Every finding on record at Claiborne Healthcare Center

Based on record review, observations and interviews the facility failed to ensure residents received adequate supervision to prevent elopement for 1 (#1) of 3 (#1, #2, #3) residents reviewed for elopement. The facility failed to provide adequate supervision for Resident #1 who was a known elopement risk. This deficient practice resulted in an immediate jeopardy situation for Resident #1 on 04/03/2026 at 5:31p.m., when he eloped from the facility through the front door unnoticed by staff while following visitors out of the building. Resident #1 had a history of exit seeking behaviors, had been identified as an elopement risk, and wore a wander guard ankle bracelet. Resident #1 was picked up by a local police officer about 0.9 miles from the facility on the interstate highway. Resident #1 was returned, uninjured, to the facility at approximately 6:45 p.m. on 04/03/2026. As a result of the investigation, it was determined the cause to be more than likely a staff member entered the door code in the system to deactivate the alarm but failed to ensure that a resident with a wander alert bracelet had not triggered the alarm and/or left the building. The immediate jeopardy situation ended on 04/03/2026 at approximately 6:45 p.m. when the resident was placed on every 30 minutes supervision and monitoring around the clock. Due to the facility's failed practice, residents are at risk to suffer with the likelihood of serious injury, serious harm, serious impairment or death. The deficient practice had the potential to affect 4 other residents in the facility who had been assessed as an elopement risk. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation.Findings:Review of the facility's policy and procedure titled Wanderer Management, Monitoring System and Resident Elopement Protocol dated 07/01/2025 revealed, in part, the following:Purpose: To monitor safety of residents at risk for elopement. To provide a system to alert staff that a resident may be attempting to leave the facility.Policy: It is the policy of the facility that all residents are afforded adequate supervision to provide the safest environment possible. Procedures: B.2. When a door alarm sounds, staff shall respond immediately and determined cause of the alarm. The staff member responding to the alarm shall check the outside of the building to determine if a resident has left the building.Review Resident #1's medical record revealed an admit date of 05/15/2023, with diagnoses that included, in part, memory deficit, dementia in other diseases classified elsewhere mild with other behavior disturbance, major depressive disorder recurrent, mild neuro-genitive disorder due to known physiological condition with behavioral disturbance, and gastric reflux disease.Review of Resident #1's Quarterly Wander Data Collection assessment dated [DATE] revealed Resident #1 was assessed to have a score of 22 indicating Resident #1 was high risk for wandering and was marked, yes resident verbally expressed desire to go home and yes the resident's wandering placed the resident in significant risk of getting to a potentially dangerous place such as outside the facility. Review of Resident #1's Brief Interview Mental Status Interview dated 04/07/2026 completed after his elopement revealed Resident #1 had a score of 4 indicating severely impaired cognition. Review of Resident #1's Quarterly Minimum Data Set, dated [DATE] revealed Resident #1 was assessed to have used a wander guard bracelet daily and ambulated independently.Review of Resident #1's comprehensive plan of care revealed a problem of:The resident is an elopement risk/wanderer with an initiation date of 12/04/2025 with interventions/approaches that included in part; Wander Bracelet related to wandering/exit seeking behaviors; Nurse to check placement every shift including skin check under bracelet. Location of bracelet on resident: Right Ankle. Further review revealed other interventions dated 05/24/2023 in place at the time of Resident #1's elopement included; check my location frequently, encourage me to participate in activities, engage me in diversional activities when indicated, observe me for agitation, pacing, repetitive verbalization of wanting to leave or go home, restlessness and report increased behaviors to the nurses, provide me with re-orientation as needed.Review of Resident #1's April 2026 Physician Orders revealed an order for a Wander Bracelet related to wandering/exit seeking behaviors; Nurse to check placement every shift, location of bracelet on resident right ankle dated 12/03/2025.Review of Resident #1's progress notes revealed the following entries: 04/03/2026 at 7:25 p.m. - This resident was brought back to the facility per local police department [at approximately 6:45 p.m.], awake alert and oriented with confused conversation noted, saying he was going home. The police officer stated that he observed resident walking the interstate highway and picked him up. He stated he asked for the resident's address and then noticed the wander guard. The police officer stated he talked to the resident's wife and she informed him the resident was at the facility and he then brought him back to the facility.Observation on 04/13/2026 at 11:00 a.m. of the facilities outside camera footage from 04/03/2026, the date of Resident #1's elopement revealed the following:5:31 p.m. Front entrance door outside camera: Three people exited the facility through the front door, Resident #1 walked out behind them, one of the visitors held the door and Resident #1 walked out. The visitors left and Resident #1 stood at the entrance door.5:33 p.m. Resident #1 turned to the entrance door and pulled on the handle in an attempt to open it, entrance door did not open. Resident #1 then walked away from the door in the direction of the east wing of the facility until he was out of camera view. 5:33:45 p.m. East wing outside camera: Resident #1 walked past the east wing door on the side walk until Resident #1 walked out of camera view.During an interview on 06/05/2026 at 4:30 p.m. S12 LPN (licensed practical nurse) reported she was working on the evening that Resident #1 eloped but was unaware of his elopement until the police came to the facility with Resident #1. S12 LPN further reported she was alerted by a CNA (certified nursing assistant) that the police were at the front entrance door and went to let the policeman in, who was a large man, and when the policeman moved aside, and Resident #1 walked forward to come inside the facility's front entrance door the alarm sounded (in response to his wander guard bracelet). S12 LPN then entered the door code to deactivate the alarm.During an interview on 04/13/2026 at 4:16 p.m. S5LPN confirmed she was assigned to Resident #1 when he eloped from the facility on 04/03/2026. S5LPN reported she last saw Resident #1 in the dining room eating dinner around 5:00 p.m. S5LPN confirmed she did not know Resident #1 had eloped until 6:45 p.m. when he was returned to the facility by a local police officer. S5LPN further reported the police officer told her Resident #1 was found walking on the interstate highway and had called Resident #1's wife. S5LPN confirmed Resident #1 did not have any injuries and his wander guard bracelet remained in place. S5LPN reported she confirmed Resident #1's wander guard bracelet was functioning. S5LPN reported Resident #1 told her he was trying to get home. During an interview on 04/14/2026 at 11:15 a.m. S9 CNA reported, she was not aware of Resident #1's elopement from the facility until she saw the police officer returning Resident #1 back to the facility. S9 CNA reported she had last saw Resident #1 during dinner, eating at the table. S9 CNA further reported Resident #1 was a wanderer and required frequent redirection and close monitoring. S9 CNA further reported after Resident #1 was returned to the facility staff went room to room and made sure all the residents were present. All staff was in-serviced on elopement, wandering and wander guard alarms and we had an elopement drill.During an interview on 04/14/2026 at 12:00 p.m. S10 CNA reported, I was sitting at the nurse's station but I didn't see Resident #1 leave out of the facility, I found out Resident #1 had eloped when the was returned by the police. S10 CNA also reported Resident #1 would often wander around the facility, confused and lost and would require redirection. S10 CNA further reported after Resident #1 eloped we were in-serviced on elopement, all the codes to the facility doors was changed and we had an elopement drill.During an interview on 04/14/2026 at 10:30 am S6 CNA confirmed she was working on the day when Resident #1 eloped from the facility. S6 CNA reported she had no knowledge of Resident #1's elopement until the police returned him to the facility. S6 CNA reported she had last saw the resident during dinner sitting at the table eating. S6 CNA further reported after Resident #1's elopement the staff on duty went room to room checking on the other resident and check all residents with wander guard bracelets to ensure they worked properly. S6 CNA confirmed Resident #1 was a wanderer and would often get lost in the facility and required frequent redirection. During an interview on 06/05/2026 at 10:00 a.m. S16 Maintenance Director reported anyone with a wander bracelet will activate the door alarm. The alarm continues to sound once activated until someone goes to the door and enters the door code into the keypad. S16 Maintenance Director confirmed there was no other way to silence the alarm. Each door had its own alarm that will go off when a wander bracelet was near. A nurse or staff member has to go to whatever door was alarming and enter the