**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and records review, the facility failed to ensure the resident environment was free of hazards for 1 of 4 residents reviewed for accidents. (Resident #81). The facility failed to ensure the safety and well-being of Resident #81 by not following procedures for exiting residents from the van using the wheelchair lift. The noncompliance was identified as PNC (past noncompliance). The IJ began on 05/28/2025 and ended on 05/28/2025. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for potential accidents, injuries, harm, or death. Findings included: Record review of a face sheet on 06/23/2025 indicated Resident #81 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included end stage renal disease (final stage of chronic kidney disease and requires kidney dialysis or transplant), diabetes mellitus, heart failure, and mild cognitive impairment. Record review of an admission MDS dated [DATE] indicated Resident #81 had clear speech, usually understood others and was usually understood. She had a BIMS score of 14 indicating her cognition was intact. The MDS indicated she received dialysis treatments and was mobile via wheelchair. Record review of physician orders records dated 06/24/2025 indicated Resident #81 had a physician's order for dialysis treatments every Monday, Wednesday, and Friday at 11:30 AM at a local dialysis center. Record review of a facility reported incident dated 05/28/2025 indicated Resident #81 was transported to the dialysis center on 05/28/2028 via the facility's van. Van Driver A lowered the wheelchair lift to the ground, re-entered the van, and proceeded to back the resident in her wheelchair out the back door of the van. The lift's platform was not flush with the van's floor and both Resident #81 and Van Driver A fell to the ground landing on the lift's platform positioned on the ground. Review of Resident #81's Progress Notes in the electronic record dated 05/28/2025 at 12:22 PM indicated the dialysis center notified the facility that resident had a fall out of the back of the van. Informed them our diver had notified us but we thanked them for the call. They reviewed with us what occurred and stated that Resident #81 did decline to go to the ER. Review of Resident #81's Progress Notes in the electronic record dated 05/28/2025 at 01:34 PM indicated the DON went to the dialysis center to check on the resident and noted a scratch to the left second finger and Resident #81 complained of a headache. The progress notes also indicated the dialysis center gave Resident #81 some Tylenol for the headache and offered to send Resident #81 to the ER for further evaluation and she refused. Review of Progress Notes dated 05/28/2025 at 02:09 PM indicated Resident #81, in an interview with the DON, said I really don't remember much. She got in the van, and we started backwards and I heard a click and we fell. She caught me though. I landed on her. I think my head hit her face. The note further indicated the MD, NP, and Resident #81's responsible party were notified of the incident. Further review of Progress Notes dated 05/28/2025 at 02:09 PM indicated the following: Transporter (Van Driver A) had arrived at dialysis center and parked, and got out of driver's side door and went to the back and opened the back doors and had began letting the lift down when she noticed a bag a resident had left and unknowingly let the lift all the way down to the ground. She grabbed the bag and went through the side door of the van, closed it behind her and unlatched the resident and began walking backwards with the resident in the wheelchair to load onto the lift. She did not know the lift was all the way down and both transporter and resident fell out of the transport van. Record review of Progress Notes dated 05/28/2025 at 02:23 PM indicated the DON offered to send Resident #81 to the hospital upon her return to the facility. The documentation indicated Resident #81 had a fall out of the back of the van, hit her head on Van Driver A's face, and scraped her finger and knee and was at risk for brain bleed, worsening health conditions, fractures, hospitalizations, and/or death. Resident declined to go to the hospital but agreed to having x-rays done at the facility. Record review of Van Driver A's written statement dated 05/28/2025 indicated she was letting the wheelchair lift down when she noticed a bag belonging to another resident on the ground. She said in her statement she reached for the bag and unknowingly let the lift all the way down to ground level. Her statement further indicated she walked to the front of the bus, entered the bus, and proceeded to back Resident #81 out of the bus and onto the lift. She said she did not notice the lift was not positioned flush with the van floor and stepped backwards, falling to the ground and landing on the floor of the lift. The statement further indicated Van Driver A caught Resident #81 as she fell backwards in her wheelchair and both the resident and wheelchair landed on top of the van driver. Record review of the maintenance director's inspection of the vehicle and lift dated 05/28/2025 indicated the van and lift were operating