**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, for 1 of 43 sampled residents, the facility, in response to an allegations of abuse, neglect, or mistreatment, failed to provide evidence that all alleged violations were thoroughly investigated and failed to report the results of all investigations to the State Survey Agency (SSA), within 5 working days of the incident. Specifically, a resident sustained a fall in a wheelchair while being transported in the facility van and the facility did not investigate the incident or report the incident to the SSA. This was determined to have occurred at an Immediate Jeopardy level. Resident identifier: 47 and 50. On 3/20/25 at 1:30 PM, an Immediate Jeopardy (IJ) was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to thoroughly investigate alleged violations, prevent further potential abuse, neglect exploitation or mistreatment while the investigation was in progress, and report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with state law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violations was verified appropriate corrective action must be taken. Specifically the facility failed to report and investigate a resident's fall during transportation in a facility vehicle. The facility had no documentation that an investigation had been conducted, no actions were taken to re-educate transportation staff on how to properly secure residents and their equipment safely to prevent falls or injury during transportation. There was no evidence that monitoring had taken place to ensure that policies were being followed and that safety practices were being adhered to. Notice of the IJ was given verbally and in writing to the Corporate President (CP) and the Regional Nurse Consultant (RNC) 1 who were present by phone, the Regional [NAME] President of Operations (RVPO), RNC 2, the Administrator (ADM), the Director of Nursing (DON), the Minimum Data Set (MDS) Coordinator, and they were informed of the findings of IJ pertaining to F 610 for resident 50. On 3/20/25 at 4:09 PM, the Administrator provided the following revised abatement plan for the removal of the Immediate Jeopardy effective 3/20/25 at 10:00 PM. Identification of Residents Affected or Likely to be Affected: The facility took the following actions to address the identified issue and prevent any additional residents from suffering an adverse outcome (Completion Date: 3/20/25 Completion Time: 10:00 PM) * Resident #50 was evaluated on 3/20/25 at 1440 (2:40 PM) by the Director of Nursing (DON) for pain and offered to be transferred to the hospital to address concerns and to be evaluated for latent injury from the fall on 2/14/25. The resident declined to go to the hospital. The resident was reminded of the treatment modalities available to him including pain medication, muscle relaxation and non-pharmacological interventions. * Resident #50's w/c [wheelchair] was evaluated for safety and to ensure proper functioning by the DON and Nursing Home Administrator (NHA) on 3/19/25. There were no concerns identified. * The NHA inititiated an initial report to the State for the van incident that occurred on 2/14/25 on 3/19/25. * The incident report for resident #50 was reviewed and updated for the event that occurred on 2/14/25 on 3/20/25 to address inaccuracies identified during the investigation initiated on 3/19/25. * The Transpiration Driver (TD) was suspended on 3/19/25 pending the outcome of the investigation. * On 3/20/25 the DON and designee(s) assessed all residents that have been transported by the facility since 2/14/25 to ensure they did not sustain any injury or falls while being transported on the facility van. No additional residents were identified. * On 3/20/25 the Regional Nurse Consultant (RNC) completed a 100% audit of risk management reports and progress notes from 2/14/25 to present to ensure all incidents to have been appropriately reviewed and investigated for potential abuse or neglect. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring (Completion Date: 3/20/25 Completion Time 10:00 PM) * On 3/20/25 the RNC conducted a Root Cause Analysis (RCA) on all transport incidents from the previous 90 days. Current residents impacted by the findings of the RCA had safety measures and resident specific interventions added to their care plans. * On 3/20/25 the RVPO educated the NHA and DON on the facility Trigger Call process, driver safety including proper securement technique of w/c dependent residents such as seatbelt placement through the arm rest and secured against post assuring seat belt is against the resident and does not have any slack as well as securing the wheelchair to the wheelchair van through the appropriate placement of the wheelchair restraints onto a fixed part of the frame of the wheelchair, how to conduct a RCA, review of incidents to ensure allegations of abuse and neglect are investigated timely, and how to ensure incident investigations are timely and complete including the Event Note Template. The Trigger Event process includes the NHA and DON notifying the RNC and RVPO of high risk events to ensure they are handled appropriately with targeted interventions and actions to investigate and prevent recurrence. Trigger Events include areas such as allegations or suspicions of abuse and neglect, fall with major injury and any incidents that occur on an outing or transport. The incident investigation process includes IDT (Interdisciplinary Team) review of an incident report daily at stand up meeting and the use of an investigation checklist to assure the investigation process is thorough and complete. The Event Note Template includes a list of the IDT members involved in the incident RCA and investigation the event date and time, a description of the event, risk factors and root cause identification, preventative measures in place prior to the event and new interventions implemented post incident. * On 3/20/25 the RVPO educated the NHA and IDT Leadership