**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews with the resident, staff, and the Medical Director, the facility failed to follow the manufacturer's instructions for wheelchair securement in a transportation van. On August 26, 2025, the Transport Driver incorrectly anchored all four securement straps to the rear wheels of the wheelchair, leaving the front of the wheelchair unsecured. As the vehicle accelerated, the unsecured wheelchair tipped backward, causing Resident #1 to fall and strike her head and back on the floor of the van. She was transported to the hospital, where she was diagnosed with posterior (back) neck and upper back pain, a superficial laceration on the tip of her tongue, paraspinal (muscles located along the spine) tenderness in the upper thoracic (part of the body between the neck and the abdomen) region, and a superficial abrasion on her right hand. A computed tomography (CT) (non-invasive imaging test that uses x-rays and computer technology to create detailed images of the body's internal structures) scan revealed no evidence of hemorrhage (bleeding) or acute fracture. Resident #1 was discharged back to the facility later that evening. The noncompliance had the high likelihood to cause serious injury, harm, impairment or death. The deficient practice affected 1 of 3 residents reviewed for accident-related incidents (Resident #1).The findings included:The undated manufacturer's instructions for wheelchair tie-downs used by the facility revealed it read in part, Attach the four tie-down hooks to solid frame members or weldments (parts joined by [NAME]), near seat level [of the wheelchair]. Ensure tie-downs are fixed at approximately 45 degrees. Do not attach hooks to wheels, plastic, or removable parts of wheelchair.Resident #1 was admitted to the facility on [DATE]. Her active diagnoses included neuropathy, chronic ischemic heart disease osteomyelitis, atherosclerotic heart disease, diabetes, amputation of the right toes and left leg above the knee, and generalized anxiety disorder.Resident #1's Minimum Data Set assessment dated [DATE] revealed she was assessed as cognitively intact. She had range of motion impairment on both sides of her lower extremities. She was dependent on staff for transfers and required setup assistance with wheelchair mobility. She was also assessed to receive scheduled and as needed pain medication. She had pain or hurting during the 5 days prior to the assessment and was documented as having pain occur rarely or not at all and described the pain as mild. She received an opioid for her pain control during the lookback period. Resident #1's orders revealed on 7/18/25 she was ordered oxycodone 5 milligram tablet every 8 hours as needed for pain. On 7/19/25 she had orders for chewable aspirin 81 milligrams one time a day related to chronic ischemic heart disease as well as clopidogrel bisulfate oral tablet 75 milligrams, an anti-platelet medication, in the morning related to atherosclerotic heart disease. During an interview on 9/10/25 at 10:33 AM Resident #1 stated the Transport Driver came to her room on 8/26/25 and rolled her out to the transport van for a dentist appointment. This van was the facility's transport van that opened in the back and had a ramp on which the Transport Driver pushed her up. The Transport Driver would always do something with the floor that would lock her wheelchair in place and to the best of her memory, the Transport Driver did something, and it seemed like she had locked the wheelchair in the van as she normally did, and Resident #1 did not know what failed this time. She confirmed her seatbelt was also in place. During transport, everything seemed normal until they had stopped at a red light. When the light turned green, the Transport Driver pressed the gas to go straight, and as the van accelerated at a normal pace, her wheelchair came loose. The chair flipped backwards resulting in her landing on her back still seated in the wheelchair. The ramp had been pulled up in the back and stored, and she hit her head on the steel ramp as she fell backwards. She bit her tongue, causing some bleeding but she could not remember how bad it bled. She stated the Transport Driver parked the van, but she could not say how long it took to come to a stop. Her back was in pain due to the sudden jerk of the wheelchair flipping over and the doctors at the hospital said she probably had some whiplash from the incident once she had made it to the emergency department. Resident #1 stated her pain was a 9 out of 10 (0 being no pain and 10 being the worst pain imaginable). The Transport Driver came into the back of the van after parking and called Emergency Medical Services (EMS) as well as the facility. Three people came from the facility to where they were parked, arriving before EMS as the van had not made it far from the facility. The three staff members who arrived at the van were the Director of Nursing, the Administrator, and the Maintenance Director. It did not take them long to get there but she was unsure of the length of time. She was still lying on her back, seated in the flipped wheelchair when the three staff members arrived. The Administrator began taking pictures of the van and the things on the floor of the van that anchored the chair to the van, and the Maintenance Director was inspecting the van. The Director of Nursing assessed her and explained they would need to wait for EMS to ensure Resident #1 was moved safely. During an interview on 9/10/25 at 12:36 PM the Transport Driver stated Resident #1 had a dental appointment on 8/26/25 at 2:30 PM. At around 2:00 PM to 2:15 PM she went to Resident #1's room to take her to the van and get her set up for transport. Once Resident #1 was in the van, she locked the wheels on the wheelchair and then secured the two front straps and two back straps from the floor of the van to the large, back wheels of the wheelchair, one front and one back strap per wheel. She then did a pull test to make sure the wheelchair did not move by pulling back on the chair handles to ensure it was securely in place and allow the automatic tension to tighten. She stated she heard the clicking of the locking mechanisms which indicated the wheelchair was securely in place. She then put on Resident #1's seatbelt. One belt went around the resident's waist and locked into the floor on the right and left side of the resident. Then another belt attached to the side wall of the van is pulled over the resident's right shoulder and locked into the waist belt. She