correctly. During observation and interview of Resident #81 on 05/23/2025 at 10:10 AM, she said she fell out of the back of the van about a week ago. She said she was sitting in her wheelchair and the driver was pulling her backwards out of the van. She said she heard something click and the next thing she knew, she and her wheelchair were falling backwards out of the van. She said she landed on top of the driver. She pointed to an area on her left second finger and said she got a scratch. There was no remaining evidence of an injury. She said she was not hurt and was not afraid to go to dialysis on the facility's van. She said the person who currently takes her to dialysis made sure the lift was in place before loading or unloading her. During observations and interviews on 06/23/2025 at 1:15 PM, the current van driver (Van Driver B) demonstrated the use of the van's wheelchair lift to load and unload a resident. Van Driver B opened the doors at the back of the bus, unlocked and lowered the lift floor, secured the safety strap at the front of the lift, and manually lowered the lift to the ground by pushing a button on the lift. The maintenance director, who was present during the demonstration, explained and demonstrated that the lift could not be lowered or raised without physically placing a finger on the button. When asked about the clicking sound Resident #81 heard, the maintenance director pointed to a metal pressure-activated sensor mat and demonstrated how when it was stepped on, a clicking sound was made, an alarm sounded, and a red flashing light was activated signaling that the lift was not flush with the van floor. The maintenance director said the lift could not have been lowered to the ground without Van Driver A manually pressing the button that lowered it. The distance from the floor of the van to the ground was 28 inches. The distance from the floor of the van to the floor of the lift at ground level was 26.5 inches. During an interview with the DON on 06/23/2025 at 10:25 AM, she said Van Driver A called the facility from the dialysis center and notified her of the incident involving the wheelchair lift and Resident #81. The DON said she went to the dialysis center and assessed the resident. She said the dialysis center had offered to send Resident #81 to the ER but she refused. The DON said she assessed Resident #81 and found no evidence of a major injury but encouraged Resident #81 to go to the ER but she refused. She said Resident #81 completed her dialysis treatment and returned to the facility where she was assessed again, neuro checks were initiated, and x-rays of Resident #81's skull, left arm, left hand, left hip, and left leg were done. She said the x-rays were negative for any injury. During an interview with the Administrator on 06/23/2025 at 11:05 AM, he said Van Driver A transported Resident #81 to the dialysis center on 05/28/2025 for the Resident's scheduled dialysis treatment at 11:30 AM. He said on 05/28/2025, Van Driver A was re-trained on neglect and the van's wheelchair lift use, screened for drug use, and suspended and sent home pending the facility's investigation of the incident and the results of the drug screen. The Administrator said the maintenance director performed a vehicle and lift inspection on 05/28/2025 and noted no issues. He said beginning 05/28/2025, the facility used city transportation for residents until they were able to train a new van driver. He said the facility immediately began abuse and neglect training of its employees after the incident. The Administrator said Van Driver A was terminated for failing to use the van's lift in a safe and accurate manner and for a negative drug screen test. He said the incident was reported to the QAPI team. A review of Resident #81's x-ray reports dated 05/28/2025 indicated she had no injuries of the skull, left arm, left hand, left hip, and left leg. A review of neuro checks completed on 05/28/2025 for Resident #81 indicated no abnormal findings. A review of Van Driver A's personnel record indicated the following: *Van Driver A applied for employment on 01/19/2024 and began work on 01/22/2024. *The latest annual nurse aide registry check, misconduct registry check, and criminal history check were completed on 02/08/2025 with no negative findings noted. *Training on abuse and neglect were completed on hire and multiple times throughout the year. *Van Driver A was trained and checked by return demonstration on the operation of the van and lift use on 02/06/25, on 03/25/25 and on again on 05/26/25. *Van Driver A was re-trained on the operation of the van and wheelchair lift on 05/28/2025. *Van Driver A was suspended on 05/28/2025 pending the investigation of the incident and results of the drug screen performed on 05/28/2025. *Van Driver A was terminated 06/05/2025 after the facility received the failed drug screen results. Record review of drug screen results for the van driver collected on 05/28/2025 at 01:35 PM indicated Van Driver A tested positive for THC (tetrahydrocannabinol, primary psychoactive compound in marijuana). A review of the facility's Van Incident Monitoring tool indicated Van Driver B received training and