on identifying, reporting and investigating neglect. The education included the definition of neglect and how to identify when a situation needs to be reported and investigated as neglect. * The NHA educated all staff involved in using the facility van for transportation on safety including proper securement technique for wheelchair dependent residents, placement of the seatbelt and what to do if an accident occurs. A documented return demonstration checklist was completed on 3/20/25 with transportation staff including the RA [Resident Advocate], DON, BOM [Business Office Manager], and AD [Activities Director] prior to their next transport. Instructions for what to do if an incident/accident occurs while performing a transport was placed in the facility van for staff to refer back to in the event of an incident/accident. * The NHA or designee will visually inspect residents being transported in the facility van prior to transport to ensure w/c is properly secured for the next 30 days. * The Corporate Nurse or RVPO will review all incident reports within one working day for three months to ensure an RCA has been conducted and the resident specific interventions are reflected in the care plan. * The NHA or designee will initiate a Trigger Call with the RVPO and RNC for all incidents that occur on the facility van to ensure appropriate action has been taken and a comprehensive plan for investigation and RCA has been developed. * The DON or designee will review all falls and transport related incidents at the daily stand-up meeting with the IDT for three months to ensure appropriate safety interventions are implemented, the resident's care plan has been reviewed and revised, and staff education has been completed as needed. * A QAPI [Quality Assessment Performance Improvement] PIP [Performance Improvement Plan] has been initiated to report on the above monitoring and auditing procedures. All findings from the PIP will be presented at the monthly QAA [Quality Assessment and Assurance] meeting. Monitoring/auditing and reporting will continue for a minimum of three months. On 3/21/25, while completing the recertification survey, surveyors conducted an onsite revisit to verify that the Immediate Jeopardy had been removed. The surveyors determined that the Immediate Jeopardy was removed as alleged on 3/20/25. Findings included: Resident 50 was admitted to the facility on [DATE] with diagnoses that included heart failure, type 2 diabetes, osteomyelitis, and diarrhea. On 3/17/25 at 10: 07 AM, an interview was conducted with resident 50 who stated the Transportation Driver (TD) was taking him to a cardiology appointment when he fell backward in his wheelchair, hit his head and neck on the floor. Resident 50 stated his wheelchair was strapped into the van and he was not sure about the placement of a seatbelt. Resident 50 stated he reported the accident when he returned to the facility and was provided an x-ray the day after the incident. Resident 50 stated the incident happened on 2/14/25 at approximately 9:30 AM. Resident 50 also stated that his roommate was also riding in the van and was a witness to the accident. Resident 50 stated he requested a copy of the incident report and was provided one. Resident 50 also stated the incident report was not accurate. Resident 50 stated he requested to have a second opinion regarding his injuries and was provided an appointment 2-3 weeks later. Resident 50 stated he spoke with the Director of Nursing (DON) about the incident the day after it occurred and was told he knew nothing about it. Resident 50's medical records were reviewed between 3/17/25 and 3/31/25. A progress note dated 2/15/25 at 8:34 PM revealed, Note text: During cares today, resident reported that he had a witnessed fall yesterday during transportation to his appointment. Resident states that he fell backwards and hit his head and neck. Fall was reported to management and MD [Medical Doctor], neuros initiated, no visible injuries but due to pain MD ordered cervical spine xrays. VS [vital signs] WNL [within normal limits]. Awaiting results on xrays. On 2/15/25 an incident report revealed, Witnessed fall: Resident: [Resident 50] .Incident location: out of facility/during transport .Incident Description: Nursing Description: Resident reported to the nurse today (2/15/25), that yesterday (2/14/25) he had a witnessed fall during transportation to his appointment. States that he fell and hit his head. Was heading to appointment, and when getting inside of the van he fell backwards and hit his head. states that heck[sic] has been hurting .Immediate action taken: Description: The resident was assessed for injuries and no injuries found. He reports tenderness to the neck on palpation. Reported to management and MD, initiated neuros and MD ordered cervical spine xrays- xrays ordered. X-ray results were negative for a fracture. Resident requested a second opinion, was referred to ortho. Alert charting initiated. IDT intervention: DON and NHA retrained the transportation driver on proper and safe transportation techniques. Also, resident's appointments to be rescheduled if the resident is not medically stable .Resident taken to Hospital? N .Injuries Observed at Time of Incident .No injuries observed at time of incident .Level of Pain: 0 .Level of Consciousness: Alert, Mobility: Ambulatory with assistance Mental Status: Oriented to Person, Oriented to Situation, Oriented to Place, Oriented to Time .Injuries Report Post Incident: No injuries observed post incident .Level of Pain: 0 .Level of Consciousness: Alert, Mobility: Ambulatory with Assistance . Mental Status: Oriented to Person, Oriented to Situation, Oriented to Place, Oriented to Time .Predisposing Environmental Factors: None .Predisposing Physiological Factors: None .Predisposing Situational Factors: Using Assistive Device .Other Info: Resident had loose bowels and was in his w/c at the time it happened. The back of his wheelchair opens backward. When