then completed another pull test by pulling back on the wheelchair by its handles and asked Resident #1 if she was comfortable or if the seat belt was too tight. Resident #1 indicated she was comfortable. The ramp was folded and stored by folding it to sit upright in the back of the van and then the doors of the van were closed. Everything continued without incident, and they stopped at a stop light. When the light turned green, she pressed the gas, and as she accelerated through the light, Resident #1 shouted, and she heard a noise from the back. She asked Resident #1 what happened, and the resident responded she had come out of the chair. The Transport Driver told Resident #1 to just hold on as she was trying to get out of the road and park. She pulled to the shoulder of the road and parked the van. The Transport Driver told Resident #1 to keep talking to her to keep her conscious and told Resident #1 she could not move her before a medical professional assessed her. The Transport Driver then called the EMS as well as the Administrator. She stated by then she had moved to the back of the van with Resident #1. The wheelchair had tipped over backwards with Resident #1 in it, resulting in her lying on the floor of the van on her back, halfway in the wheelchair with her buttock having shifted up to the middle of the back rest of the wheelchair. She stated Resident #1 asked if she could get her up and the Transport Driver told her she could not move her due to the increased risk of injury. Resident #1 told the Transport Driver she thought she had hit her head. The top of Resident #1's head was up against the ramp which was folded and stored behind Resident #1. At no point did she move the resident or move any items including the ramp due to the risk of moving the resident, causing more injury. The only thing she moved was to unlock the right front anchor strap which was still secured on the wheel and the van floor when she first entered the back of the van. She did this to get back to Resident #1 without having to step over the anchors. The Director of Nursing and Administrator arrived 7 to 10 minutes prior to EMS arriving. The Transport Driver stated she demonstrated how she had anchored Resident #1's wheelchair in the van for the Maintenance Director, Director of Nursing, and Administrator. This was completed while still pulled over to the side of the road. After the demonstration, she was informed she could not drive the van again until the investigation was completed and she had been reeducated on how to secure resident wheelchairs in the van. The Maintenance Director drove the van back to the facility. The Transport Driver indicated she attended training, watched instructional videos, and took tests during the investigation which she completed on 9/2/25 and she was now currently monitored with a monitoring tool by the Maintenance Director. The Transport Driver stated she was educated that by attaching both the front and rear anchors to the same rear wheel on each side, the frame of the wheelchair was still free to rotate and flip over. She stated she had done it correctly in the past as far as she could recall and did not know why she attached it this way on 8/26/25.During an interview on 9/10/25 at 2:23 PM the Maintenance Director stated he was in the building when the incident happened on 8/26/25, and he got a call from the Administrator to come to the location of the incident. The Administrator informed him an incident had occurred during transport of Resident #1 in the facility van. When he arrived, EMS was already there on the scene, and the side door was open and through the side door he noted Resident #1 lying on her back. The Director of Nursing and Administrator were already on there as well. EMS was in the process of getting Resident #1 out of the van, and once the resident was safely removed from the van and on the way to the hospital, he was then able to examine the van, and they could start their investigation. The Transport Driver explained what happened and he asked her how she had attached the anchor straps to the chair and floor of the van. She demonstrated how she attached the anchors to the wheelchair, and it was done incorrectly. He stated when a wheelchair was anchored in a transport van, it must be anchored by the front and back frame of the wheelchair. Wheels should never be used to anchor a wheelchair down. Also, she had anchored the left front and back anchors to the same larger back left wheel and anchored the right front and back anchors to the same larger back right wheel. Because she anchored both the back and front anchors to the same wheel on either side, the frame was still free to rotate while the back wheels stayed stationary. When the van had accelerated, the wheelchair was free to rotate backwards, causing the incident. He stated they inspected the van and found all parts were functioning correctly.The EMS narrative dated 8/26/25 revealed EMS documented that upon arrival, Resident #1 was found laying on her back in a transport van. The resident was partially in her wheelchair and partially on the floor of the van. Resident #1 indicated she tipped over during transport and now her neck and upper back were hurting. No deformities were noted with assessment. Resident #1 was lifted from the floor and placed back in her wheelchair. The facility staff present informed EMS she did take blood thinners, and she had hit her head. Resident #1 was transferred to the ambulance and was complaining of 8 out of 10 pain in her neck and back. Resident #1 was transported to the hospital. Resident #1's hospital record dated 8/26/25 revealed Resident #1 was in a vehicle transport going to an appointment when her wheelchair flipped backwards resulting in her striking her head on the floor of the van. Resident #1 indicated she saw stars but did not lose consciousness. She suffered back and neck pain as well. She was transported to the emergency department for further evaluation. Resident #1 indicated she had posterior neck pain and upper back pain but was otherwise at her baseline. She denied any other symptoms. She was documented to take clopidogrel bisulfate and aspirin but denied any other anticoagulant medication. CT scans demonstrated no evidence of hemorrhage or acute fracture. Blood work was unremarkable for acute issues and Resident #1 was discharged back to the facility on 8/26/25.A nursing note dated 8/26/25 revealed Resident #1 was documented to have returned to the facility via transport Med-X/stretcher from hospital where