was checked off by return demonstration on the use and operation of the facility van and lift on 06/13/2025. Follow-up checks by return demonstration by Van Driver b were noted completed on 06/16/2025, 06/17/2025, 06/18/2025, 06/19/2025, 06/20/2025, and 06/23/2025 with no issues noted. A review of the facility's policy on the use of the facility van and wheelchair lifts undated and titled Employee Auto Training Handbook indicated the following: Serious violations include but are not limited to: Driving under the influence of alcohol or drugs . Lift Operation Procedures and Checklist: Wheelchair lifts make it possible to load wheelchairs of all weights in and efficient and safe manner. However, lifts are potentially hazardous equipment. They must be maintained and operated properly. Considerable caution and awareness is needed when operating a lift. No one but the vehicle operator should operate the vehicle wheelchair lift. Lifts may differ slightly in structure and function, Therefore, each vehicle operator should be familiar with all the lifts likely to be used Unloading: . 3.Staff will operate lift from to up position to assure the lift is in correct position, flush with van floor and ensure front safety barrier is locked before loading the resident onto the lift . A review of the facility's policy undated policy titled Transportation of a Resident indicated the following: 3. Residents must be physically assisted in and out of the vehicle by a trained employee using appropriate transfer techniques. A review of the facility's undated policy titled Employee Drug Free Workplace Policy indicated the following: It is the policy of this facility to maintain a safe, drug-free working environment through the use of education and for cause drug testing. All staff employee by the company is prohibited, during wok time, from using, distributing or being under the influence of prohibited drugs, alcohol,or abusing prescription drugs, whether on the company's premises or elsewhere. The noncompliance was identified as PNC (past noncompliance). The IJ began on 05/28/2025 and ended on 05/28/2025. The facility had corrected the noncompliance before the survey began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards and each resident received adequate supervision as is possible for 2 of 6 resident (Resident #1 and Resident #2) reviewed for accidents and hazards. 1.The facility failed to ensure Resident #1 did not wander outside of the facility and down the road while wearing a wander guard. On 1/04/2025 Resident #1 while wearing a wander guard left the facility through the front door and was seen walking down the road by another resident's family member who notified the facility of Resident #1's whereabouts. The non-compliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began 01/04/2025 and ended on 01/08/2025. The facility corrected the non-compliance before surveyor's entrance. 2.The facility failed to ensure Resident #2 was properly strapped down in the van to prevent Resident #2's wheelchair from flipping over backwards during transport. On 2/21/2025 during transport to dialysis by the contract transport service Resident #2's wheelchair flipped over backwards in the van causing Resident #2 to have head and neck pain. The non-compliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began 02/21/2025 and ended on 02/25/2025. The facility corrected the non-compliance before surveyor's entrance. This failure could place residents at risk of harm and serious injuries due to lack of supervision and failure to follow protocols. Findings included: Record review Resident #1's Face sheet dated 3/25/2025 indicated Resident #1 was admitted to the facility on [DATE] with the most recent admission on [DATE]. Resident #1 was a [AGE] year-old female admitted with diagnosis of severe dementia with anxiety (agitation, restlessness, and difficulty concentrating stemming from confusion and disorientation), hypertension (high blood pressure), and muscle weakness. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 04 indicating severe cognitive impairment. The MDS Assessment indicated Resident #1 required supervision or touching assistance with walking 150 feet. Record review of Resident#1's care plan dated 11/04/2021 indicated: Resident #1 was at risk for wandering, Resident #1 had a wander guard in place with interventions that included: .3. Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. 4. Identify pattern of wandering: is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. 