the driver was at the light, the resident had another episode of loose BM [bowel movement], he got agitated and started to scream and thrash around while in wheelchair. His erratic movements caused the back of his wheelchair to reclined backward, which caused him to lean backward. According to driver, resident didn't land on the floor and did not hit his head on the floor or anything .Statements: Staff on 2/17/25 On Friday the 14th of March, [Resident 50] was having a cardiology appointment at [facility]. [Resident 50] was secured appropriately in the van according to our regular safety standards. When I went to get him, he was having diarrhea and a bad day as well, as he was so sad. Before we left the building, I changed his brief twice, so while we are driving he kept on yelling in the van because he also had diarrhea twice on our way. While this is happening, I always encourage him, and promise him that I will help him do a brief change when we get to the [facility]. So we got to the light close to the [facility], the moment it was green, I moved the car, all I heard was shit I just had diarrhea again. The he said I'm falling down, so I quickly park the van by the side of the road, he was still strapped with the seat belt, but he was down with his wheelchair. I asked him if hit his head and he said no, so I helped him up, and we continued our trip . Agencies/People notified: DON on 2/15/25 at 8:34 PM, Physician 2/15/25 at 8:34 PM. On 3/19/25 at 9:33 AM, an interview was conducted with resident 47 who stated he was sitting in the back seat of the van when the accident occurred on 2/14/25. Resident 47 stated he was wearing a seat belt. Resident 47 stated the TD placed the hooks of the straps to the frame of the wheelchair. Resident 47 stated, something in the front came undone. [TD] pushed on the gas and the wheelchair fell backward. Resident 47 stated the TD had to put the hooks back on the front of the wheelchair and re-tighten it down again. Resident 47 stated he did not remember if resident 50 hit his head, but he fell backward really fast. Resident 47 stated the TD stopped the van and opened the door to check on resident 50. Resident 47 stated he did not remember if resident 50 was wearing a seatbelt. Resident 47 stated resident 50 told him when he turned his head he could hear his bones popping and his neck hurt. Resident 47 stated resident 50 told everyone about the accident and asked for an x-ray right away but did not get on until the next day. On 3/19/25 at 9:40 AM, a follow-up interview was conducted with resident 50. Resident 50 stated he was not assessed after he returned to the facility. Resident 50 stated he was seen at [facility] on 3/7/25 and obtained a note stating that he had whiplash. Resident 50 stated he had a follow-up appointment on 3/28/25 for an MRI (Magnetic Resonance Imaging). Review of the facility abuse investigations revealed no documentation or investigation of resident 50's fall in the transportation van on 2/14/25. On 3/19/25 at 2:26 PM, an interview was conducted with the DON. The DON stated the TD was transporting resident 50 to an appointment. The DON stated that while riding in the van, resident 50 had a bowel movement and was yelling at the TD. The DON stated the TD told him the light turned green and he started to move and resident 50 fell down in the van. The DON stated they did a risk management on the incident and did not report it to the State Survey Agency (SSA). The DON stated he did not know why. The DON stated it did not seem like it was abuse or neglect. On 3/19/25 at 3:18 PM, an interview was conducted with ADM who stated resident 50 was having diarrhea really bad on the day of the incident. The ADM stated the TD was taking resident 50 to an appointment and he had 2 bowel movements in the van. The ADM stated that the TD reported that resident 50 freaked out for lack of a better term. The ADM stated that he did not think that the TD was accelerating when resident 50 fell back, but that he was already in motion. The ADM stated that he did not go and investigate because the TD told him the chair opened up and the resident did not have any injuries. The ADM stated if there was an accident in the van the process that should have been followed was that 911 should have been called and the resident should have been assessed. The ADM stated the TD should have reported to incident to him immediately. The ADM stated the TD notified him of the incident after returning to the facility but does not remember what time it was. The ADM stated he did not have any documentation. The ADM stated if a resident had an accident in the van he should be notified immediately. The ADM stated once notified, he should conduct an investigation. The ADM stated he did not investigate this incident because the TD reported the resident did not hit his head or receive any harm and that the wheelchair was secured. The ADM did not ask about how the chair was secured. The ADM stated it could have made a difference. The ADM stated he did not think to do an investigation. The ADM stated he did talk to the resident about the incident that day or the day after, he did not remember which. The ADM stated resident 50 was apologetic to the TD about the diarrhea. The ADM stated he was not aware that the resident was having ongoing pain. The ADM stated he was told the following day that the resident hit his head by either the DON or the nurse over his section. The ADM stated he did not think it would be considered neglect. The ADM stated they probably should have reported it. [Cross-refer F689]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined, for 2 of 43 sampled residents, that the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, one resident fell backwards while being transported in a facility van due to not being secured properly and the resident sustained an injury to the head/neck. This was determined to have occurred at an Immediate Jeopardy level. Also, a resident with