she had been evaluated for possible head injury from a fall. The nurse documented the hospital found negative findings from CT scans and lab work up.A provider note dated 8/27/25 revealed the Nurse Practitioner saw Resident #1 and documented Resident #1 was in a transport van headed to a dental appointment when the van accelerated, causing her wheelchair to tip over. She struck her head, neck, and back on the floor of the van. She also bit her tongue and sustained scrapes. She was taken to the emergency department where CT scans of the head and cervical spine were performed, all of which were negative for acute findings. She was discharged back to the facility with instructions to rest in bed for a few days. Resident #1 reported persistent pain, particularly in the shoulders and neck, and was ordered oxycodone 5 mg every 8 hours as needed for pain. Resident #1's diagnoses were acute whiplash injury, contusion of tongue, and pain. During an interview on 9/11/25 at 10:05 AM the Medical Director stated she was notified of the incident on 8/26/25, the day it happened. She further stated the main concern with an accident of this type would be internal bleeding because of the fall which thankfully did not occur. Another concern would be fractures because of the impact of the fall. She stated they had been seeing her regularly due to her medical condition and the incident to monitor Resident #1's status. The Medical Director stated the resident had not mentioned any fear of transportation or increase in her pain since the initial acute pain from the fall. During an interview on 9/11/25 at 10:54 AM the Director of Nursing (DON) stated on 8/26/25 she was informed by the Administrator they had to go because there had been a van incident. They got in the Administrator's car and arrived in less than 5 minutes. The van was parked on the shoulder of the road, and the Director of Nursing heard the Transport Driver saying, I'm in here as she opened the passenger front door. At that point she saw the Driver in the back of the van with Resident #1. The resident was in the wheelchair, on her back, with the front wheels in the air. Resident #1 told the Director of Nursing she bit her tongue and there was some bleeding but there was no pooling of blood as well as no indication or observed risk of choking on blood by Resident #1. EMS arrived shortly after the DON assessed Resident #1. EMS got in the van, assessed the resident and asked her questions. EMS transferred Resident #1 to a stretcher, placed her in the ambulance, and took her to the hospital. The Director of Nursing, Transport Driver, Administrator, and Maintenance Director examined the van. They had the Transport Driver demonstrate how she had anchored the wheelchair in the van. The Transport Driver had anchored both left and right front and rear straps to the rear wheels. At that point they determined the wheelchair had been anchored incorrectly by the Transport Driver.During an interview on 9/11/25 at 12:10 PM the Administrator stated she received a call from the Transport Driver on 8/26/25 and she told her there had been an incident with the van. The Administrator found out where the transport van was parked and then instructed the Transport Driver to call 911 if she had not done so. The Administrator then got the Director of Nursing and told her what she knew, and they got in her car and drove to the transport van. She stated Resident #1 was alert and oriented and talking with her and the other staff members. While the Director of Nursing assessed the resident, she called the Maintenance Director and asked him to come to the location as well so that he could examine the transport van after Resident #1 was taken care of. She stated shortly after this, EMS arrived and worked with the Director of Nursing to safely transfer Resident #1 to the ambulance and take her to the hospital. While this was happening, the Maintenance Director arrived. After Resident #1 had been transferred to the ambulance, she requested the Transport Driver demonstrate to her, the Director of Nursing, and Maintenance Director, how she had anchored the wheelchair to the van. Following her demonstration, they understood she had attached the anchors incorrectly to the rear wheels on both sides. The Transport Driver was suspended from transportation, and the Maintenance Director drove the van back to the facility. The Administrator was notified of the immediate jeopardy on 9/10/25 at 4:12 PM.The facility provided the following corrective action plan:1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice.On 8/26/25 Resident #1's wheelchair tipped backwards in the facility transportation van due to the transportation driver failing to follow manufacturer's instructions for wheelchair securement. The driver had improperly anchored both left and right front and rear straps to the rear wheels, leaving the front of the wheelchair unsecured. When the vehicle accelerated, the wheelchair tipped backwards, causing Resident #1's head and back to strike the floor of the van. Emergency services were called, and Resident #1 was transported to the hospital where she was treated for posterior neck pain, upper back pain, a superficial tongue laceration, paraspinal tenderness, and a superficial abrasion to her right hand. A CT scan revealed no evidence of hemorrhage or acute fracture, and the resident was discharged back to the facility the evening of 8/26/25.On 8/26/25, the transportation driver was removed from driving duties pending retraining and competency validation. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. On 8/26/25 the facility conducted a 100% audit of progress notes, transport log and interview with the Transportation Driver of in-house facility residents' transports for the past 90 days by the Assistant Director of Nursing (ADON) that was completed on 8/27/25, with no concerns identified. The Assistant Director of Nursing reviewed the transport log to identify any resident that would potentially be transported with facility van. No residents were to be transported until investigation and retraining completed. All scheduled appointments were scheduled by the Transportation Driver with a contracted outside transportation company beginning 8/27/25. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur.The facility has two employees who drive the transportation van. The Transportation Driver is the primary driver and the Maintenance Director is the back up driver. The Administrator audited on 8/26/25 the transport employee files: audit to include training, valid driver's license, van maintenance checklist to include proper alignment of the wheelchair between the tie down straps, attaching the rear tie down straps to the rear frame, front tie down straps to the front frame, ensuring tightness on both the front and rear tie downs, and securing seatbelt around resident, and employee vehicle policy to include but not limited to vehicle purpose, driver licensing, maintenance of company van, proof of insurance on company van, traffic violations, usage of cellular phone, accidents involving company vehicle, theft of company vehicle and driver responsibilities in regards to operation of vehicle, use of seatbelts and securement devices and reporting requirements with no concerns identified. The Maintenance Director did the initial education for the Transportation Driver on site of incident and return demonstration on 8/26/25. The Administrator reviewed the manufacturer's video and training documents provided by the facility and re-educated post incident on 8/27/25. The Maintenance Director conducted education and an initial return demonstration with the Transportation Driver, Director of Nursing and Administrator on 8/26/25 that included proper securement of the wheelchair and van anchors per manufacturer's instructions. Outside Maintenance Director from a sister facility provided additional education to the Administrator, Maintenance Director and Transportation Driver regarding proper securement of the wheelchair and van anchors per manufacturer's instructions on 9/2/25. On 8/27/25 the Administrator initiated 100% in-service with the Maintenance Director and Transportation Driver about proper securement of wheelchairs during transport per manufacturer's instructions. The in-service was completed by 8/28/2025. All newly hired Transport Drivers will be in-serviced by the Maintenance Director during orientation to include the skills check list. The skills check list includes but is not limited to a competency validation of loading, securing and unloading a resident and a return demonstration. The Maintenance Director sent the van out for inspection that included checking functional status of the wheelchair anchors that was completed on 8/27/25 with no concerns identified. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. Include dates when corrective action will be completed. On 8/26/25 the facility initiated 10% audit of all residents being transported by the facility to be completed by the Maintenance Director weekly x 4 weeks then monthly x 2 months utilizing the Van Transport Audit Tool to ensure proper securing of the resident before leaving the facility and this was taken to Quality Assurance committee meeting on 8/26/25. This audit is an observational audit to determine proper securement of the resident, wheelchair, and van anchors. The results will be documented on the Van Transport Audit Tool. All areas of concern will be addressed by the Administrator and/or Maintenance Director immediately.The Administrator will forward the results of the Van Transport Audit Tool to the Executive Quality Assurance Committee to include Administrator, Director of Nursing, Assistant Director of Nursing, Quality Assurance Nurse, Infection Control Preventionist/Staff Development Nurse, Activities Director, social workers, unit managers and unit coordinators, Maintenance Director, Minimum Data Set nurse, Dietary Manager, Medical Director and additional staff representatives monthly x 3 months for review to determine trends and / or issues that may need further interventions put into place and to determine the need for further and / or frequency of monitoring. Completion date 9/3/25Onsite validation of the facility's corrective action plan was completed on 9/11/25. The initial audit results were reviewed. The in-service education records completed 9/2/25 were reviewed. Interviews with the Transport Driver and Maintenance Director as well as observations of a demonstration of anchoring a wheelchair to a transport van by both staff members were completed. The monitoring results were reviewed, and the Quality Assurance meeting minutes were reviewed. The facility's immediate jeopardy removal date of 9/3/25 was validated.

Based on observation, record review and interviews with staff, Nurse Practitioner, Medical Examiner and Physician, the facility failed to protect a resident's right to be free from neglect for 1 of 3 sampled residents reviewed for neglect (Resident #1). On 3/4/24, Nursing Assistant (NA) #1 disregarded Resident #1's physician orders and plan of care for the assessed need of 2 person assistance with Activities of Daily Living (ADL) care and provided care to the resident without assistance. During care, NA # left the resident positioned on his right side with the bed at waist height and turned his back to get a washcloth. Resident #1 rolled off the bed, landing face down on the tile floor. Resident #1 was transferred to the emergency room where a Computerized Tomography (CT) scan revealed a closed fracture of the left distal femur (a break of the thigh bone just above the knee) and a small skin tear to the left elbow. Resident #1 was on a blood thinning medication and he had multiple medical comorbidities making him vulnerable and at high risk for injury. The death certificate dated 3/31/24 listed the cause of death as complications of a left femur fracture. Immediate jeopardy began on 3/4/24 when NA #1 neglected to provide Resident #1 with the necessary care and services required to provide care safely. The immediate jeopardy was removed on 4/19/24 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower level and severity of D (no harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put in place were effective. The findings included: This tag is cross-referenced to: F689: Based on observation, record review, staff, Nurse Practitioner, Medical Examiner and Physician interviews, the facility failed to provide Activities of Daily Living (ADL) care safely to a dependent resident for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #1). On 3/4/24 Nursing Assistant (NA #1) began providing care to Resident #1 when he left the resident positioned on his right side with the bed at waist height and turned his back to get a washcloth. Resident #1 rolled off the bed, landing face down on the tile floor. Resident #1 was transferred to the emergency room where a Computerized Tomography (CT) scan revealed a closed fracture of the left distal femur (a break of the thigh bone just above the knee) and