code to silence that alarm.During an interview on 04/13/2026 at 1:45p.m. S2 DON (director of nurses) reported on 04/03/2026 around 7:00 p.m., S5LPN notified her Resident #1 had eloped from the facility. S5 LPN reported to her that the police had returned him uninjured. S5 LPN reported Resident #1 had been picked by the police walking on the interstate highway. S2 DON reported a head count of all the other residents in the facility was done to account for all the residents. Resident #1's wander-guard was checked to ensure it functioned properly, and Resident #1 was placed on every 30 minute monitoring. All wander guard bracelets in use in the facility were checked to ensure proper functioning. All staff were in-serviced on the facility's elopement policy and all door codes were changed. Statements were taken from all staff on duty on 04/03/2026. S1 Interim Administrator was notified.During an interview on 04/13/2026 at 9:00 a.m. S1 Interim Administrator confirmed Resident #1 had eloped from the facility on 04/03/2026. S1 Interim Administrator confirmed he saw Resident #1 follow visitors through the entrance door on the facilities outside camera footage. S1 Interim Administrator reported as a result of this incident the DON in-serviced department heads and staff on the facility elopement policies, maintenance director checked all doors and wander guard alarms on 04/03/2026, all facility door codes were changed. All resident assessed as wanderers and at risk for elopement care plans were updated and elopement drill were done. S1 Interim Administrator further reported putting signs at each facility door requesting visitors not to allow resident out of the facility without speaking to a nurse.During an interview on 06/05/2026 at 2:45 p.m. S8 Corporate Nurse, S13 Administrator and S2 DON, confirmed the root cause of Resident #1's elopement on 04/03/2026 was more than likely a staff member entered the door code in the system to deactivate the alarm but failed to ensure that a resident with wander alert bracelet had not triggered the alarm and/or left the building. S8 Corporate Nurse, S13 Administrator and S2 DON further confirmed all staff on duty at the time of Resident #1's elopement were interviewed and failed to confess to deactivating the alarm by entering a door code.Review of Resident #1's medical record revealed Resident #1 was discharged on 04/09/2026 to a local inpatient geriatric psychiatric facility and had not returned to the facility.Through observation, interview and record review, surveyors were able to verify that the facility has implemented the following actions to correct the deficient practice. Review of the facility's corrective actions with a completion date of 04/07/2026 revealed the following:1. Resident #1 was assessed immediately upon return to the facility on [DATE] at 6:45 p.m. by S8LPN.2. All Residents were accounted for by a head count on 04/03/2026 to ensure safety. 3. Written statements taken from all staff on duty at the time of the elopement on 04/03/2026.4. All facility doors and wander guards alarms were assessed on 04/03/2026 for proper functioning. Exit codes to all facility doors were changed. Door signs posted instructing visitors not to allow resident out of the facility doors. Door alarm codes were changed. On 04/07/2026 an inspection of the facility doors was completed by the alarm service company as requested by S16 Maintenance Director. All testing failed to indicate there was a maintenance issue with any of the facility doors.5. Resident #1 was placed on every 30 min monitoring to ensure of whereabouts from 04/03/2026 to 04/07/2026.6. All-staff in-services on the facility wandering and elopement policies, visitor interaction and reporting and response expectations were started on 04/03/2026 and completed by 04/07/2026 which included competency tests by S2 DON.7. Elopement/wander guard assessments and care plans on all residents in the facility who were at risk for elopement were updated by nursing administration by 04/06/2026.8. The facility Elopement Binder was assessed to be up to date on 04/03/2026 by S2 DON.9. Elopement Drills was conducted with all staff on 04/04/2026 and 04/07/2026 by S2 DON10. All residents monitored by S2DON/designee through incident report review, observation and communication with staff for potential risk of elopement.11. Administrator to conduct elopement drill quarterly for up to a year and then biannually afterwards. 12. The Quality Assurance team will meet weekly for the next eight weeks to review compliance with the plan of action. Facility Monitoring Plan:Monitor exit door signage for placement weekly for 4 weeks (maintenance and administration).Staff education completion, one time audit by DON/staff development at 30 daysCare Plans monitored weekly for 4 weeks by DON for accuracy and updates. Door alarm functionality checks daily per facility practice daily.Door alarm functionality check daily per facility practice by nursing and maintenance.Random staff interviews for elopement awareness weekly for 4 weeks by administrator/DON. Validation of review of the facility's corrective actions revealed the following:1. Review of Resident #1's progress notes for revealed he was assessed immediately upon return to the facility on by S8LPN on 04/03/2026 at 6:45pm.2. Review of the facility investigative documentation revealed a count of all residents in the facility was done to ensure safety on 04/03/2026. All residents were accounted for.3. Review of the facility's investigative documentation revealed written statements taken from all staff on duty at the time of the elopement on 04/03/2026.4. Review of the facility's monitoring documentation initiated on 04/02/2026 revealed documentation of assessment of all facility doors and wander guards alarms on 04/07/2026 for proper functioning. Further review revealed exit codes to all facility doors were changed on 04/07/2026. Observation on 04/13/2026 at 9:00 a.m. revealed signage stating, Do not let residents out the door. Ask nurses if they are allowed to go out. Warning!! on all doors of the facility.Review of the facility's alarm service company's invoice dated 04/07/2026 revealed and confirmed the facility's doors were inspected and the door codes were changed. Services performed: changed codes on exit doors, tested wander guard on all doors, range tested good and replaced overlay on smoking door. Showed maintenance how to program the panel and change codes. All testing failed to indicate there was a service issue with any of the facility doors.5. Review of Resident #1's medical record revealed documentation of the monitoring of Resident #1's whereabouts every 30 minutes from 04/03/2026 to 04/07/2026.6. Review of the facility's training records revealed documentation of all-staff in-services done on the facility's wandering and elopement policies, visitor interaction and reporting and response expectations were started on 04/03/2026 and completed by 04/07/2026 which included competency tests by S2 DON. Review of 16 staff competency tests revealed the answer to the question: What should staff do when a door alarm sounds? was correctly marked as Respond immediately and check the outside of the building.7. Review of the medical records of residents who were at risk for elopement and had a wander guard alarm revealed care plans were documented as reviewed and up to date with problems and approaches addressing risk for elopement. Further review revealed all residents who at risk were reassessed by nursing administration by 04/06/2026.8. Review of the facility's Elopement binder on 04/14/2026 revealed all residents who were assessed as elopement risks and who wore a wander guard bracelet were included in the elopement binder with photos.9. Review of the facility's training documentation revealed an elopement drill was conducted with all staff on 04/04/2026 and 04/07/2026.10: Review of the facility's monitoring documentation revealed monitoring of all residents for risk of elopement by S2DON/designee through incident report review, observation and communication with staff for potential risk of elopement initiated on 04/04/26.11. Review of the facility training documentation revealed documentation of on-going facility elopements drills that were held on 04/04/2026 and 04/07/2026.12. Observation on 4/13/2026 at 8:00 a.m. revealed a sign stating, Do not let residents out the door. Ask nurses if they are allowed to go out. Warning!! was posted on each facility door.13. Review of the facility training records revealed all staff in-services on the facility elopement policy and procedure was initiated on 04/04/2026 and completed on 04/07/2026 with competency examinations.14. Review of the facility monitoring revealed documentation of monitoring of resident care plans weekly for 4 weeks by DON for accuracy and updates.15. Review of the facility's maintenance documentation revealed documentation of daily door alarm checks for functionality and daily monitoring of sign presence. Observation on 04/14/2026 at 3:45p.m. Of the activation of the facility's door alarm in response to a resident with a wander guard alarm in close proximity confirmed functionality.16. Review of the facility's monitoring documentation revealed random staff interviews were conducted to ensure competency of the facility's elopement policies and procedures. Interviews during the survey confirmed knowledge of the facility's policies on elopement and documentation by staff. Additional interviews on 06/05/2026 with S12 LPN, S5 LPN, S14 Activities Director and S15 Social Service Assistant/CNA confirmed knowledge that the facility's policy and procedure for elopement included checking the outside of the building to determine if a resident had left the building.

