays. Report was sent over stat and no injuries were noted on x rays. On [DATE] Nursing and transportation staff were educated immediately requirements of having a CNA or nurse who is Cardiac Pulmonary Resuscitation(CPR) certified to provide non-emergency transport of residents and having two staff members who meet the requirements to transport residents. Education is ongoing with all nursing and transportation staff and will not work till completed. On [DATE] QA nurse met with the therapy director to put in place for all residents to be screened for appropriate mobility devices for transport. Emergency Q/A and safety meeting was held on [DATE] at 9:30am and [DATE] at 6 pm and included the following persons: *Nursing Home Administrator *Medical Director *Director of Nursing (DON) * Assistant DON *QA/Infection Preventionist *Social Services *MDS Nurse *Medical Records Nurse *Staff Development Nurse *Treatment Nurse *Charge Nurse Topics addressed: *IJ Finding- F689 *Root cause analysis *Corrective action plan *Staff Education *Systemic Changes *Monitoring Plan The Abuse, Neglect, Exploitation, and Misappropriation Prevention Program policy was reviewed. No revisions were required. On [DATE] 1 on 1 in-services on Abuse, Neglect, and Misappropriation, as well as, Requirements and Safety of Non-emergent Transportation were done with the Administrator by DON and ADON. A directive in-service was started on Saturday [DATE] by the [NAME] President of Clinical Operations on Resident safety during transport and Fall Response for all Nursing Staff. On [DATE] Staff who are allowed to transport residents were verified by checking to make sure they are on the company's insurance policy and CPR certified by the DON. The Q/A Nurse reviewed/monitored Resident#1's most recent MOS and most recent therapy screen for appropriate transportation on [DATE]. CONCLUSION: Based on the immediate corrective actions taken, staff education completed, systemic practice changes, and monitoring processes established, Pinecrest Guest Home alleges that the Immediate Jeopardy was abated as of [DATE]. Validation: The SA validated on [DATE] through interview and record review that all actions to remove the immediacy were completed on [DATE] and the IJ was removed on [DATE] prior to the SA exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect a resident from accidents hazards when the facility failed to obtain immediate medical assistance when a resident sustained a fall from a wheelchair in the facility van and was not assessed by licensed personnel for approximately 42 miles while being transported back to the facility while lying on the floor for one (1) of four (4) sampled residents. (Resident #1). The facility's failure to ensure Resident #1 was properly secured and transported safely, under trained supervision, resulted in her fall from a wheelchair in the facility van. Resident #1 was transported back to the facility while lying on the floor of the facility van for approximately 42 miles and arrived back at the facility at 2:40 PM. This failure and a lack of immediate assessment by licensed personnel placed the resident in a situation that was likely to cause serious injury, serious harm, serious impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), which began on [DATE], when Resident #1 sustained a fall from a wheelchair in the facility van and was not assessed by licensed staff for approximately thirty (30) minutes during transport. The State Agency (SA) notified the Administrator of the IJ on [DATE] at 04:20 PM and provided an IJ Template. The SA validated the Removal Plan on [DATE], and determined that the IJ was removed on [DATE], prior to SA exit. Therefore, the scope and severity for CFR 483.25(d)(1)(2) Accidents/Hazards - F689 was lowered from a J to a D while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: A review of the facility's policy, Transportation Assistant Document, dated Copyright 2024, revealed, Position Purpose; Provides transport assistive services to assigned residents in accordance with care plans, facility policies and procedures and at the direction of supervisor(s); Required Qualifications . Certified Nursing Assistant in good standing with the state . Current CPR/BLS (Cardiopulmonary Resuscitation/Basic Life Support) certifications. A review of the facility's policy, Transporting a Resident (Facility Van), dated Copyright 2025, revealed, .It is the policy of this facility to provide residents safe, non-emergency transportation to doctor's appointments . 3.Facility will ensure that residents who require an escort to appointments due to cognitive or physical limitations have arrangements made ahead of time .6. Each resident will be secured in a seat with a seatbelt or in their wheelchair secured with wheelchair tie downs . Record review of the incident report dated [DATE] revealed Resident arrived at facility in facility van accompanied by facility employee. Resident positioned on buttocks, resting on bilateral footrests. Resident WC (wheelchair) foot pedals resting on van floor. WC secured with four floor harnesses. Tilted forward slightly. Lap seat belt buckled but not tightened across resident abdominal area. Pressure cushion tilted forward slightly and down towards floors at front edge of WC seat, resting against mid-thoracic region of back. Resident's left foot extended straight beneath back bench seat, sock intact. Right lower extremity extended forward slightly with knee flexed and right foot resting in front of pelvic region. Sock is intact to right foot. Does not recall how she came to be seated on bilateral WC footrests on van floor. During an interview on [DATE] at 3:49 PM, the Resident Representative (RR) for Resident #1, she explained that the Director of Nursing Services (DNS) informed them that Resident #1 had fallen out of her wheelchair in the van during transport and was returned to the facility unsecured on the floor. They stated that the Administrator should have contacted emergency services and not transported the resident alone. They