multiple falls did not have interventions in place to prevent additional falls. Resident identifiers: 1, 47, and 50. On 3/20/25 at 1:30 PM, an Immediate Jeopardy (IJ) was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to identify hazard(s) and risk(s); evaluate and analyze the hazard(s) and risk(s); implement interventions to reduce hazard(s) and risk(s); and monitor for effectiveness and modify the interventions when necessary. Specifically, the facility failed to ensure that staff transporting residents and their equipment were trained on how to secure residents properly to prevent falls or injury. Notice of the IJ was given verbally and in writing to the Corporate President (CP) and the Regional Nurse Consultant (RNC) 1 who were present by phone, the Regional [NAME] President of Operations (RVPO), RNC 2, the Administrator (ADM), the Director of Nursing (DON), the Minimum Data Set (MDS) Coordinator, and they were informed of the findings of IJ pertaining to F 689 for resident 50. On 3/20/25 at 4:09 PM, the Administrator provided the following revised abatement plan for the removal of the Immediate Jeopardy effective 3/20/25 at 10:00 PM. Identification of Residents Affected or Likely to be Affected: The facility took the following actions to address the identified issue and prevent any additional residents from suffering an adverse outcome (Completion Date: 3/20/25 Completion Time: 10:00 PM) * Resident #50 was evaluated on 3/20/25 at 1440 (2:40 PM) by the Director of Nursing (DON) for pain and offered to be transferred to the hospital to address concerns and to be evaluated for latent injury from the fall on 2/14/25. The resident declined to go to the hospital. The resident was reminded of the treatment modalities available to him including pain medication, muscle relaxation and non-pharmacological interventions. * Resident #50's w/c [wheelchair] was evaluated for safety and to ensure proper functioning by the DON and Nursing Home Administrator (NHA) on 3/19/25. There were no concerns identified. * The NHA inititiated an initial report to the State for the van incident that occurred on 2/14/25 on 3/19/25. * The incident report for resident #50 was reviewed and updated for the event that occurred on 2/14/25 on 3/20/25 to address inaccuracies identified during the investigation initiated on 3/19/25. * The Transpiration Driver (TD) was suspended on 3/19/25 pending the outcome of the investigation. * On 3/20/25 the DON and designee(s) assessed all residents that have been transported by the facility since 2/14/25 to ensure they did not sustain any injury or falls while being transported on the facility van. No additional residents were identified. * On 3/20/25 the Regional Nurse Consultant (RNC) completed a 100% audit of risk management reports and progress notes from 2/14/25 to present to ensure all incidents to have been appropriately reviewed and investigated for potential abuse or neglect. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring (Completion Date: 3/20/25 Completion Time 10:00 PM) * On 3/20/25 the RNC conducted a Root Cause Analysis (RCA) on all transport incidents from the previous 90 days. Current residents impacted by the findings of the RCA had safety measures and resident specific interventions added to their care plans. * On 3/20/25 the RVPO educated the NHA and DON on the facility Trigger Call process, driver safety including proper securement technique of w/c dependent residents such as seatbelt placement through the arm rest and secured against post assuring seat belt is against the resident and does not have any slack as well as securing the wheelchair to the wheelchair van through the appropriate placement of the wheelchair restraints onto a fixed part of the frame of the wheelchair, how to conduct a RCA, review of incidents to ensure allegations of abuse and neglect are investigated timely, and how to ensure incident investigations are timely and complete including the Event Note Template. The Trigger Event process includes the NHA and DON notifying the RNC and RVPO of high risk events to ensure they are handled appropriately with targeted interventions and actions to investigate and prevent recurrence. Trigger Events include areas such as allegations or suspicions of abuse and neglect, fall with major injury and any incidents that occur on an outing or transport. The incident investigation process includes IDT (Interdisciplinary Team) review of an incident report daily at stand up meeting and the use of an investigation checklist to assure the investigation process is thorough and complete. The Event Note Template includes a list of the IDT members involved in the incident RCA and investigation the event date and time, a description of the event, risk factors and root cause identification, preventative measures in place prior to the event and new interventions implemented post incident. * On 3/20/25 the RVPO educated the NHA and IDT Leadership on identifying, reporting and investigating neglect. The education included the definition of neglect and how to identify when a situation needs to be reported and investigated as neglect. * The NHA educated all staff involved in using the facility van for transportation on safety including proper securement technique for wheelchair dependent residents, placement of the seatbelt and what to do if an accident occurs. A documented return demonstration checklist was completed on 3/20/25 with transportation staff including the RA [Resident Advocate], DON, BOM [Business Office Manager], and AD [Activities Director] prior to their next transport. Instructions for what to do if an incident/accident occurs while performing a transport was placed in the facility van for staff to refer back to in the event of an incident/accident. * The NHA or designee will visually inspect residents being transported in the facility van prior to transport to ensure w/c is properly secured for the next 30 days. * The Corporate Nurse or RVPO will