Based on record review and interviews, the facility failed to ensure each resident was treated with respect and dignity in a manner and in an environment that promotes or enhances his or her quality of life for 1 (#6) of 6 (1, #2, #3, #4, #5, #6) sampled residents. The facility failed to ensure communication by staff was dignified and respectful while assisting Resident #6 with care. Findings:Review of the facility's Resident Rights policy (revised 04/2017) revealed:Facilities shall have a written policy on resident rights and shall post and distribute a copy of those rights. In addition to the basic civil and legal rights enjoyed by other adults, residents shall have the rights listed below. Facility policies and procedures must be in compliance with these rights. Residents shall: .b. Be treated as individuals in a manner that supports their dignity; . Review of Resident #6's medical record revealed and initial admission date of 06/17/2025 with diagnoses including, in part, acquired absence of left leg above knee, Diabetes Mellitus due to underlying condition with diabetic polyneuropathy, peripheral vascular disease unspecified, essential (primary) hypertension, other schizophrenia, and chronic combined systolic (congestive) and diastolic (congestive) heart failure. Review of Resident #6's 02/24/2026 Significant Change MDS (Minimum Date Set) revealed Resident #6 had a (Brief Interview Mental Status) of 15 which indicated intact cognition. During an interview on 04/14/2026 at 2:35 p.m. Resident #6 reported a CNA was in the room yesterday changing her and complaining of her back while providing incontinent care. Resident #6 further reported when CNA was done, she told the CNA she wanted to get back up and the CNA asked the nurse who was tending to Resident #6's roommate if she had to get Resident #6 back up. During an interview on 04/16/2026 at 2:50 p.m. S5 LPN (Licensed Practical Nurse) reported she heard Resident #6 ask to be assisted back into her wheelchair and heard S6 CNA say there was not going to be any up and down tonight, with an attitude. During a phone interview on 04/15/2026 at 10:02 a.m. S6 CNA reported on 04/13/2026 in the afternoon Resident #6 had asked to be changed and once changed, asked to get back up in wheelchair. S6 CNA further reported she asked S5 LPN if Resident #6 could stay in the bed and that it was a lot on her back getting Resident #6 in and out of bed. S6 CNA also reported S5 LPN said to get Resident #6 up and S6 CNA told S5 LPN it was on her back and not S5 LPNs back. During an interview on 04/15/2026 at 11:58 a.m. S7 CNA reported she was in Resident #6's room the afternoon of 04/13/2026 helping S5 LPN with Resident #6's roommate's care while S6 CNA was assisting Resident #6 with care. S7 CNA further reported she heard S6 CNA ask S5 LPN if she had to get Resident #6 up. During an interview on 04/16/2026 at 7:50 a.m. S2 DON (Director of Nursing) reported an investigation revealed S6 CNA's communication in front of Resident #6 was unprofessional in conduct and not respectful.

Based on observations and interviews the facility failed to ensure nurse staffing data information was posted daily and retained for a minimum of 18 months. Findings:Observation on 03/16/2026 at 1:15 p.m. failed to reveal nurse staffing data information was posted. Observation on 03/17/2026 at 1:00 p.m. failed to reveal nurse staffing data information was posted. During an interview on 03/17/2026 at 1:09 p.m. S1 Interim Administrator reported the daily nurse staffing data information was not posted and should be. During an interview on 03/17/2026 at 2:00 p.m. S1 Interim Administrator reported she was unable to locate the daily staffing data information postings since 08/27/2025 and the daily postings should have been retained at least 18 months.

Based on record review and interview the facility failed to develop a comprehensive care plan for 1 (#14) of 1 resident reviewed for urinary tract infection. Findings:Review of the facility's Care Plans, Comprehensive, Person-Centered policy, last review date 06/02/2025 revealed the following, in part:Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. Review of Resident #14's medical record revealed an admit date of 06/17/2025 with a diagnosis of personal history of urinary tract infections (UTI). Review of S6Nurse Practitioner progress note created 01/27/2026 revealed the following, in part:Levofloxacin Oral Tablet 750 MG, Give 1 tablet by mouth one time a day for wound infection for 14 Days, 750 milligrams, active, 01/22/2026 to 02/05/2026. Cranberry-Vitamin C-Inulin, UTI-Stat Oral Liquid, Give 30 milligrams by mouth two times a day related to personal history of urinary tract infections, active, 07/18/2025. Chronic UTI: Chronic, asymptomatic. Continue Estrace cream intravaginally at bedtime three times per week. Patient on Levaquin for osteo, should cover for UTI as well. Encourage hydration and routine hygiene measures. During an interview on 03/17/2026 at 1:55 p.m., S2DON reported Resident #14 had a UTI on 01/27/2026 and was treated. During an interview on 03/17/2026 at 2:30 p.m., S3Corporate Nurse verified a care plan was not completed for Resident #14's urinary tract infections.

Based on observations and interviews the facility failed to accommodate the needs of 1(#29) resident of 2 residents reviewed for environment. The facility failed to ensure resident's call light remained within reach. Findings: Review of the facility's Resident Call System policy with review date of 03/28/2023 revealed in part: Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation. Policy interpretation and implementation:1. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor. Review of Resident #29's 12/29/2025 Quarterly MDS assessment revealed in part, Resident #29 had a BIMS score of 00 which indicated severe cognitive impairment and did not have any functional impairment to upper or lower extremities. An observation on 03/16/2026 at 8:25 a.m. revealed Resident #29 lying in bed with dresser positioned at foot of bed. Further observation revealed Resident #29's call light lying on floor behind Resident #29's dresser. During an interview on 03/16/2026 at 8:30 a.m., S5Social Services Assistant confirmed Resident #29's call light was out of reach and should always be within reach of Resident #29. Observation on 03/18/2026 at 1:05 p.m. revealed Resident #29 lying in bed with eyes closed. Further observation revealed Resident #29s call light lying on the floor between Resident #29's foot of bed and dresser. During an interview on 03/18/2026 at 1:10 p.m., Resident #29's roommate, Resident #48, reported he calls for assistance when Resident #29 yells out for help. During an interview on 03/18/2026 at 1:14 p.m., S2DON observed Resident #29's call light on the floor out of Resident #29's reach and confirmed call light should be kept within Resident #29's reach.

Based on record review, observation and interview the facility failed to ensure the outside dumpster lids were closed. Findings:Review of the provider's Food-Related Garbage and Refuse Disposal policy, reviewed and revised 03/05/2026 revealed the following, in part:7. Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter. Observation on 03/16/2026 at 8:14 a.m. revealed both of the dumpster's lids were completely open to the backside of the dumpster. During an interview on 03/16/2026 at 8:15 a.m., S4Dietary Manager verified both of the dumpster lids were completely open to the backside of the dumpster.