a small skin tear to the left elbow. Resident #1 was on a blood thinning medication and he had multiple medical comorbidities making him vulnerable and at high risk for injury. The death certificate dated 3/31/24 listed the cause of death as complications of a left femur fracture. Review of the Initial Allegation Report dated 4/18/24 revealed the facility's Director of Nursing (DON) became aware of Resident #1's allegation of resident neglect from the State Survey Agency. The alleged incident occurred on 3/04/24 at 2:50 PM. The resident received a bath and the aide turned away from the bed to retrieve cloth and resident rolled from bed resulting in fall. The Investigation Report dated 4/19/24 completed by the DON for the neglect allegation related to Resident #1 documented the accused staff member (NA #1) was noted to be aware of 2 person ADL care requirement, however, the NA felt he could provide care independently because he had worked with the resident for over a year. A fall occurred during care as a result of care plan not being followed. The report indicated Resident #1 sustained serious bodily injury and the allegation was substantiated. The Administrator and Director of Nursing (DON) were notified of Immediate Jeopardy on 4/17/24 at 5:51 PM. The facility provided the following credible allegation of Immediate Jeopardy removal: Identify those recipients who have suffered, or are likely to surer, a serious adverse outcome as a result of the noncompliance Resident # 1 noted to have received activities of daily living (ADL) care by NA #1 on 3-4-24. While receiving care, NA#1 noted to be providing care independently with Resident # 1 on his right side with bed at waist height. During care, it is noted that resident had a fall from the bed while NA#1 turned from care to retrieve bath cloth. Resident noted to have 2 person ADL (activities of daily living) ordered. Resident was noted to be sent to ER and returned with left leg injury. Resident remained in facility until new onset of facial drooping noted and was sent to ER 3/18/24 where he was discovered to have renal stones leading to sepsis whereupon resident aspirated and became unresponsive leading to a hospice admission at a local Hospice House instead of returning to facility for hospice care. NA #1 noted to be out of work indefinitely since 3/8/2024 with no expected return to work date. All residents receiving ADL care with concentration on residents with orders and care plans for 2 person assist with ADLs (Activities of Daily Living) identified as Recipients at Risk for neglect. Residents with orders and care plans for 2 person assist with ADLs shall be identified through audit entitled 2 person ADL care order Audit completed by Director of Nursing no later than 4/17/2024. Audit shall be completed by reviewing all active residents' current orders and care plans to ascertain all Recipients at Risk for neglect. Entity shall complete facility wide audit of Residents at Risk, no later than 4/17/2024. Results of audit identifying residents with 2 person assist with ADL care, shall be reviewed by facility Quality Assurance Committee (Physician services, Administrator, Director of Nursing, Quality Assurance Coordinator, Rehab Manager, Staff Development Coordinator, Social Worker, Environmental Services Director) on 4/18/2024 and results ensured to be communicated clearly in facility software to all nursing staff (Nurses and Nurse Aide 1). Software communication noted to populate in ADL documentation grid for all nurses and nurse aides and is populated through the ADL care plan once any orders are received and is documented by care planning nurse. Current care plan and communication shall be validated by Quality Assurance Committee by 4/18/24. Resident #1 shall have neglect reported via Initial Allegation Report by Director of Nursing to Health Care Personnel Investigation 4/18/2024. Director of Nursing shall also notify neglect to adult protective services on 4/18/24. Audits entitled 2 Person ADL Care Audit to include physician orders, care planning and staff observation shall be completed by Quality Assurance Coordinator on 4/18/2024. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring, and when the action will be complete: The Quality Assurance Committee shall also adopt new 2 Person assist with ADL Care Icon to be placed at foot of bed for any Residents at Risk as to improve process, in order to more clearly identify Residents at Risk with 2 person ADL care ordered. Once Committee has ensured accuracy of audit, as well as communication through facility software and new icon, all nursing staff shall receive education by Staff Development Coordinator or their designee, regarding all residents currently at risk. Education to encompass all residents receiving ADL care will include instruction on safety with ADL care to include gathering supplies and equipment, ensuring proper positioning in bed to provide safety, awareness of bed height and leaving residents in a safe position with call light in place. Education shall also include current list of all Residents at Risk, with 2 person ADL care and where their orders and care plan, may be identified in facility software, care plan awareness through new Icon and expectations regarding 2 person assist with ADL care. Residents / responsible party shall also be contacted by Resident Services Coordinator by 4/18/2024 to ensure permission to place Icon as to avoid any dignity issues and documented acceptance. Additionally, all staff shall receive education on facility policy for Resident Abuse and Neglect to include policy entitled Resident Abuse Prohibition Policy and Procedures with concentration on residents at higher risk for falls during ADL care requiring 2 people and to report to the Administrator / Director of Nursing, any witnessed abuse or neglect of care for these residents not meeting facility expectations. Education shall be completed and all efforts to encompass entire staff present 4/18/2024. Any staff not present 4/18/2024 shall have attempts made to complete education by phone no later than 4/18/2024 with messages left for any not spoken to, to contact facility as soon as possible for education, as to prevent future serious adverse outcomes from occurring. Education shall be documented on In-service Training Report. Staff Development Coordinator shall notify nursing supervisor of any nursing staff on the schedule who have not received in-servicing so that education may be delegated and completed for any nursing staff that may enter facility after 4/18/24. 