confirmed Resident #1 was admitted to a medical center on [DATE] due to Congestive Heart Failure, Urinary Tract Infection, and Septicemia. During an interview on [DATE] at 4:15 PM, with the Administrator, he explained he transported Resident #1 alone to an appointment approximately thirty-five (35) miles away. He stated the resident began scooting forward, fell to the floor of the van, and did not verbally respond after the fall. He confirmed he did not seek emergency assistance and drove back to the facility with the resident lying on the floor between the back of a van seat and the wheelchair. During an interview on [DATE] at 11:15 AM, with the DNS, she explained she was unaware that the Administrator transported Resident #1 alone and did not call emergency services after the fall. They described the resident's position as lodged between the wheelchair and van seat, with her legs extended and the seatbelt loose. Emergency services were contacted at 2:43 PM and arrived at 2:50 PM. The DNS confirmed the Administrator had not contacted them during the return transport. During an observation on [DATE] at 3:00 PM, the Administrator demonstrated the resident's position on the van floor, confirming the resident was lodged between the wheelchair and a van seat with her legs extended and unrestrained. A record review of Resident #1's admission Record revealed an admission date of [DATE] with diagnoses including Major Depressive Disorder, Dementia, Lung Cancer, Panic Disorder, and Difficulty Walking. A record review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of six (6), indicating severely impaired cognition. The MDS identified Resident #1 as non-ambulatory and dependent on a wheelchair for mobility. The facility implemented the following plan to remove the Immediate Jeopardy: Incident on [DATE] Resident #1 was transported to an appointment by the Administrator in a wheelchair at 1:06pm with no assistance from nurse or certified nursing assistant(CNA). At 1:49pm on [DATE] the Administrator called LPN#1 to inform her that Resident#1 had slipped from wheelchair, but he stated she was not injured and was on the way back to the facility with the resident. Director of Nursing(DON) was notified by LPN#1 that the Administrator was on the way back to the facility with the resident in the transportation van. At 2:40pm on [DATE], the Administrator arrived and DON, Assistant Director of Nursing(ADON), Quality Assurance(Q/A) nurse and LPN#1 went out to the van to assess the resident. Resident #1 was on the floor of the van with the wheelchair at her back. DON and ADON assessed Resident#1 without moving resident with no apparent injuries noted. Resident#1 rated pain 0 using a 0-10 pain scale. Ambulance service was notified at 2:43pm by the Charge Nurse. The van doors were shut and air turned up with DON and ADON at her side to ensure she was safe until the ambulance arrived. At approximately 2:50pm two ambulances arrived along with the fire department. Using three(3) person total assistance, the wheelchair was unlocked from its 4-point harness. Leg rests were moved outward and folded from the sides of the wheelchair. Wheelchair was gently moved backwards from the Resident#1. Resident#1 verbally stated she was okay. Emergency Medical Services(EMS) personnel transferred Resident#1 onto a sheet from the floor of the van with 4-person total manual lift. Resident#1 was brought to the local hospital and was evaluated by the emergency department provider. Resident#1 arrived back at the facility at 6:46pm by ambulance with no further orders at the time. Upon resident's arrival it was noted x-rays were not obtained at the emergency department. Medical Doctor(MD) was notified and x-rays were ordered for 23 views. Portable x-ray performed the x-rays. Report was sent over stat and no injuries were noted on x rays. On [DATE] Nursing and transportation staff were educated immediately requirements of having a CNA or nurse who is Cardiac Pulmonary Resuscitation(CPR) certified to provide non-emergency transport of residents and having two staff members who meet the requirements to transport residents. Education is ongoing with all nursing and transportation staff and will not work till completed. On [DATE] QA nurse met with the therapy director to put in place for all residents to be screened for appropriate mobility devices for transport. Emergency Q/A and safety meeting was held on [DATE] at 9:30am and [DATE] at 6pm and included the following persons: *Nursing Home Administrator *Medical Director *Director of Nursing (DON) * Assistant DON *QA/Infection Preventionist *Social Services *MOS Nurse *Medical Records Nurse *Staff Development Nurse *Treatment Nurse *Charge Nurse Topics addressed: *IJ Finding- F689 *Root cause analysis *Corrective action plan *Staff Education *Systemic Changes *Monitoring Plan The Abuse, Neglect, Exploitation, and Misappropriation Prevention Program policy was reviewed. No revisions were required. On [DATE] 1 on 1 in-services on Abuse, Neglect, and Misappropriation, as well as, Requirements and Safety of Non-emergent Transportation were done with the Administrator by DON and ADON. A directive in-service was started on Saturday [DATE] by the [NAME] President of Clinical Operations on Resident safety during transport and Fall Response for all Nursing Staff. On [DATE] Staff who are allowed to transport residents were verified by checking to make sure they are on the company's insurance policy and CPR certified by the DON. The Q/A Nurse reviewed/monitored Resident#1's most recent MOS and most recent therapy screen for appropriate transportation on [DATE]. CONCLUSION: Based on the immediate corrective actions taken, staff education completed, systemic practice changes, and monitoring processes established, Pinecrest Guest Home alleges that the Immediate Jeopardy was abated as of [DATE]. Validation: The SA validated on [DATE] through interview and record review that all actions to remove the immediacy were completed on [DATE] and the IJ was removed on [DATE] prior to the SA exit.