Based on record reviews and interviews the facility failed to protect resident's right to be free from verbal abuse by a staff member for 1 (Resident #1) of 3 (Resident #1, Resident #2, Resident #3) sampled residents. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of the facility's Abuse Prohibition Policy dated 05/17/2024 revealed in part: Intent: Each resident has the right to be free from abuse, mistreatment, neglect, corporal punishment, involuntary seclusion, and financial abuse. Policy: 1. The facility will prohibit neglect, mental or physical abuse, including involuntary seclusion and the misappropriation of property or finances of residents. Definitions: Verbal abuse is defined as the use of, oral, written or gestured language that willfully includes disparaging or derogatory terms to resident or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Examples of verbal/mental abuse include, but are not limited to, cursing, yelling, saying thing to frighten a resident, denying food or care, isolating a resident etc. Review of the facility's Self-Reported Incident Report initiated on 03/11/2025 revealed in part: Victim: Resident #1 Accused: S4 CNA (Certified Nursing Assistant) Allegation: Verbal Abuse-substantiated Employee S4 CNA was immediately suspended pending investigation. After facility investigation substantiated allegation of verbal abuse, the employee was terminated. Review of Resident #1's medical record revealed an admitted [DATE] with a re-admission on 06/03/2024. Resident #1's diagnoses included but not limited to Post-Traumatic Stress Disorder, Schizoaffective disorder-Bipolar type, Anxiety disorder, and Major Depressive disorder. Review of Resident #1's Minimum Data Set assessment dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status score of 15 which indicated Resident #1 was cognitively intact. Review of signed statement provided by Resident #1 on 03/11/2025 revealed in part: Resident #1 voiced to S4 CNA she did not want a dinner tray, then changed her mind and notified S4 CNA. Resident #1 voiced the S4 CNA acted as she did not hear her. Resident #1 voiced that everyone in the dining room was served except for her. Resident #1 voiced S4 CNA continued to fill the dinner cart with trays. Resident #1 voiced she was tired of waiting and went to go outside. Resident #1 reported S4 CNA was coming by with the cart as she was going out the door and S4 CNA was talking fast and yelling at her. Resident #1 voiced she shouted back and went out the door to get away. Resident #1 voiced S3 LPN (Licensed Practical Nurse) intervened and provided her dinner tray. Resident #1 voiced later as she passed S4 CNA on the hall to her room S4 CNA started yelling and talking fast saying b**** you got the right one. Review of signed statement provided by S4 CNA on 03/11/2025 revealed in part: S4 CNA voiced before dinner started Resident #1 told and her that she did not want a dinner tray. S4 CNA voiced after dinner was served and she was loading dinner carts for the hall, Resident #1 came into the dining room demanding her dinner tray. S4 CNA voiced she completed the cart and Resident #1 was headed out the door when she went to give Resident #1 her tray. S4 CNA voiced Resident #1 snapped at her. S4 CNA voiced she tried to talk to Resident #1 to let her know it was a misunderstanding. S4 CNA she left to take the cart to the hall and voiced S3 LPN told her to calm down. Review of signed statement provided by S3 LPN on 03/11/2025 revealed in part: S3 LPN voiced she was at the nurse's station when she overheard loud shouting coming from the dining area. S3 LPN voiced she walked toward the dining room door that opened to the patio and observed S4 CNA in the doorway and Resident #1 on the patio. S3 LPN reported Resident #1 yelled b**** I don't want the tray motherf***er and was yelling more that she could not understand. S3 LPN voiced S4 CNA yelled you a motherf***er and b***h too. S3 LPN voiced she asked S4 CNA and Resident #1 to please just stop talking. S3 LPN reported S4 CNA went on with the dining cart and Resident #1 remained on the patio. During an interview on 03/31/2025 at 12:04 p.m. S1 Administrator confirmed she was the facility's abuse coordinator. S1 Administrator reported she was notified of the verbal abuse incident regarding S4 CNA and Resident #1 by S3 LPN and S2 DON (Director of Nursing) by phone around 8:20 p.m. on 03/11/2025. S1 Administrator reported S3 LPN obtained a written statement from Resident #1 and S4 CNA and sent S4 CNA home. S1 Administrator reported she was notified S4 CNA and Resident #1 got into a cursing match in the dining room and resident smoking area after dinner was served in the dining room and trays were being sent to the halls. S1 Administrator reported she spoke with Resident #1 the next morning in her office and was notified by Resident #1 of the same. S1 Administrator reported S3 LPN noted no changes in Resident #1 and she noted no changes in Resident #1 when she spoke with her then next morning. S1 Administrator reported life satisfaction rounds were performed with no concern noted and continued weekly. S1 Administrator reported the S4 CNA was terminated 03/12/2025. During an interview on 03/31/2025 at 1:30 p.m. Resident #1 reported the incident that happened between her and S4 CNA, S4 CNA started cursing at her first. Resident #1 reported she told S4 CNA she did not want a dinner tray but changed her mind. Resident #1 reported S4 CNA started hollering and screaming at her in the dining area. Resident #1 reported she hollered and screamed back and went to the smoking patio to get away because she was embarrassed. Resident #1 reported S4 CNA came after her and S3 LPN broke it up. Resident #1 reported when she went back to her room, S4 CNA was sitting in one of the chairs on the hall and started yelling. Resident #1 reported S3 LPN sent her home and reported S4 CNA. Resident #1 reported she spoke with S1 Administrator, and S2 DON about the incident. Resident #1 reported she was fine, denied any concerns, and felt safe at the facility. During an interview on 03/31/2025 at 3:58 p.m. S3 LPN reported when the verbal abuse incident occurred after dinner between S4 CNA and Resident #1 she was at the nurses station in front of the dining area charting on the computer. S3 LPN reported during dining there was sometimes just loud talking and was not anything out of the ordinary loudness was occurring until she heard Resident #1 call S4 CNA a motherf***ing b***h*. S3 LPN reported she got up to see what was going on and saw Resident #1 headed to the smoking patio and S4 CNA stood in the door and said no you're the mother***ing b***h not me S3 LPN reported she told S4 CNA to stop and S4 CNA was talking as she went away but she could not understand her and Resident #1 remained on the smoking patio. S3 LPN reported she notified S1 Administrator of the incident. S3 LPN reported S1 Administrator told her to send S4 CNA home and S4 CNA sat in the front lobby and wrote her statement and left. S2 DON was on vacation during the time of the survey and could not be reached by phone. During a phone interview on 04/01/2025 at 3:11 p.m. S4 CNA reported Resident #1 notified her she did not want a dinner tray. S4 CNA reported Resident #1 came into the dining room after dinner was served and trays were being prepared to take to the halls and told her from across the dining room she wanted a tray. S4 CNA reported she made eye contact with Resident #1 to let her know she heard her and put her tray on top of the cart she was preparing. S4 CNA reported as Resident #1 was going out to the smoking patio she told Resident #1 she heard her the first time and had put her tray on top of the cart to bring to her. S4 CNA reported Resident #1 got loud and screamed at her. S4 CNA reported she was trying to tell Resident #1 it was all a misunderstanding. S4 CNA reported she and Resident #1 did not call each other names and she did not curse or anything like that because that would be unprofessional. S4 CNA reported the nurse came and told them not to be loud. S4 CNA reported she then took a break. S4 CNA reported she was told to write her statement and was sent home. S4 CNA reported she had not been back to the facility and confirmed she was terminated the next day. During the survey, in-service records and monitoring records were reviewed and it was determined that the facility had implemented the following corrective actions to correct the deficient practice prior to entering the facility. Review of the facility's corrective action plan initiated on 03/11/2025 with completion date of 03/13/2025 consisted of the following: The accused, S4 CNA, was suspended on 03/11/2025 and terminated on 03/12/2025. Resident life satisfaction were performed on Resident #1 and residents who resided on Resident #1's hall and completed on 03/12/2025 with no concerns noted. Further resident life satisfaction rounds were performed on 03/20/2025 on 03/28/2025 with no concerns noted. The administrator will continue resident life satisfaction rounds weekly for 4 weeks and then monthly for 3 months. The administrator will monitor the results of life satisfaction rounds and grievance logs along with the QA committee to ensure any issues are addressed. The facility completed an in-service with staff on 03/13/2025 regarding verbal abuse prevention and response which included understanding, identifying, preventing, and reporting allegations of verbal abuse.