2 Person assist with ADL Icon shall be placed at foot of bed for all Residents at Risk by Quality Assurance Coordinator by 4/18/2024. Audits entitled 2 Person ADL Care Audit shall be completed by Quality Assurance Coordinator 4/18/2024 monitoring for compliance of education completed as to ensure prevention on possible neglect. Alleged Immediate Jeopardy Removal Date: 4/19/24 Onsite validation of the immediate jeopardy removal plan was conducted on 4/19/24. The validation included staff interviews, observation, and record review. Inservice sign in sheets and staff interviews verified in-services were completed on the Abuse and Neglect Policy and Procedure with a concentration on residents at higher risk for falls during ADL care. Staff verified their understanding of neglect and the importance of providing residents with their assessed level of assistance. Additionally, staff revealed during education they had the opportunity to ask questions on resident Abuse and Neglect. Evidence of audits were reviewed for Abuse and Neglect and identifying Residents at Risk. Resident interviews were conducted with no issues identified. Observation of ADL care revealed staff provided the necessary assistance to meet the resident's assessed needs. The immediate jeopardy removal date of 4/19/24 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff, Nurse Practitioner, Medical Examiner and Physician interviews, the facility failed to provide Activities of Daily Living (ADL) care safely to a dependent resident for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #1). On 3/4/24 Nursing Assistant (NA #1) began providing care to Resident #1 when he left the resident positioned on his right side with the bed at waist height and turned his back to get a washcloth. Resident #1 rolled off the bed, landing face down on the tile floor. Resident #1 was transferred to the emergency room where a Computerized Tomography (CT) scan revealed a closed fracture of the left distal femur (a break of the thigh bone just above the knee) and a small skin tear to the left elbow. Resident #1 was on a blood thinning medication and he had multiple medical comorbidities making him vulnerable and at high risk for injury. The death certificate dated 3/31/24 listed the cause of death as complications of a left femur fracture. Immediate jeopardy began on 3/4/24 when NA #1 failed to provide care safely to Resident #1. The immediate jeopardy was removed on 4/19/24 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower level and severity of D (no harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put in place were effective. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included, chronic atrial fibrillation (a type of irregular heartbeat that causes the heart to beat too quickly), heart failure, diabetes mellitus, peripheral artery disease (a condition in which narrowed arteries reduce blood flow to the arms or legs), and obesity. Resident #1's quarterly Minimum Data Set, dated [DATE] revealed he was cognitively intact. He was assessed as dependent with bed mobility, incontinence care and bathing. Resident #1 was not coded for any falls since the prior assessment. The MDS indicated the resident's weight as 325 pounds and he was coded for receiving an anticoagulant. A review of the active physician orders for March 2024 included the following orders: - Two person assist with ADL care (order start date 11/01/22). - Eliquis (anticoagulant) 5 milligrams twice daily Resident #1's care plan initiated on 10/24/22 and reviewed on 12/20/23 revealed he was at risk for falls related to impaired mobility, multiple comorbidities, and continuous oxygen (02). Interventions initiated on 11/01/22 included two people assisting with care. An interview was conducted with NA #2 on 4/16/24 at 2:29 PM. She indicated Resident #1 was a two person assist as he was a heavy-set man, and she always had another NA to help her provide his care. NA #2 revealed she would check in the FYI (for your information) section of the computer to see what care a resident needed. An interview on 4/17/24 at 1:09 PM was conducted with NA #3. She revealed Resident #1 was a 2 person assist with ADL care. NA #3 indicated she looked in the computer to see what type of care a resident needed. On 4/17/24 at 1:25 PM the Director of Nursing (DON) stated Resident #1 had extension bars on his bed that extended the bed frame out 8 inches on either side of the bed and a larger mattress to fit the bed frame. The Nurse note dated 3/4/24 completed by Nurse #1 revealed NA# 1 called nursing staff to Resident #1's room at 2:50 PM. Resident #1 was noted laying on his side undressed on the floor with the bed in the high position. NA #1 stated he was turning Resident #1, and he kept on rolling off the bed onto the floor. The Supervisor was notified and on assessment Resident #1 was noted to have blood upon inspection but could not locate the source due to his positioning. The note documented Resident #1 was on a blood thinner. EMS (Emergency Medical Service) were notified, and Medical Doctor notified. Order was obtained to send Resident #1 to (name of hospital) for evaluation. The Fall Incident/Accident Report initiated on 3/4/24 and signed completed on 3/4/24 by Unit Manager Nurse was reviewed. The report revealed while care was being provided Resident #1 was turned to face the door, the NA turned his back to get a cloth and Resident #1 landed face down on the floor. NA #1 was interviewed by phone on 4/16/24 at 5:29 PM. NA #1 indicated on 3/4/24 he positioned Resident #1 on his right side in the middle of bed. He indicated he (NA #1) turned to the tray table to grab a washcloth. He indicated while he was turned away from the bed he looked in the mirror in the room and saw the resident move his leg and he roll off the bed face first onto the floor. NA #1 indicated he was aware Resident #1 was a two person assist according to the care plan. When asked why he provided care without another staff member's assistance on 3/4/24 he indicated there was a lot going on that day, it was close to shift change, he worked with Resident #1 daily, and thought he could provide incontinence care alone. NA #1 indicated Resident #1 was able to assist with his turning and repositioning in bed. A follow up interview with NA #1 was conducted by phone on 4/17/24 at 4:10 PM. He revealed on 3/4/24 the bed was at waist height when the resident rolled onto the floor. NA #1 stated Resident #1 did not hit his head when he fell. In a phone interview on 4/16/24 