5. If the resident is exit seeking, stay with the resident and notify the charge nurse by calling out, sending another staff member, call system, etc. Record review of Resident #1's medication administration record dated January 2025 indicated: Monitor for function of wander guard every shift and as needed for preventative and was signed as functioning on 1/3/2025 night shift. Record review of Resident #1's weekly skin assessment dated [DATE] indicated Resident #1 did not have any skin issues. Record review of Resident #1's elopement risk assessment dated [DATE] indicated a score of 9 which indicated low risk for elopement. Record review of incident report dated 01/04/2025 revealed: elopement on 1/04/2025 at 9:10am from the reception/lobby. No injuries were observed at the time of the incident and Resident #1 was not taken to the hospital. Record review of the facility's Provider Investigation report dated 01/09/2025 revealed the following: The resident went out the front door and was observed by another family member about 60 yards away from the facility. They notified the facility, and the resident was returned with no injuries. During an observation on 3/25/2025 at 3:00 PM the Administrator and DON demonstrated Resident #1's wander guard at the front door and the door did not alarm or lock. The Corporate Maintenance Director provided a new wander guard and when approached at the front door the door locked, when the new wander guard approached the front door when the door was open, and alarm sounded. During an interview on 3/25/2025 at 3:00 PM the DON said Resident #1 went out the front door of the facility. She said Resident #1's wander guard did not lock the front door or alarm. The DON said the wander guard had been checked on the night shift prior to the morning of the incident and said it was functioning. She said after the incident and Resident #1 was returned to the facility the malfunctioning wander guard was replaced with a new one and Resident #1 was placed on 1 to 1 supervision. She said Resident #1 was discharged later that day to a facility with a secured unit. During an interview on 3/25/2025 at 3:00 PM the Administrator said the Resident #1's wander guard did not lock the front door or alarm. He said sometime between it being checked on the night shift and the incident the wander guard malfunctioned and did not work. He said another resident's family member took a picture of the resident walking down the road and showed it to the facility and the facility went and retrieved Resident #1 without incident. Resident #1 was returned to the facility and a new wander guard was placed on Resident #1. He said a head-to-toe assessment was completed on Resident #1 with no injuries found. He said later that same day the resident was transferred to another facility with a secured unit. Record review of QAPI notes dated 01/04/2025 indicated that the meeting was attended by the following members: Administrator, DON, ADON, Medical Director, Social Services, Dietary, MDS Nurse, Activity Director, Therapy, and Medical Records. The interventions and plan for correction included: 1. Self report to HHSC. 2. Interview the resident completed on 1/4/2025. 3. Take statements from everyone involved or with potential knowledge/involvement completed 1/4/2025. 4. Determine if resident will be able to remain in the facility with any new interventions. Resident #1 was transferred to a new facility with a secured unit on 1/4/2025. 5. 1 on 1 monitoring for resident involved until evaluated by the IDT and further instructions are provided. Completed on 1/4/2025. 6. Complete risk management entry for elopement and complete elopement event note and elopement risk assessment for the resident involved. Document conclusion in the risk management entry of PCC (records system). Completed on 1/4/2025. 7. Complete an elopement risk assessment for all other residents. Completed 1/4/2025. 8. Complete the QA tool for elopements. Completed 2/4/2025. 9. Update the care plan for the resident who exited with new interventions. Completed 1/4/2025. 10. Review and update the plan of care as needed of any resident who has been assessed to be a high risk for elopement. Completed 1/4/2025. 11. Perform trauma informed PRN assessment on affected resident and initiate/update care plan interventions as needed. Completed 1/4/2025. 12. If known, in-service staff related to findings and ways to prevent residents exiting. In-services on abuse, neglect, and elopement initiated on 1/4/2025. 13. Notification to families to mindful of residents attempting to exit the facility and not to share the door code with the residents. Completed on 1/10/2025. 14. Place signage at visitor exits to be mindful of residents attempting to exit the facility and not to share a door code with the residents. Completed 1/4/2025. 15. The Medical Director was notified of this plan. Completed 1/4/2025. Record review of Resident #1's electronic medical record indicated Resident #1 discharged from the facility on 1/4/2025. Record review of 1 to 1 monitoring sheets dated 1/4/2025 from 9:30 AM to 3:45 PM. Record review of Missing Resident/Elopement Monitoring tool dated 1/4/2025 through 2/4/2025 indicated: 1. The locking mechanism or alarm functioned properly on all exit doors of the facility. 