Based on record reviews and interviews the facility failed to implement written policies and procedures for 1 (Resident #1) of 2 (Resident #1, Resident #3) residents reviewed with incidents in the past 4 months. An incident report was not completed for a verbal abuse incident involving Resident #1. Findings: Review of the facility's Policy for Resident and Visitor Accident Report dated as reviewed June 2024 revealed in part: A. Procedure Reporting of Resident Incidents and Visitor Accidents: An Incident Report must be completed by the person reporting the incident or the supervisor on the shift that the incident occurred. B. Resident Incident/Accidents: 1. Licensed nurse must: e. Notify the physician family, legal representative. 5. Document in the medical record -Date and Time of Incident -Nature of injury -Circumstances surrounding the incident (FACTS ONLY) -Resident's account of the incident -Names of witnesses -Time that the physician and family were notified -Physician orders received -Condition of resident (VS, Orthostatic BPs (Blood Pressures), mental status, physical status, etc. [et cetera/and other things]) -Disposition of resident (example: transferred to hospital, etc.) -Action taken to prevent a re-occurrence -Follow up documentation regarding the resident's treatment and condition -Other pertinent data Review of Resident #1's medical record revealed an admitted [DATE] with a re-admission 06/03/2024. Resident #1's diagnoses included but not limited to Post-Traumatic Stress Disorder, Schizoaffective disorder-Bipolar type, Anxiety disorder, and Major Depressive disorder. Review of Resident #1's Minimum Data Set assessment dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status score of 15 which indicated Resident #1 was cognitively intact. Review of Resident #1's progress notes for March 2025 failed to reveal documentation of a verbal abuse incident on 03/11/2025. Review of the facility's Incidents by Incident Type report for the date range 11/01/2024 to 03/31/2025 failed to reveal an incident on 03/11/2025. During an interview on 03/31/2025 at 3:58 p.m. S3 LPN (Licensed Practical Nurse) reported she notified S1 Administrator of the verbal abuse incident involving Resident #1 on 03/11/2025 and had not completed an incident report regarding the incident. During an interview on 03/31/2025 at 4:20 p.m. S1 Administrator confirmed S3 LPN notified her of the verbal abuse incident regarding Resident #1 on 03/11/2025. S1 Administrator confirmed an incident report was not completed as per policy and should have been.

Based on observation and interviews, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition by failing to ensure 1) dishwasher food trap was cleaned out preventing water from overflowing onto the kitchen floor, 2) refrigerator #1 was not leaking water onto the floor and 3) freezer #1 contained food items maintained at a safe temperature range to keep foods frozen. This deficiency had the potential to affect the health and safety of persons entering or working in the kitchen. Findings: Observation on 01/27/2025 at 6:30 a.m. during initial kitchen tour revealed the kitchen area with water standing approximately 1/2 inch deep and 3 feet wide at the entry door of the kitchen between the dishwasher and the steam table. Further observation revealed water pooling on the floor under refrigerator #1 extending approximately 2 feet into the floor walkway of the dry food storeroom. Observation of external temperature reading on freezer #1 revealed -5 degrees (F) Fahrenheit and internal temperature reading revealed 38 degrees F. During an interview on 01/27/2025 at 7:30 a.m. S9 Dietary Manager acknowledged maintenance issues with the refrigerator/freezers and dishwasher and water leakage from the dishwasher and refrigerator/freezer but had not repaired them. S9 Dietary Manager reported he was not aware of the temperature variance for freezer #1. During an interview on 01/29/2025 at 2:00 p.m. S12 Service Technician acknowledged there was kitchen equipment that needed repair. During an interview on 01/29/2025 at 3:45 p.m. S1 Administrator acknowledged the kitchen maintenance issues and reported she felt the kitchen deficiencies were more of a training issue with staff.

Based on observations and interview the facility failed to store, prepare, distribute and serve food under sanitary conditions. The facility failed to ensure food was stored properly to prevent cross contamination, utensils were not properly stored when not in use, freezer without a thermometer, and undated food items. This had the potential to affect the 70 residents who received food trays from the kitchen. Findings: Observation on 01/27/2025 at 6:30 a.m. during a brief tour of the kitchen revealed the following: 1.Ground beef stored on the top shelf of freezer sitting on top of an opened box of frozen fish, directly above an open box of cookie dough and bags of frozen vegetables. 2.Flour scoop left on top of a box on a shelf above the flour bin not bagged, sugar scoop left inside the container, food serving plates and cover lids stored in an upright position. 3.Upright back-up freezer containing food items without a thermometer 4.Undated items: 1/2 gallon Pimento cheese spread, gallon Ranch dressing, gallon sweet and sour sauce, and a 32 ounce jar of lemon juice. Open and undated items: 5 pound block sliced cheese with exposed slices, sandwich size Ziploc bag of cherry pie filling, gallon bag uncooked fried squash, opened gallon cole slaw dressing, and a box containing a 5 gallon open/unsecured bag of powdered food thickener. During an interview on 01/27/2025 at 7:30 a.m. S9 Dietary Manager acknowledged the above kitchen deficiencies related to professional standards for food service safety, sanitary conditions and the prevention of foodborne illness that should have been instituted prior to the survey.

Based on record reviews and interviews, the facility failed to ensure residents were free from unnecessary medications for 2 (#5, #29) out of 5 (#5, #28, #29, #45, #265) residents reviewed for unnecessary medications. The facility failed to monitor Resident #5 for bleeding while receiving an anticoagulant and Resident #29 for edema while receiving a diuretic. Findings : Resident #5 Review of Resident #5's medical records revealed an admitted [DATE] with the following diagnoses, including in part: cerebral infarction due to thrombosis of unspecified precerebral artery and paroxysmal atrial fibrillation. Review of Resident #5's physician's orders revealed an order dated 03/20/2023 for Eliquis Oral Tablet 5 mg (milligram); give 1 tablet by mouth two times a day for anticoagulant. Further review revealed an order dated 09/09/2022 for anticoagulant medication - monitor for discolored urine, black tarry stools, sudden severe headache, nausea and vomiting, diarrhea, muscle joint pain, lethargy, bruising, and sudden changes in mental status every shift. Review of Resident #5's January MAR (Medication Administration Record) failed to reveal bleeding was monitored the month of January. During an interview on 01/29/2025 at 10:00 a.m. S5 LPN (Licensed Practical Nurse) reported Resident #29 receives an anticoagulant and confirmed bleeding had not been monitored in January and should have been. During an interview on 01/29/2025 at 10:05 a.m. S4 Corporate Nurse acknowledged Resident #5 was not monitored for bleeding while receiving an anticoagulant for the month of January and should have been. Resident #29 Review of Resident #29's medical records revealed an admitted [DATE] with the following diagnoses, including in part: chronic systolic (congestive) heart failure and edema/unspecified. Review of Resident #29's comprehensive care plan revealed the resident has hypertension (HTN), CHF (congestive heart failure) - monitor for and document any edema/notify MD (medical director). Review of Resident #29's physician's orders revealed an order dated 01/08/2025 for Bumex oral tablet 1 mg; give 1 tablet by mouth one time a day for heart failure. Review of Resident #29's January MAR failed to reveal edema was monitored from January 4-21st. During an interview on 01/29/2025 at 8:50 a.m. S5 LPN reported Resident #29 has edema in her lower extremities and receives a diuretic. S5 LPN acknowledged edema was not monitored from January 4-21st. During an interview on 01/29/2025 at 10:05 a.m. S4 Corporate Nurse acknowledged Resident #29 was not monitored for edema from January 4-21st while receiving a diuretic and should have been.