at 1:12 PM Nurse #1 stated that when she arrived in Resident #1's room on 3/4/24, she found Resident #1 on the floor lying between Bed A and Bed B. He was on his side and she observed some blood but she could not tell where it was coming from, and she wanted to send Resident #1 out for evaluation in case of head injury as he was receiving a blood thinner. She revealed Resident #1 was a larger man and required two persons for assistance with his ADL care. The Unit Manager Nurse was interviewed on 4/17/23 at 9:31 AM. The Unit Manager Nurse revealed when she arrived at Resident #1's room on 3/4/24, the resident was on the floor face down with slight weight on his left side. She indicated NA #1 worked with the resident daily and the resident was a two person assist as he was a heavy man. She reported Resident #1 fell onto the tile floor. The Unit Manager Nurse called 911, the hospital to notify them they had a fall resident and the RP (responsible person). She stated that EMS arrived at the facility within 5 minutes of her call. Review of the emergency room (ER) report dated 3/4/24 revealed upon arrival at 4:09 PM EMS reported an obese, chronically ill-appearing, but awake, alert, Glasgow Coma Scale (a scale used to objectively describe the extent of impaired consciousness) of 15 (a score of 15 means you are fully awake, responsive and have no problems with thinking ability or memory). A Computerized Tomography (CT) scan was conducted in the ER of Resident #1's left lower extremity and revealed a comminuted non-displaced fracture of distal femoral meta-epiphysis (rounded long end portion of the bone) with fracture line extending to the lateral femoral condyle (a break in the lower part of a bone) with extension to posterior lateral femoral condyle. The resident was assessed by orthopedics and the fracture was non-operative. He was splinted at bedside and returned to the facility on 3/5/24. Review of the physician progress note dated 3/11/24 documented Resident #1 was sent out to the ER on [DATE] following a fall from bed while being adjusted in bed. He was noted with some bleeding and concerned for a head injury as on Eliquis. CT scan revealed a closed fracture of the left distal femur. The orthopedist was consulted, determined the fracture was nonoperative and the resident was splinted at bedside. Post splint x-ray showed stable positioning and the resident was cleared to discharge to the facility. Review of the nurse notes dated 3/17/24 documented the resident was complaining of chest pain at 10:30 AM. The Supervisor was notified of the resident's cardiac history (chronic atrial fibrillation), 911 was called, and the resident was transported to the ER by EMS for evaluation and treatment. Review of the physician progress note dated 3/18/24 documented Resident #1 was sent out to the ER on [DATE] for concern of acute chest pain. A complete blood count showed no leukocytosis (high white blood cell count may indicate an infection or inflammation in the body). Cardiac tests were unremarkable, (for heart proteins leaking into the blood) and the resident was discharged back to the facility. Review of the nurse note dated 3/18/24 at 11:46 AM indicated the resident was seen by Nurse Practitioner #1 for follow up of chest pain. Resident #1 was noted to have right sided facial droop, a fixed pupil and acute disorientation. Resident #1 was sent to the ER for evaluation and treatment. Review of the emergency room report dated 3/18/24 at 12:44 PM revealed Resident #1 presented as a prehospital code stroke due to a change in mental status. The resident was afebrile, chronically ill-appearing and had a left lower extremity in a splint due to recent fracture. An EKG (electrocardiogram) revealed atrial fibrillation with premature atrial contraction (PVC is associated with an increased risk of atrial fibrillation) and a chest x-ray revealed pulmonary venous congestion with hypoventilatory changes (breathing that is too shallow or slow to meet the needs of the body). Review of the Discharge summary dated [DATE] revealed Resident #1 was reviewed by the Tele-neurologist for suspected stroke. The stroke was ruled out and suggested probable acute metabolic encephalopathy (metabolic encephalopathy occurs when problems with your metabolism cause brain dysfunction). He was treated with antibiotics for a complicated UTI (urinary tract infection that carries a higher risk of treatment failure and typically require longer antibiotic courses) and aspiration pneumonia (occurs when food or liquid is breathed into the airways or lungs instead of being swallowed). The Discharge Summary documented that due to Resident #1's age related debility and poor improvement the family decided on comfort measures. Resident #1 was discharged from the hospital on 3/29/24 to an inpatient hospice facility. Review of Resident #1's death certificate dated 3/31/24 listed the cause of death as complications of a left femur fracture. An interview was conducted with the Medical Examiner (ME) on 4/17/24 at 12:39 PM. She indicated she had reviewed Resident #1's medical history after she received the body for autopsy which revealed he fractured his ankle 3 years prior. The Medical Examiner indicated after a fall or broken bone patients were never the same and the femur fracture precipitated a decline in the body. The ME indicated Resident #1 was not a young man, had many comorbidities and determined the cause of death was due to blunt force trauma to the femur. The Nurse Practitioner was interviewed by phone on 4/16/24 at 3:24 PM. He revealed Resident #1 had a history of atrial fibrillation, was on a blood thinner, and after his fall on 3/4/24 the facility sent Resident #1 out immediately to evaluate for head injury (individuals taking a blood thinner are at higher risk of brain bleeding, following a head injury). The Nurse Practitioner indicated the resident was diagnosed with a femur fracture, received a soft cast in the ER and returned to the facility that same day. He indicated on 3/17/24 Resident #1, was sent to the ER for a complaint of chest pains, where a cardiac evaluation was unremarkable for heart proteins leaking into the blood, and the resident returned to the facility. The Nurse Practitioner revealed he followed up with Resident #1 on 3/18/24 and sent him back to the ER for a facial droop and slurred speech. He stated within a two-week period, Resident #1 had no further falls, had two hospital visits and with his contributing comorbidities he did not see how the fracture could have contributed to his