review all incident reports within one working day for three months to ensure an RCA has been conducted and the resident specific interventions are reflected in the care plan. * The NHA or designee will initiate a Trigger Call with the RVPO and RNC for all incidents that occur on the facility van to ensure appropriate action has been taken and a comprehensive plan for investigation and RCA has been developed. * The DON or designee will review all falls and transport related incidents at the daily stand-up meeting with the IDT for three months to ensure appropriate safety interventions are implemented, the resident's care plan has been reviewed and revised, and staff education has been completed as needed. * A QAPI [Quality Assessment Performance Improvement] PIP [Performance Improvement Plan] has been initiated to report on the above monitoring and auditing procedures. All findings from the PIP will be presented at the monthly QAA [Quality Assessment and Assurance] meeting. Monitoring/auditing and reporting will continue for a minimum of three months. On 3/21/25, while completing the recertification survey, surveyors conducted an onsite revisit to verify that the Immediate Jeopardy had been removed. The surveyors determined that the Immediate Jeopardy was removed as alleged on 3/20/25. Findings included: 1. Resident 50 was admitted to the facility on [DATE] with diagnoses that included heart failure, type 2 diabetes, osteomyelitis, and diarrhea. On 3/17/25 at 10:07 AM, an interview was conducted with resident 50, who stated while being transported to a medical appointment on 2/14/25 at about 9:30 AM, in the facility van, he had fallen backward and hit his head. Resident 50 stated he was unhappy because the incident report he received from the administration was not accurate in the details of the accident. Resident 50 stated his wheelchair was strapped to the floor of the vehicle but he could not recall if he had a seatbelt on. Resident 50 stated he fell backward while the van was in motion and hit his head and neck on the floor of the van. Resident 50 stated his roommate, Resident 47, was also in the van and witnessed the accident. Resident 50 stated the incident report said the Transportation Driver (TD) had to sit the wheelchair back up but the resident did not fall. Resident 50 stated that after the fall he had pain to the base of his skull and when turning his neck he heard a cracking sound. Resident 50 stated he told staff about it upon returning from his appointment, but was not assessed. Resident 50 stated he received an x-ray the following day. Resident 50 also stated when he spoke with the Director of Nursing (DON), he was told he had not heard anything about it. Resident 50 stated that 2-3 weeks after his fall he went for a second opinion. Resident 50's medical record was reviewed between 3/17/25 and 3/31/25. An admission Minimum Data Set, dated [DATE] revealed resident 50 had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. Resident 50's physician orders included: a. Referral for Orthopedic for Neck Pain Revision date; 2/26/25. b. Acetaminophen Oral tablet; Give 650 mg [milligram] every 4 hours as needed for pain. NOTE: 3 GM [grams] daily from all sources. Order date: 1/28/25. Resident 50's care plan included: a. The resident has limited physical mobility r/t [related to] Bilateral BKA [below knee amputation] and multiple wounds on BLE [bilateral lower extremities] and on coccyx. Date initiated: 1/29/25, Revision on 3/14/25. The goal was, The resident will remain free of complications related to immobility, including contracture's, thrombus formation, skin-breakdown, fall related injury through the next review date. Date initiated:1/29/25, Target date: 5/12/25. Interventions included, Monitor/document/report PRN [as needed] any s/sx [signs/symptoms] of immobility: contractures forming or worsening, thrombus formation, skin-breakdown, fall related injury. Date initiated: 1/29/25. b. The resident is at risk for falls r/t Hx [history] of BKA, bilateral multiple wounds and needs for assistance with ADL [activities of daily living] at times. Date initiated: 1/29/25, Revision on: 3/14/25. Interventions included, 2/15/25 FALL-IDT intervention: DON [Director of Nursing] and NHA [Nursing Home Administrator] retrained the transportation driver on proper and safe transportation techniques. Also, resident's appointments to be rescheduled if the resident is not medically stable. Date initiated: 2/17/25 .; Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Date initiated: 1/29/25; Follow facility fall protocol if a fall occurs. Date initiated: 1/29/25. Resident 50's progress notes documented: a. On 2/15/25 at 8:34 PM, a Health Status Note revealed, Note Text: During Cares today, resident reported that he had a witnessed fall yesterday during transportation to his appointment. Resident states that he fell backwards and hit his head and neck. Fall was reported to management and MD [Medical Doctor], neuros initiated, no visible injuries but due to pain, MD ordered cervical spine X-rays. VS [vital signs] WNL [within normal limits]. Awaiting results on X-rays. b. On 2/15/25 at 10:48 PM, a Health Status Note revealed, Note Text: Resident continues on neuro checks, no delayed injuries noted, no c/o [complaints of] pain or discomfort r/t the incident expressed during this shift. bed in the lowest position, call light within reach. c. On 2/17/25 at 5:40 AM, an Alert Note revealed, Note Text: Resident being monitored due to recent unwitnessed fall. residents neuros have been wnl. No changes to LOC [level of consciousness]. d. On 2/17/25 at 9:56 AM, a Health Status Note revealed, Note Text: MD was notified of and reviewed the cervical Spine x-ray results, NNO [no new orders]. e. On 2/26/25 at 11:03 AM, a Health Status Note revealed Resident requested a second opinion regarding the pain he has in his neck following the fall in the van. A referral for Orthopedic for Neck Pain was made. f. On 3/7/25 