Based on record reviews and interviews the facility failed to ensure residents' medical records reflected the resident's wishes for 1 (#20) of 26 residents reviewed for advance directives. The facility failed to ensure Resident #20's medical records were consistent with resident's wishes for DNR (Do Not Resuscitate). Findings: Review of undated policy titled Do Not Resuscitate Order revealed: Policy Statement Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect. Policy Interpretation and Implementation 1. Do not resuscitate orders must be signed by the resident's attending physician on the physician's order sheet maintained in the resident's medical record. Review of Resident #20's medical record revealed an admitted [DATE] with diagnoses that included, in part, metabolic encephalopathy, type 2 diabetes mellitus with diabetic nephropathy, acquired absence of left and right leg above the knee, other specified peripheral vascular diseases, dementia, and functional quadriplegia. Review of Resident #20's LaPOST (Louisiana Physician's Orders for Scope of Treatement) signed on 12/23/2024 revealed a check beside DNR/Do not attempt resuscitation (Allow Natural Death). Review of Resident #20's profile header on EHR (electronic health record) failed to indicate a code status. Review of Resident #20's current physician orders failed to reveal an order for code status of DNR. Review of Resident #20's care plan revealed have decided that I am a 12/23/2024 DNR . Review of Resident #20's 12/11/2024 Quarterly MDS (Minimum Data Set) revealed Resident #20 had a BIMS (Brief Interview Mental Status) score of 03, which indicated a severe cognitive impairment. During an interview on 01/28/2025 at 4:14 p.m. S11 LPN (Licensed Practical Nurse) was asked by this surveyor where to find Resident #20's code status. S11 LPN reviewed Resident #20's EHR profile header initially and then reviewed physician orders and reported no code status was found and should have been there. During an interview on 01/28/2024 at 4:30 p.m. S3 DON (Director of Nursing), with S4 Corporate Nurse present, reviewed Resident #20's LaPOST and reported she would initially pull up the LaPOST and reported Resident #20 was a DNR. S3 DON acknowledged there was no order for Resident #20's code status of DNR and should be. During an interview on 01/28/2025 at 4:32 p.m. S4 Corporate Nurse confirmed there was not an order for Resident #20's Code status of DNR and should be.

Based on record review, observation and interviews, the facility failed to provide services that met professional standards for 1 (#36) of 26 sampled residents. The facility failed to ensure safe oral medication administration practices by leaving medications at the bedside. Findings: Review of the facility's Medication Administration policy dated 07/08/2024 revealed in part: 27. Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely. Review of Resident #36's medical record revealed an admitted [DATE] with diagnoses that include in part anxiety disorder, encephalopathy, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side and arthropathy. Review of Resident #36's MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 15 indicating intact cognition. Observation on 01/27/2025 at 1:45 p.m. with S3 DON (Director of Nursing) and S4 Corporate Nurse revealed 2 medicine cups sitting on the bedside table in reach of Resident #36; first cup containing 1 blue and red capsule, 7 white tablets and 1 orange tablet and a second cup containing 2 white tablets and 10 pink tablets. During an interview on 01/27/2025 at 1:45 p.m. Resident #36 reported a lady brought them in and left them for him to take and he was not sure what the pills were or what they were for. During an interview on 01/27/2025 at 1:45 p.m. S3 DON and S4 Corporate Nurse confirmed the medications should not be left on the bedside table. Review of Resident #36's physician's orders failed to reveal an order for self-administration of medications. Review of Resident #36's evaluations failed to reveal an evaluation for self-administration of medications. During an interview on 01/29/2025 at 11:10 a.m. S4 Corporate Nurse acknowledged there is no evaluation or physician's order for Resident #36 to be able to keep meds at the bedside or self-administer medications.

Based on observations, interviews and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident to meet resident's medical and nursing needs for 1 (#265) of 26 sampled residents. The facility failed to ensure: 1.) Resident #265 had an order and was care planned for left knee immobilizer and non-weight bearing to left leg. 2.) Resident #265 received diuretic as ordered by the physician due to diuretic not being reordered timely as per policy. Findings: Review of Resident #265's medical record revealed an admitted [DATE] with diagnoses that included, in part, other fracture of left femur sequela, unspecified fracture of lower end of left femur subsequent encounter for closed fracture with routine healing, type 2 Diabetes, morbid (severe) obesity due to excess calories, chronic obstructive pulmonary disease, chronic combined systolic (congestive) heart failure, atherosclerotic heart disease of native coronary artery with unspecified angina pectoris, and chronic kidney disease unspecified. Review of Resident #265's 01/17/2025 Medicare 5 day MDS (minimum data set) revealed a BIMS (Brief Interview Mental Status) score of 15, which indicated Resident #265 was cognitively intact. 1.) Review of Resident #265's physician orders failed to reveal an order for left knee immobilizer and non-weight bearing to left leg. Review of Resident #265's care plan failed to reveal a care plan for having left knee immobilizer and non-weight bearing status. Review of 01/10/2025 general nurses' note indicated: . At 7:15 p.m. received resident from ______________ hospital per stretcher . splint intact to left lower leg . Observation on 01/27/2025 at 1:29 p.m. revealed Resident #265 wearing a full length knee immobilizer to left leg. During an interview on 01/27/2025 at 1:29 p.m. Resident #265 reported she had broken a few bones in the left leg and was non-weight bearing to that leg. Observation on 01/28/2025 at 12:51 p.m. revealed Resident #265 was lying in bed with knee immobilizer in place to left leg. During an interview on 01/29/2025 at 3:30 p.m. S3 DON (Director of Nursing) confirmed Resident #265 did not have a physician order for left leg knee immobilizer or non-weight bearing to left leg and should have. S3 DON confirmed Resident #265 was not care planned for having left knee immobilizer with interventions and should have been. 2.) Review of Policy and Procedure Manual with revised date 10/01/2019 Section: Medication Policies Subsection: Ordering and Receiving Medications from Pharmacy Subject: Ordering and Receiving Non-Controlled Medications revealed: Policy All medication orders will be faxed to the pharmacy or submitted via EHR using the 'MOST ORIGINAL' order. It will be the responsibility of the facility to re-order the medications to avoid any lapse in therapy. Procedure: . 6. Refill Medication Ordering-Maintenance Reorders. B. All refills must be ordered before the last dose is administered. Reorder medications 3-4 days in advance of need to assure an adequate supply is on hand. Review of Resident #265's current physician orders revealed an order dated 01/15/2025 for Bumex oral tablet 1mg (milligram) (Bumetanide) - Give 2 tablets by mouth two times a day for diuretic. Review of Resident #265's January 2025 MAR (medication administration record) revealed Bumex oral tablet 1mg was not administered on 01/27/2025 for the 0800 and 1400 doses. During an interview on 01/27/2025 at 1:43 p.m. Resident #265 reported she takes Bumex twice a day and had not had a morning dose today. Resident #265 further reported the nurse told her they were out of her Bumex and she was going to order some. During an interview on 01/27/2025 at 2:15 p.m. S10 LPN (Licensed Practical Nurse) reported Resident #265's Bumex should have been ordered and was not.

Based on observation and interviews the facility failed to ensure dependent residents were provided activities of daily living (ADLs) for 1 (#47) of 26 sampled residents. The facility failed to ensure Resident #47's fingernails and toe nails were trimmed. Findings: Review of Resident #47's medical revealed an admitted [DATE] with diagnoses that included, in part, end stage renal disease, dependence on renal dialysis, type 2 diabetes mellitus, paraplegia incomplete, and other intervertebral disc degeneration thoracic region. Review of Resident #47's care plan revealed an ADL self-care performance deficit r/t (related to) intervertebral disc degeneration, thoracic region, other cord compression, paraplegia incomplete with interventions that included, in part, personal hygiene: substantial/maximal assistance, and nail care as needed. Review of Resident #47's 01/04/2025 Quarterly MDS (Minimum Data Set) revealed Resident #47 had a BIMS (Brief Interview Mental Status) score of 12, which indicated a moderate cognitive impairment. Observation on 01/27/2025 at 8:20 a.m. revealed Resident #47's nails on bilateral hands and toenails were long, extending past the end of fingertips and extending past the end of toes. During an interview on 01/27/2025 at 8:20 a.m. Resident #47 reported she did not like her fingernails and toenails long and had asked staff to trim her nails but they would always come to trim her nails while she was out at dialysis so they were never trimmed. During an interview on 01/27/2025 at 2:35 p.m. S3 DON (Director of Nursing) and S4 Corporate Nurse observed Resident #47's fingernails and toenails and acknowledged both were long and should have been trimmed.