2. Wander guard bracelets were in place every shift. Record review of Trauma Informed PRN Assessment dated 1/4/2025 indicated Resident #1 had no trauma from the incident. Record review of Elopement Risk Assessment dated 1/4/2025 indicated a score of 28 which indicated high risk for elopement. Record review of the care plan for Resident #1 indicated revised on 1/4/2025 indicated a new intervention for 1 to 1 monitoring of Resident #1 until alternate placement could be arranged. Record review of in-services dated 1/4/2025-1/5/2025 titled Abuse, Neglect, Elopement, ways to prevent resident exiting, reporting concerns with 135 employee signatures. Record review of elopement drills dated 1/7/2025, 1/9/2025, 1/15/2025, 1/17/2025, 1/21/2025, and 1/23/2025 indicated multiple drills across multiple shifts had been conducted. Observation of signage on the front door of the facility on 3/25/2025 at 3:00 PM notifying families to be mindful of residents attempting to exit the facility and not to share door code with the residents. On 3/25/25 at 10:51 am the Administrator, and DON were informed of IJ. The non-compliance was identified as past non-compliance. The IJ began on 1/04/2025 and ended on 2/4/2025. The facility had corrected the noncompliance before the investigation began. 2. Record review of the electronic face sheet dated 3/24/2025 for Resident #2 indicated Resident #2 was admitted to the facility on [DATE] with diagnosis that included: end stage renal disease (kidneys do not function properly), hyperkalemia (excessive amount of potassium in the blood), and muscle weakness. Record review of Resident #2's quarterly MDS dated [DATE] indicated Resident #2 had a BIMS score of 11 which indicated mild cognitive impairment. The MDS assessment indicated Resident #2 required supervision or touching assistance for transfers. Record review of Resident #2's care plan dated 9/22/2023 and revised on 2/5/2024 indicated Resident #2 had end stage renal disease and was on dialysis on Mondays, Wednesdays, and Fridays with interventions that included: 1. Encourage resident to do for the scheduled dialysis appointments, resident received dialysis on Mondays, Wednesdays, and Fridays. The resident had an ADL self-care performance deficit with interventions that included: 1. the resident uses a wheelchair. The resident was at risk for falls gait/balance problems with interventions that included: 1. Skin assessment, new pain medication, xrays ordered, neuros started, 3rd party transportation on hold for in-servicing their staff on van safety/buckling and monitoring in place. Record review of nursing progress note dated 2/21/2025 at 6:00 AM written by LVN C indicated Notified by transport driver, while on the way to drop off resident at dialysis, residents wheelchair tilted backwards resulting in resident falling backwards in chair. Driver states resident stated he was ok to continue to dialysis appointment. Record review of nursing progress note dated 2/21/2025 at 10:30 AM written by LVN C indicated Resident returned from dialysis and is complaining of neck pain post fall from this morning. New order received for xray of neck due to neck pain. Record review of nursing progress note dated 2/21/2025 at 10:30 AM written by the DON indicated Resident denied any pain medication at this time and stated he would let us know if he needed anything. Record review of nursing progress note dated 2/21/2025 at 11:40 AM written by the DON indicated Down to check on resident at this time to see how he is doing; resident is stating that his head/neck is bothering him and asked if he could get something for pain at this time. MD was notified and new order for Tylenol 325mg every 4 hours as needed for pain. (medication was administered at this time to resident) Attempted to notify [family] but no answer at this time. Record review of nursing progress note dated 2/21/2025 at 12:03 PM written by the DON indicated Down to follow up with resident and he does state that the Tylenol was effective. Record review of nursing progress note dated 2/21/2025 at 1:46 PM written by the DON indicated Went down to check on resident at this time and he stated that he was feeling ok. Inquired again if resident was wanting to go to ER (resident had been asked when incident initially occurred if he would like to go be he did not feel he needed to go at that time and wanted to proceed going to dialysis) to get checked out and he stated well I feel like I guess I should. Explained that xrays had been taken and results were pending when I last looked however if felt he needed to be checked out we could certainly send him. He thought for a minute and stated he felt like he ought to go ahead and go just to be safe. MD notified of request and new orders given to transport to ER for evaluation and treatment. Record review of nursing progress noted dated 2/21/2025 at 5:42 PM written by ADON B indicated Resident returned via wheelchair with [facility] van transport from [hospital] ER related to fall, resident cleared from ER and sent back to facility with no changes in medications or orders. Record review of facility incident report dated 2/21/2025 at 6:00 AM indicated Resident #2 had a fall with no other information. Record review of hospital paperwork dated 2/21/2025 indicated no acute findings and Resident #2 was discharged back to the facility with no new orders. During an interview on 3/24/2025 at 10:33 AM Resident #2 said on the day he fell in the van the Contract Van Driver did not strap him down in the van. He said the Contract Van Driver was trying to go up the hill in the driveway and his wheelchair flipped backwards. He said the Contract Van Driver stopped and picked him back up in the van. He said he told the Contract Van Driver he was having