at 2:07 PM, a Health Status Note revealed, Resident had an appointment today at [name omitted] Orthopedic Center. [Facility] transported to and from the appointment. Reason for Appointment: Neck Pain. Facility Comments/Questions: None. Findings at Appointment: Base of Skull pain; Cervical x-rays showing degenerative changes. New orders/Recommendation: External PT; Cervical MRI [magnetic resonance imaging]; Can try Tizanidine 2mg at night as needed; Tylenol, topical medications (Icy hot, lidocaine patches, etc). Next Appointment: PRN [as needed]. Transport coordinator was notified. MD notified. On 2/15/25 an incident report revealed, Witnessed fall: Resident: [Resident 50] .Incident location: out of facility/during transport .Incident Description: Nursing Description: Resident reported to the nurse today (2/15/25), that yesterday (2/14/25) he had a witnessed fall during transportation to his appointment. States that he fell and hit his head. Was heading to appointment, and when getting inside of the van he fell backwards and hit his head. states that heck[sic] has been hurting .Immediate action taken: Description: The resident was assessed for injuries and no injuries found. He reports tenderness to the neck on palpation. Reported to management and MD, initiated neuros and MD ordered cervical spine X-rays- X-rays ordered. X-ray results were negative for a fracture. Resident requested a second opinion, was referred to ortho. Alert charting initiated. IDT intervention: DON and NHA [Nursing Home Administrator] retrained the transportation driver on proper and safe transportation techniques. Also, resident's appointments to be rescheduled if the resident is not medically stable .Resident taken to Hospital? N[no] .Injuries Observed at Time of Incident .No injuries observed at time of incident .Level of Pain: 0 .Level of Consciousness: Alert, Mobility: Ambulatory with assistance Mental Status: Oriented to Person, Oriented to Situation, Oriented to Place, Oriented to Time .Injuries Report Post Incident: No injuries observed post incident .Level of Pain: 0 .Level of Consciousness: Alert, Mobility: Ambulatory with Assistance . Mental Status: Oriented to Person, Oriented to Situation, Oriented to Place, Oriented to Time .Predisposing Environmental Factors: None .Predisposing Physiological Factors: None .Predisposing Situational Factors: Using Assistive Device .Other Info: Resident had loose bowels and was in his w/c at the time it happened. The back of his wheelchair opens backward. When the driver was at the light, the resident had another episode of loose BM [bowel movement], he got agitated and started to scream and thrash around while in wheelchair. His erratic movements caused the back of his wheelchair to reclined backward, which caused him to lean backward. According to driver, resident didn't land on the floor and did not hit his head on the floor or anything .Statements: Staff on 2/17/25 On Friday the 14th of March, [Resident 50] was having a cardiology appointment at [facility]. [Resident 50] was secured appropriately in the van according to our regular safety standards. When I went to get him, he was having diarrhea and a bad day as well, as he was so sad. Before we left the building, I changed his brief twice, so while we are driving he kept on yelling in the van because he also had diarrhea twice on our way. While this is happening, I always encourage him, and promise him that I will help him do a brief change when we get to the [facility]. So we got to the light close to the [facility], the moment it was green, I moved the car, all I heard was shit I just had diarrhea again. Then he said I'm falling down, so I quickly park the van by the side of the road, he was still strapped with the seat belt, but he was down with his wheelchair. I asked him if hit his head and he said no, so I helped him up, and we continued our trip . Agencies/People notified: DON on 2/15/25 at 8:34 PM, Physician 2/15/25 at 8:34 PM. On 2/15/25, a cervical spine x-ray was obtained for resident 50. The findings of the x-ray documented that the lower cervical spine and cervicothoracic junction was incompletely imaged given shoulder positioning. Patient in pain and could not reposition. The report documented no acute fracture was evident. The impression documented that the Patient may ultimately benefit from CT [computed tomography] or MRI [magnetic resonance imaging] if symptoms persist. On 3/7/25, a referral note to the Orthopedic clinic documented the reason for the referral was neck pain. The findings at the appointment documented Base of skull pain. The New Orders/Recommendations documented physical therapy, cervical MRI, Tizanidine at night as needed and Tylenol and topical medications for pain. The Orthopedic provider documented an associated diagnoses of cervical spondylosis and whiplash injury to the neck. On 3/19/25 at 8:22 AM, an interview was conducted with the Transportation Driver (TD), who stated that he made the medical appointments for residents and transported them to most of the appointments. The TD stated if a resident was in a wheelchair he would take the big van. The TD stated on the day of resident 50's appointment, resident 50 had diarrhea during the ride to his appointment and got upset. The TD stated that resident 50 said he was falling down. The TD stated that he did not know how the wheelchair fell, but it was while the van was in motion. The TD demonstrated that the back of the w/c was flat on the floor of the van. The TD stated that he pulled over and stopped immediately. The TD stated resident 50 was holding onto the seatbelt strap. The TD stated the wheelchair floor straps were tensioned on the floor. The TD also stated that he placed the seatbelt on resident 50. The TD stated the seatbelt went on top of the arms of the wheelchair, then the TD stated he could not remember if the seat belt went over or under the arm rests. The TD stated he sent a text to contact the facility about what