Based on record reviews and interviews, the facility failed to ensure all certified nursing assistant (CNA) staff had documented new hire and/or annual competency demonstrations for all skills related to their expected roles for 2 out of 5 personnel files reviewed. This had the potential to affect all 72 residents residing in the facility. Findings: Review of S6CNA's personnel file revealed S6CNA's date of hire was 08/07/2024. Further review revealed no documented evidence of any competencies being completed upon hire. Review of S7CNA's personnel file revealed S7CNA's date of hire was 12/06/2023. Further review revealed no documented evidence of any competencies being completed upon hire and/or annually. During an interview on 01/29/2025 at 9:30 a.m., S8Human Resources, reported he could not produce documentation of competencies being completed upon hire and/or annually for S6CNA and S7CNA . During an interview on 01/29/2025 at 10:00 a.m., S1Administrator, acknowledged skill competencies had not been completed by employees S6CNA and S7CNA prior to providing patient care and should have been. During an interview on 01/29/2025 at 10:30 a.m., S4Corporate Nurse reported CNA competency checks had not been completed on S6CNA and S7CNA upon hire and should have been.

Based on record review and interviews, the facility failed to ensure the Quality Assessment and Assurance (QAA) committee meeting included the required 6 staff members for the facility's last 2 quarterly committee meetings. Findings: Review of the facility's QAA committee sign-in sheets dated 06/12/2024 and 10/30/2024 failed to reveal S2Medical Director was in attendance. During an interview on 01/29/2024 at 1:40 p.m., S1Administrator acknowledged S2Medical Director or representative were not in attendance of the quarterly QAA meetings on 06/12/2024 and 10/30/2024. S1Administrator further reported she was not aware the facility's Medical Director was required to attend. During an interview on 01/29/2024 at 1:45 p.m., S3DON (Director of Nursing) reported S2Medical Director does not regularly attend QA meetings.

Based on interviews and record reviews, the facility failed to ensure residents were free from accident hazards during transport resulting in a fall for 1 (#1) of 3 (#1, #2, #3) sampled residents who required transportation to appointments. S7Van Driver, S8Van Driver and S4Transportation CNA (Certified Nurse Assistant) failed to ensure Resident #1's mode of transportation was verified by his nurse which led to his fall. This deficient practice resulted in an actual harm for Resident #1 on 04/09/2024 at 1:45 p.m., when S7Van Driver attempted to load Resident #1 via wheelchair onto the facility van for a doctor's appointment when he was required to be transported by ambulance on a stretcher. S7Van Driver reported Resident #1's wheelchair tilted backwards after loading it onto the van lift. S7Van Driver further reported Resident #1's wheelchair fell backwards and slid down the front of her legs to the ground with his head resting on her foot. Resident #1 reported feeling increased anxiety prior to and during other transports after the incident on 04/09/2024. Resident #1's physician ordered antianxiety medication to be administered to Resident #1 prior to being transported due to newly diagnosed anxiety disorder unspecified after this second fall from the facility van lift and previous fall from the facility van lift on 02/14/2024. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses that included, in part, End Stage Renal disease, dependence of renal dialysis, acquired absences of left leg above knee and right leg above knee. Further diagnoses from 02/16/2024 included displaced fracture of third cervical vertebra, sprain of ligaments of cervical spine, and sequela related to a subsequent encounter for fracture. Review of Resident #1's MDS (Minimum Data Set) assessment dated [DATE], revealed Resident #1 was assessed as moderately impaired cognition with a BIMS (Brief Interview for Mental Status) score of 12. Resident #1's functional status was assessed to require 2 person total assist for transfers and 2 person extensive assist for bed mobility. Review of Resident #1's Comprehensive Care Plan revealed Resident #1 had a witnessed fall without injury on 04/09/2024 while being loaded onto the van. Resident #1's wheelchair tipped backwards, Resident #1's body slid down the van driver's leg with his head landing on the driver's foot. Resident #1 was assessed by nursing staff and immediately transported to the hospital emergency department for evaluation and treatment via emergency transportation. Interventions placed after the fall included anti-tippers were applied to Resident #1's wheelchair to aid in stabilization and to prevent it from tipping over. Review of Resident #1's Physician's Orders revealed an order dated 04/29/2024 to refer to Senior Psychological to evaluate and treat. Further review of Resident #1's Physician's orders revealed an order dated 04/23/2024 for Klonopin oral tablet 0.5mg (milligram) give 1 tablet by mouth in the morning every Monday, Wednesday, Friday for anxiety disorder unspecified administer prior to dialysis transport. Review of Certification of Ambulance Transportation revealed: Signed by S9Medical Director - revealed transportation details for Resident #1 - Monday, Wednesday, Friday start 03/06/2024, location (dialysis), and mobility: bed confined. All three of the following criteria must be met: (1) unable to ambulate, (2) unable to get out of bed without assistance, and (3) unable to safely sit in a chair or wheelchair; musculoskeletal: non-healed fractures requiring ambulance, amputation. Review of facility's investigation following Resident #1's fall on 04/09/2024 revealed: Summary: the fall was reenacted after resident was sent to emergency room . It was determined that resident's chair was top heavy due to his bilateral AKA (above the knee), and with the slight incline to the lift, this caused the chair to flip over backwards. The interdisciplinary team determined that adding anti-tippers would help prevent wheelchair from tipping over backwards in the future Incident witness statement on 04/09/2024 - S4Transportation CNA - I walked in S6Social Service Director's office and asked her was Resident #1 to go by ambulance, she asked me to call and confirm the pickup. When I called to confirm by ambulance I was told nothing was scheduled. Then I called the van driver and told him that he had to transport Resident #1 because an ambulance was not scheduled for a transport pick up. Incident witness statement on 04/09/2024 - S5LPN (Licensed Practical Nurse) - This nurse was approached by S4Transportation CNA and S8Van Driver. They asked me for paperwork and how he usually travels. I said he has gone out on stretcher every time since his accident on 02/14/2024. Incident witness statement on 04/09/2024 - S7Van Driver - I S7Van Driver was in training today He (Resident #1) then stated that he was not sure about a lady driver due to his prior accident, but then S8Van Driver stated he was there assisting me with training, Resident #1 then stated he was okay with that I rolled Resident #1 up on lift with hands, once Resident #1 was up on lift, I still had my left hand on lift preparing to lock the wheelchair. The back of Resident #1's wheelchair started tilting, I then tried to move swiftly to catch chair but was unable to stop it from falling .Resident #1's chair tilted backwards hitting both of my legs and his head hit my right foot . Previous incidents - on 02/14/2024 - wheelchair flipped over backwards while being loaded in van, injury - displaced fracture of the third cervical vertebra. During an interview on 04/29/2024 at 10:10 a.m. Resident #1 reported the facility had been transporting him by ambulance to appointments but on 04/09/2024, the day he fell , they had to use the van to take him to his appointment. Resident #1 acknowledged he didn't like it when they put him on the van because every time he could feel his wheelchair leaning back. Resident #1 stated, They never should have dropped me. Resident #1 confirmed feeling nervous when he had to go out for appointments. During an interview on 04/29/2024 at 11:15 a.m. S6Social Services Director reported Resident #1 must go by ambulance and if he can't go by ambulance the appointment should be rescheduled. S6Social Services Director confirmed S8Van Driver should have been aware of Resident #1's need to be transported by ambulance. S6Social Services Director reported Resident #1 seemed anxious recently since his falls and had voiced concerns about riding on the van. During an interview on 04/29/2024 at 11:40 a.m. S10Assistant Administrator reported she verbally told the staff Resident #1 was to be transported by ambulance after a previous fall. S10Assistant Administrator acknowledged the day of the incident the S7Van Driver did not know the transportation mode required for Resident #1. S10Assistant Administrator confirmed S4Transportation CNA made the determination Resident #1 could go by van and should not have. S10Assistant Administrator acknowledged S4Transportation CNA did not ask Resident #1's nurse how to transport him. S10Assistant Administrator confirmed Resident #1 voiced the day of the incident he was apprehensive with a female van driver. During an interview on 04/29/2024 at 11:50 a.m. S1DON (Director of Nursing) acknowledged Resident #1 told the S8Van Driver he had reservations regarding being transported in the van by a female driver. During an interview on 04/29/2024 at 11:55 a.m. S2Corporate Nurse acknowledged Resident #1 was supposed to be transported by ambulance to appointments since the previous fall incident on 02/14/2024. During an interview on 04/29/2024 at 12:30 p.m. S5LPN reported on 04/09/2024 someone came up to her (S5LPN did not remember who) and asked how Resident #1 was supposed to be transported and she told them by ambulance. During an interview on 04/29/2024 at 12:45 p.m. S7Van Driver confirmed on the day of the incident she was still in training when she introduced herself to Resident #1 and he said oh Lord, that's how this happened to me referring to Resident #1's neck brace from a previous fall. S7Van Driver stated as she was rolling the wheelchair up onto the ramp of the van lift which is slanted, the wheelchair starting tilting backwards. S7Van Driver confirmed Resident #1 and the wheelchair stayed propped on her legs and the wheelchair slid down to the ground. S7Van Driver reported the day of the incident S4Transportation CNA told her and S8Van Driver Resident #1 did not have an appointment with _____ambulance so they assumed the facility had to transport Resident #1 via the facility van. During an interview on 04/29/2024 at 1:20 p.m. S4Transportation CNA reported there was a misunderstanding the day Resident #1 fell because the appointment that day had not been scheduled with _____ambulance for transportation. S4Transportation CNA acknowledged she should have asked the nurse how Resident #1 was to be transported but she did not. S4Transportation CNA further acknowledged Resident #1 was worried about going on the van. During a telephone interview on 04/29/2024 at 1:35 p.m. S8Van Driver reported he had transported Resident #1 before and he went by ambulance after his previous fall. He further reported on 04/09/2024 he and S7Van Driver asked S6Social Services Director and S5LPN (not Resident #1's nurse) how Resident #1 was to be transported and was told by ambulance. He confirmed S4Transportation CNA told him _____ambulance did not have him scheduled so Resident #1 would have to be transported by van. S8Van Driver reported Resident #1 was scared to get on the van lift and told S7Van Driver, as he pointed to his Miami J collar, this is what happened to him the last time they put him on van. During an interview on 04/30/2024 at 7:55 a.m. Resident #1 stated, I don't want to ever fall again and I thought I was going to get help from the nursing home. During a telephone interview on 04/30/2024 at 8:00 a.m. S9Medical Director reported Resident #1 told him he had another fall and went to the hospital but did not injure himself this time. S9Medical Director confirmed Resident #1 told him he gets anxious before he goes to dialysis and was supposed to be going by stretcher. S9Medical Director reported he ordered Klonopin for Resident #1 to be given prior to dialysis to ease his anxiety which he confirmed was due to the falls Resident #1 had. During an interview on 04/30/2024 at 9:20 a.m. S3LPN reported prior to the incident on 04/09/2024 Resident #1 had always gone by stretcher to appointments. S3LPN (Resident #1's nurse) reported the staff did not ask her on 04/09/2024 how resident was to be transported and if they had she would have told them only by stretcher. S3LPN reported Resident #1 does seem more anxious now. During an interview on 04/30/2024 at 10:00 a.m. S1DON acknowledged Resident #1 was not transported by stretcher on 04/09/2024 which resulted in a second fall and Resident #1 appeared to have increased anxiety after the fall on 04/09/2024. On 04/30/2024, S7Van Driver, S8Van Driver, S3LPN, S5LPN, and S4Transportation CNA were interviewed about transporting residents and all staff confirmed they received an in-service on Resident #1 is to be transported by stretcher and the process to find a resident's mode of transportation when leaving for appointments. During an observation on 04/29/2024 at 10:10 a.m. Resident #1's wheelchair had anti-tippers in place to prevent his wheelchair from tipping backwards. Review of Resident Appointment Schedule posted at nurse's station revealed appointments for Resident #1 noted transport by _____ambulance. The facility implemented the following actions on 04/09/2024 and 04/10/2024 to correct the deficient practice and prevent further reoccurrence with completion on 04/10/2024: 1. Anti-tippers immediately placed on Resident #1's wheelchair. 2. Staff In-Serviced on 04/09/2024 that Resident #1 is to be transported by ambulance services only until further evaluation. Appointment transportation - appointment schedule is to have listed how a resident is to be transported, whether it is by ambulance or facility van. In-service included an additional amputee resident requiring transport by ambulance. 3. Audit completed for residents with bilateral knee amputations to determine if anti-tippers are needed for wheelchair, two resident's identified and anti-tippers put in place. 4. Random monitoring of residents with bilateral knee amputations requiring transportation weekly x 2 months beginning on 04/09/2024 and ongoing.