death. A phone interview was conducted with the Medical Doctor on 4/17/24 at 2:47 PM. He indicated during Resident #1's hospital stay on 3/18/24, he was diagnosed with an UTI (urinary tract infection), an acute kidney injury, renal stones, and during that hospital stay he had an infection that overwhelmed his system and had an acute aspiration event. The MD indicated Resident #1's infection, UTI, and renal stones would have occurred regardless of the fall, and the hospital record highlighted the aspiration pneumonia as a contributing factor. The Medical Doctor indicated he saw no connection between his fall/fracture and expiration. The Director of Nursing (DON) was interviewed on 4/17/24 at 5:00 PM. The DON revealed staff were trained to look in the computer for resident care needs and NA #1 should have followed their policies and procedures. He indicated Resident #1 was care planned and documented in the computer for a two person assist with ADL care and any residents requiring extensive assistance with ADL's staff should use 2-person assistance with care. The Administrator and DON were notified of Immediate Jeopardy on 4/17/24 at 5:51 PM. The facility provided the following credible allegation of Immediate Jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: · Resident # 1 noted to have received Activities of Daily Living (ADL) care by NA #1 on 3-4-24. While receiving care, NA #1 noted to be providing care independently with Resident #1 on his right side with bed at waist height. During care, it is noted that resident had a fall from the bed while NA #1 turned from care to retrieve bath cloth. Resident noted to have 2 person ADL (activities of daily living) ordered. Resident was noted to be sent to emergency room (ER) and returned with left leg injury. Resident remained in facility until new onset of facial drooping noted and was sent to ER 3/18/24 where he was discovered to have renal stones leading to sepsis whereupon resident aspirated and became unresponsive leading to a hospice admission at a local Hospice House instead of returning to facility for hospice care. NA #1 noted to be out of work indefinitely since 3/8/2024 with no expected return to work date. All residents receiving ADL care with concentration on residents with orders and care plans for 2 person assist with ADLs (Activities of Daily Living) identified as Recipients at Risk for accidents and failure to provide safe care. Residents with orders and care plans for 2 person assist with ADLs shall be identified through audit entitled 2 person ADL care order Audit completed by Director of Nursing no later than 4/17/2024. Audit shall be completed by reviewing all active residents' current orders and care plans to ascertain all Recipients at Risk for accidents and failure to provide safe care. Entity shall complete facility wide audit of Residents at Risk, no later than 4/17/2024. Results of audit identifying residents with 2 person assist with ADL care, shall be reviewed by facility Quality Assurance Committee (Physician services, Administrator, Director of Nursing, Quality Assurance Coordinator, Rehab Manager, Staff Development Coordinator, Social Worker, Environmental Services Director) on 4/18/2024 and results ensured to be communicated clearly in facility software to all nursing staff (Nurses and Nurse Aide 1). Software communication noted to populate in ADL documentation grid for all nurses and nurse aides and is populated through the ADL care plan once any orders are received and is documented by care planning nurse. Current care plan and communication shall be validated by Quality Assurance Committee by 4/18/24. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: · The Quality Assurance Committee shall also adopt new 2 Person assist with ADL Care Icon to be placed at foot of bed for any Residents at Risk as to improve process, in order to more clearly identify Residents at Risk with 2 person ADL care ordered. Once Committee has ensured accuracy of audit, as well as communication through facility software and new icon, all nursing staff shall receive education by Staff Development Coordinator or their designee, regarding all residents currently at risk. Education to encompass all residents receiving ADL care will include instruction on safety with ADL care to include gathering supplies and equipment, ensuring proper positioning in bed to provide safety, awareness of bed height and leaving residents in a safe position with call light in place. Education shall also include current list of all Residents at Risk, with 2 person ADL care and where their orders and care plan may be identified in facility software, care plan awareness through new Icon and expectations regarding 2 person assist with ADL care. Residents / responsible party shall also be contacted by Resident Services Coordinator by 4/18/2024, to ensure permission to place Icon as to avoid any dignity issues and documented acceptance. Education shall be completed and all efforts to encompass entire staff present 4/18/2024. Any staff not present 4/18/2024 shall have attempts made to complete education by phone no later than 4/18/2024 with messages left for any not spoken to, to contact facility as soon as possible for education, as to prevent future serious adverse outcomes from occurring. Education shall be documented on In-service Training Report. Staff Development Coordinator shall notify nursing supervisor of any nursing staff on the schedule who have not received in-servicing so that education may be delegated and completed for any nursing staff that may enter facility after 4/18/24. Staff Development Coordinator shall additionally add lesson plan to Orientation packet to encompass all new hires as well. 2 Person assist with ADL Icon shall be placed at foot of bed for all Residents at Risk by Quality Assurance Coordinator by 4/18/2024. Alleged Immediate Jeopardy Removal Date: 4/19/24. Onsite validation of the immediate jeopardy removal plan was conducted on 4/19/24. The validation included staff interviews, observation, and record review. Inservice sign in sheets and staff interviews verified in-services were completed on 2- person assist with ADL care. Education was confirmed for facility nursing staff. Observation of staff providing 2-person assistance with ADL care revealed no issues. Evidence of audits were reviewed for 2 person ADL care and the current list of identified Residents at Risk. Resident interviews were conducted with no issues identified. The immediate jeopardy removal date of 4/19/24 was validated.