happened and was told to make a progress note, which the TD said he did. The TD stated it might have been the next day. On 3/19/25 at 9:19 AM, an observation was made of the TD demonstrating how a wheelchair would be secured in the large facility van. The TD raised the wheelchair with the van lift and pulled the wheelchair into the van. The TD locked the brakes on the wheelchair. From the back, the TD placed the two hooks on the left and right sides of the frame of the wheelchair. Going to the front of the wheelchair, the TD showed that the front straps would not reach the wheelchair so he released the tension on the straps so he could apply the hooks. The TD applied the hooks to the outside of each of the wheels of the wheelchair. The TD then checked to ensure the wheelchair was secure. The TD demonstrated that he put the seatbelt over the arm of the wheelchair, but under the arm of the resident and across the resident's body, and secured it into the buckle on the floor. The State Surveyor [SS] asked how resident 50 fell back and the TD stated, honestly, I do not know. The SS asked what the TD saw when he looked in the rear view mirror and the TD stated that initially he did not look in the rear view mirror as he was trying to find a place to pull over. The TD stated after pulling over, he went to the back of the van and asked resident 50 if he was ok, and resident 50 stated that he was. The TD stated that he did not assess resident 50 but sat the chair up and continued to the appointment at the hospital. The TD stated after getting resident 50 cleaned up and to his appointment, he contacted the facility about what had happened. The TD stated he spoke with the Director of Nursing (DON). After returning to the facility the TD stated he spoke with the Administrator (ADM), and was asked several questions about what had happened. The TD stated resident 50's roommate, resident 47, was also in the van and was a witness to the incident. On 3/19/25 at 9:33 AM, an interview was conducted with resident 47 who stated he was present in the van when resident 50 fell backward in his wheelchair. Resident 47 stated he was sitting in the back seat of the van. Resident 47 stated the strap hooks were on the frame of resident 50's wheelchair. Resident 47 stated, something in the front came undone. Resident 47 stated that the TD pushed on the gas and the wheelchair fell backward. Resident 47 stated he did not remember if resident 50 hit his head, but stated he fell backwards really fast. Resident 47 stated that the TD stopped the van and opened the van door to see if resident 50 was ok. Resident 47 stated that the TD took the residents' to their appointments and then back to the facility. Resident 47 stated resident 50 told him after returning that his neck hurt and he could hear his bones popping. Resident 47 stated resident 50 told everyone about falling in the van. Resident 47 stated resident 50 asked to have an x-ray done right away, but did not get one until the next day. Resident 47 stated that after the chair fell, the TD had to put the hooks back on the chair and re-tighten the chair down again. On 3/19/25 at 9:40 AM, a follow-up interview was conducted with resident 50. Resident 50 stated his wheelchair was specialized for him. A crossbar was observed under the seat of the wheelchair near the back of the frame. The front of the wheelchair had small wheels attached to the frame by bars on either side of the chair and the bars were angled downward where the wheel was attached. Resident 50 stated that was where the front straps were attached. Resident 50 stated, again, that he was not assessed when he returned to the facility. Resident 50 stated he was seen at [facility] on 3/7/25 and obtained a note stating that he had whiplash. Resident 50 stated he had a follow-up appointment scheduled on 3/28/25 for an MRI (Magnetic Resonance Imaging). It should be noted that upon inspection of resident 50's wheelchair it was observed by the State Surveyor that the chair back did not recline backwards as previously reported in the facility incident report. On 3/19/25 at 1:28 PM, a follow-up interview was conducted with the TD who provided transportation schedules for the months of February and March of 2025. The TD stated 99.9% of the time, he was the staff member who transported residents to their appointments. The SS and the TD reviewed the schedules day by day and marked off residents day by day who ended up not going to their appointments. On 3/19/25 at 1:36 PM, an interview was conducted with the AD who stated she was approved to drive the facility vans. The AD stated the last time she drove the facility van was last week. The AD stated she took a resident to get a hot dog. The AD stated she took residents shopping every other Tuesday as well. The AD stated the TD had shown her how to secure resident wheelchairs into the big van. The AD stated the TD showed her to secure the floor strap hooks onto the back and front of the wheelchair frame. The AD stated that the seatbelt should go across the resident and over the armrests of the wheelchair. The AD stated she did not have anyone verify the resident's wheelchair was secured before leaving the facility grounds. The AD stated she had completed the computer based training for the company but none of the training was specific to transportation in the facility vehicle. The AD stated she had not been provided any guidance about what she should do should she have an accident, and she had not seen any transportation policies. The AD stated she had not had any accidents while driving residents in the van. The AD stated she was told about the accident the TD had while transporting resident 50 and resident 47. The AD stated that she overheard the TD talking about the accident and the TD stated that the wheelchair had tipped back. The AD stated that she had not been provided any additional training or instructions for driving residents in the facility van after the accident with