pain but the Contract Van Driver continued on to dialysis. He said he told them at dialysis he was in pain also. He said when he got back to the facility the nurse checked him over and he complained of head and neck pain. He said the facility sent him out to the ER to get checked out. He said he no longer is having any pain to his head and neck. During an interview on 3/24/2025 at 11:10 AM the Contract Van Driver said on 2/21/2025 at approximately 5:00 AM he got to the facility and put the resident on the van. He said he placed Resident #2 on the ramp and raised the ramp. He said he then pushed Resident #2 forward, he said he usually used 2 front straps, and 2 back straps when securing a resident in the van. He said when he drove off and going up the incline in the facility parking lot Resident #2 flipped back in his wheelchair. He said he stopped the van and got out to check if Resident #2 was ok, and said Resident #2 told him that he was fine and to continue on to dialysis. He said he picked Resident #2 upright in his wheelchair and continued on to dialysis. He said he did not notify anyone of the fall until later on that day. He said he had no idea how the incident happened. During an interview on 3/24/2025 at 11:30 AM the Facility Van Driver said she picked up Resident #2 from dialysis on the day he fell on the Contract Van. She said when she picked him up about 10:30am the Dialysis Tech pushed him out to the van that day and said Resident #2 was complaining of severe head and neck pain because he fell backwards in the Contract Van that morning. She said she brought Resident #2 straight back to the facility and said when she got there the Contract Van Driver was at the facility to report the fall that happened that morning. Said she reported to the nurse that Resident #2 was complaining of head and neck pain. She said to properly secure a resident's wheelchair in the van there should be 2 tie down straps at the front of the wheelchair and 2 tie down straps at the back of the wheelchair, she said then there is a seatbelt that goes across the resident to hold the resident in the chair. She said if all straps are applied appropriately there would be no way a resident's wheelchair could flip over backwards. During an interview on 3/24/2025 at 12:26 PM the Dialysis Tech said on 2/21/2025 Resident #2 never complained of pain until the end of his treatment and then he told her that he had fallen in the van on his way to dialysis that morning. She said she did not administer anything for pain while he was at dialysis that day. She said the Contract Van Driver did not notify anyone at dialysis that Resident #2 had fallen that morning. During an Observation and interview on 3/24/2025 at 12:43 PM the Contract Van Driver demonstrated how to correctly strap down a wheelchair in the van. At the end of the demonstration the surveyor asked the Contract Van Driver if it was plausible that on the day Resident #2 fell in the van that Resident #2 was not secured properly in the van and the Contract Van Driver said yes. During an interview on 3/25/2025 at 10:25 AM the Corporate Maintenance Director said to properly secure a resident's wheelchair in the van there should be 2 tie down straps at the front of the wheelchair and 2 tie down straps at the back of the wheelchair, he said then there is a seatbelt that goes across the resident to hold the resident in the wheelchair. He said if all straps are applied appropriately there would be no way a resident's wheelchair could flip over backwards and the wheelchair should not move in the van. During an interview on 3/25/2025 at 10:40 AM the DON said on 2/21/2025 at approximately 10:30 AM the Contract Van Driver came to the facility to report to her that Resident #2 had fallen in the van that morning. She said the Contract Van Driver did not report it to the facility that morning when it happened but waited until later in the day. She said the Contract Van Driver told her he asked Resident #2 if he was ok and Resident #2 said he was, so he continued with transporting Resident #2 to dialysis. She said the Contract Van driver said he had not reported the incident to dialysis. During an interview on 3/25/2025 at 11:04 AM the Administrator said on 2/21/2025 he received a call from the Contract Van Drivers supervisor stating the Contract Van Driver was going to the facility to let them know about and incident that had happened that morning. He said at approximately 10:30 AM he overheard the Contract Van Driver telling the DON that Resident #2 had fallen in the van that morning. He said the Contract Van Driver said he loaded Resident #2 on the van and when leaving the facility parking lot incline Resident #2 flipped backwards in his wheelchair. He said the Contract Van Driver immediately stopped the vehicle and asked Resident #2 if he was ok and Resident #2 said lets just go on to dialysis. He said Resident #2 denied any pain, so he continued transport to dialysis. Record review of Contract Van Drivers successful completion of the Passenger Assistance Safety and Sensitivity 7.0 Two-day Driver Certification Program including sensitivity training, left operating procedures, wheelchair and occupant