Based on record review and interview, the facility failed to develop and implement a comprehensive care plan for 1 (#1) of 3 (#1,#2,#3) sampled residents reviewed. The facility failed to: 1. Develop a care plan for Resident #1's diagnosis of anxiety, and 2. Develop and implement a care plan for Resident #1's transportation mode. Findings: Review of Resident #1's Medical Records revealed admitted [DATE] with the following diagnoses, in part: acute on chronic systolic (congestive) heart failure, type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema, other lack of coordination, muscle wasting and atrophy, acquired absence of right leg above the knee, acquired absence of left leg above the knee other polyosteoarthritis, dependence on renal dialysis, and spondylosis without myelopathy or radiculopathy/lumbosacral region. Review of Resident #1's Comprehensive Care Plan failed to reveal a problem and approach for a diagnosis of anxiety and receiving an antianxiety medication. Further review failed to reveal a problem and approach for Resident #1's required mode of transportation by ambulance to appointments and dialysis. Review of Resident #1's Physician's Orders revealed an order dated 04/29/2024 to refer to Senior Psychological to evaluate and treat. Further review revealed an order dated 04/23/2024 for Klonopin oral tablet 0.5mg (milligram) give 1 tablet by mouth in the morning every Monday, Wednesday, and Friday for anxiety disorder unspecified administer prior to dialysis transport. Review of Certification of Ambulance Transportation form signed by S9Medical Director revealed transportation details for Resident #1 - Monday, Wednesday and Friday start 03/06/2024, location (dialysis), and mobility: bed confined. All three of the following criteria must be met: (1) unable to ambulate, (2) unable to get out of bed without assistance, and (3) unable to safely sit in a chair or wheelchair; musculoskeletal: non-healed fractures requiring ambulance, amputation. During an interview on 04/29/2024 at 11:40 a.m. S10Assistant Administrator reported she verbally notified the staff Resident #1 was to be transported by ambulance only after Resident #1's fall on 04/09/2024. S10Assistant Administrator acknowledged the lack of written documentation to transport Resident #1 by ambulance could have led staff to think it was okay to transport Resident #1 by facility van. During a telephone interview on 04/30/2024 at 8:00 a.m. S9Medical Director confirmed Resident #1 told him he gets anxious before he goes to dialysis. S9Medical Director confirmed he ordered Klonopin for Resident #1 to be given prior to dialysis to ease his anxiety.

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

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

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

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