resident 50. On 3/19/25 at 1: 54 PM, an interview was conducted with the BOM who stated she provided transportation occasionally for residents. The BOM stated the last time she provided transportation was about 2 months ago when she took a resident to the bank. The BOM stated when she first started working at the facility, the DON and the TD had trained her on how to secure a wheelchair in the facility van. The BOM stated that she was taught to lower the ramp, put the wheelchair on, lock the wheels, raise the ramp, and hook the belt on the bottom of the chair. The BOM stated she never had to do a return demonstration, she just had to repeat back what she saw them do. The BOM stated she thought there was a clip on the floor that the wheelchair was attached to. The BOM stated the seatbelt should be placed over the wheelchair armrest and secured. The BOM stated if a resident needed to be transported she would have the TD or the AD drive the van. The BOM stated she thought the DON did a demonstration and training recently. The BOM stated she had not heard of any resident related falls while being transported. On 3/19/25 at 2:03 PM, an interview was conducted with the RA who stated she had been authorized to transport residents in the van but had not done so since October 2024. The RA stated she had been trained how to secure a wheelchair into the van. The RA stated the ADM and the TD did the training. The training included using the lift, making sure the wheelchair brakes were on, and placing the floor straps on the front and the back of the wheelchair by the hooks. The RA stated the hooks were supposed to be put on the frame of the wheelchair. The RA stated the seatbelt should be brought across the resident and hooked into the buckle down near the floor. The RA stated the seatbelt would go over the arm rests, but as close to the body as possible. The RA stated she had a brief discussion at an all staff meeting about 3 months ago and about a year ago about safe transporting of residents. The RA stated they were all verbal trainings. The RA stated the training held one month ago was just for transportation about safety. The RA stated it was written documentation read to them about why safety was important, what to watch for, examples were reviewed, staff looked at pictures of buckles, and there was a wheelchair demonstration. The RA stated the ADM and the TD showed how to secure the buckles across the wheelchair. The RA stated one staff member did a return demonstration, but she did not do a return demonstration. The RA stated she had not had any residents fall while she transported them. The RA stated during the training they also talked about what supplies and tools should be in the van. The RA stated she had been instructed what to do if a resident fell during a transport, which would be pull over, assess for wounds, clear the surrounding areas, and report immediately to the facility. The RA stated staff who should be notified would be nurse management. The RA stated if there was no visible injury, the resident should be assisted. The RA stated there could be an injury even if it was not visible. The RA stated if the resident was in pain or there was a suspected injury, she would contact the facility administrator and take direction from him. The RA stated she was aware of the incident with resident 50. The RA stated resident 50 came to her after the incident and wanted to discuss the incident report as he felt it was inaccurate. The RA stated she did not know about the incident before resident 50 came to speak with her. The RA stated resident 50 was upset that the TD had stated that he had not fallen to the ground during the transport and that he was thrashing around, and that he did not hit his head. The RA stated resident 50 told her that resident 47 was a witness. The RA stated after resident 50 spoke to her he appeared to be more calm about the situation. The RA stated she was not the first person resident 50 had reported this to and it was several days after the event. The RA stated resident 50 told her he fell and hit his head and did not give any more details. The RA stated she did not have reason not to believe resident 50's account of what happened. On 3/19/25 at 2:26 PM, an interview was conducted with the DON who stated he did not recall the last time he transported a resident in the facility van. The DON stated that the corporation had a computer based training for transportation drivers on safe driving practices. The DON stated staff who were eligible to drive the van, did a background check, provided a copy of their driver's license, completed a driver's safety training, and the DON was unsure if a driving history was checked on the staff member. The DON stated he and the ADM trained the staff on how to transport a resident in the facility van. The DON stated demonstration was used on how to safely buckle up residents, how to strap the wheelchair in the van, and how to use the van lift. The DON stated he told staff to ensure the locks were engaged on the wheels of the wheelchair and the floor straps were secured to each corner of the wheelchair. The DON stated that he preferred the floor straps to be connected to the frame of the wheelchair, but if there was no other area the strap could be placed on the wheel. The DON stated the seatbelt should be placed over the hips of the resident and under the armrests if there was space. The DON stated a training was done after the most recent incident with resident 50. The DON stated prior to that incident staff were doing computer based training. The DON stated that they also provided verbal education along with a demonstration on how to secure a wheelchair in the facility van. The DON stated that demonstration was provided by himself and the ADM. The DON stated there was no documentation of the training. The DON stated that nobody used the big van except the TD, the ADON, and himself. The DON stated he did not know if the computer based