securement valid January 09, 2025, through January 09, 2027. Observation of training video titled Retractable wheelchair tie-downs to secure wheelchair superior van and mobility. Video was accessed at https://youtu.be/mY_GThwGdbI?si=zQH-3ntbRIcPyck0 which indicated there should be 2 tie down straps in the front of the wheel chair and 2 tie down straps at the back of the wheelchair and the seatbelt that goes across the resident. Surveyor requested the facility policy and procedure regarding wheelchair tie down procedure and none was provided. Record review of QAPI notes dated 02/21/2025 indicated that the meeting was attended by the following members: Administrator, DON, ADON, Medical Director, Social Services, Dietary, MDS Nurse, Activity Director, Therapy, and Medical Records. The interventions and plan for correction included: 1. Self report to HHSC. Completed 2/21/2025. 2. The Contract van services was removed from service for resident transport on 2/21/2025. 3. The Contract Van Services were to educate drivers before services to be reinstated. Completed on 2/25/2025. 4. The Contract Van Driver was not allowed to transport for the facility pending investigation. Completed 2/21/2025. 5. Take statements from everyone involved or with potential knowledge/involvement. Completed 2/21/2025. 6. Begin abuse/neglect in-service for all staff who transport or assist with transporting residents in the van. Started on 2/21/2025. 7. In-service staff who transport or assist with transporting residents in the van on the following (with return demonstration): How to safely load and unload residents in the van using the lift, properly securing a resident in the van, ambulatory resident -securing with a seatbelt, Non-ambulatory resident-securing the wheel chair and the resident. Started 2/21/2025. 8. Maintain a list of staff who have completed training and provided return demonstration regarding transporting a resident in the van. Staff not listed will not transport residents. Completed on 2/24/2025. 9. Complete risk management entry as other in PCC. Attempt to determine the root cause of the incident. Document conclusion in this risk management entry of PCC. Fall Note completed 2/21/2025. 10. Perform trauma informed PRN assessment on affected resident and initiate/update care plan interventions as needed. Completed 2/21/2025. 11. The medical director was notified of this plan. Completed on 2/21/2025. Record review of in-service titled Van Training/Proper Tie Down Procedures Dated 2/24/2025 provided by the Corporate Maintenance Director and signed by the Facility Van Driver. Record review of Education Sign in Sheet with the topic Wheelchair securement during Transport dated 2/25/2025 signed by the Contract Van Service 6 employees. Record review on plan of correction submitted to the facility by the Contract Van Services indicated: 1. All transporters will receive reinforcement education of reasons for following all safety precautions, with visual confirmation. Education for log implementation will be provided also with the date to be completed of 2/26/2025. 2. Log to be implemented to record daily checks that all belts are to be checked daily prior to vehicle use to confirm safe and correct functioning to be completed daily with implementation by 2/26/2025. Supervisor will check logs of all vehicles used weekly to ensure compliance. If a vehicle is not used on a given day, it should be marked as not used on the log for that day. 3. [Contract Van Driver] will show correct use of all safety belts and sign acknowledgement of importance for checking safe functioning and ensuring correct use every time. He will also acknowledge who and how to reach out for support if he is unsure of a procedure or safe functioning completed 2/26/2025. Supervisor will monitor patients for safe travel and follow up with [Contract Van Driver] weekly for 2 months, then as needed, to ensure compliance and provide support for [Contract Van Driver] to be successful in safely transporting patients. Record review of Follow up Training Completion Sheet 2025 for the Contract Van Driver indicated his supervisor had signed completion for 4 weeks dated 2/21/2025 through 3/21/2025. Record review of Daily Checklist for Securement Device(s) Functionality dated March 2025 for multiple transport vehicles dated 3/3/2025 through 3/23/2025. Record review of facility in-services titled Abuse, Neglect, Resident Rights dated 2/21/2025 with 130 facility employee signatures. Record review of Trauma informed PRN assessment dated [DATE] at 12:40 PM indicated Resident #2 did not experience any trauma from the incident. Record review of employee questionnaires on abuse/neglect completed on 2/21/2025 with no concerns noted. Record review of resident safe surveys on abuse/neglect completed on 2/21/2025 with no concerns noted. Record review of monitoring of the Facility Van Driver completed 2/21/2025 through 2/27/2025 with no concerns noted. On 3/25/25 at 10:51 am the Administrator, and DON were informed of IJ. The non-compliance was identified as past non-compliance. The IJ began on 2/21/2025 and ended on 2/25/2025. The facility had corrected the noncompliance before the investigation began.