Hurricane Health And Rehabilitation

F-F689. Due to the facility's corrective measures, the noncompliance was determined to be past-noncompliance.

The facility's corrective action plan, which was developed and implemented by 4/23/24, included the following measures:

a. On 4/22/24, the date of the incident involving Resident 3, the facility entered into an agreement with an organization to implement and provide training and new protocols to transport facility residents. The organization utilized by the facility had experience manufacturing wheelchair securement's and occupant restraint systems for transporting individuals with special needs. All staff who performed transportation services for the facility were reeducated on proper securement of residents during transport, which included training videos produced by the contracted organization. Transportation staff attested to the completion of

the training by signing training records. Transportation staff were then required to complete a post-training test.

b. On 4/22/24, all staff members who performed transportation services were required to read and sign the Fleet Safety Program book.

c. On 4/23/24, staff members were interviewed regarding safety during transportation. Administrative staff also interviewed residents to determine if there were additional concerns about safety during transportation.

d. The facility's Quality Assurance Performance Improvement (QAPI) Committee approved the updated driver safety training program and implemented the following QAPI activities:

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 1 of 3 465101 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465101 B. Wing 07/30/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hurricane Health and Rehabilitation 416 North State Street Hurricane, UT 84737

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 -The transportation supervisor will audit the transport of each driver daily for 2 weeks, followed by audits on 3 random days of the week for 1 week, with an audit 1 day per week for 1 week. The transportation supervisor Level of Harm - Actual harm will perform ongoing random audits.

Residents Affected - Few -The transportation supervisor or designee will validate transportation driver's pre and post-securement, documenting the results every week for 4 weeks then bi weekly for 2 weeks, and 3 random audits every month thereafter.

-The transportation supervisor will report any trends or concerns to the QAPI committee for review for 90 days. Any discrepancies will be addressed at time of discovery.

Findings Include:

Resident 3 was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED]. Resident 3's diagnoses included diabetes mellitus type 2, hypotension, muscle weakness, a need for assistance with personal care, and difficulty in walking.

On 4/22/24 at 4:28 PM, the facility electronically submitted a Form 358: Facility Reported Incident Initial Report (Form 358) to the Survey State Agency (SSA). The facility reported that on 4/22/24 at 1:00 PM, Resident 3 sustained injuries while being transported in a facility van by Transportation Driver (TD 1). On the Form 358, the facility documented that TD 1 explained, a car stopped right in front of him and he had to slam

on his brakes. The resident [resident 3] slid out of her chair hit both of her knees and is feeling pain in both knee's (sic). The facility documented that Resident 3 was evaluated by a facility RN, emergency medical services (EMS) was called, and the resident was transported to the emergency room of a local acute care hospital.

On 4/24/24, the facility electronically submitted a Form 359: Follow-up investigation report (Form 359) to the SSA. In their investigation, the facility reported that TD 1 explained that he neglected to put the lap belt on Resident 3 when transporting the resident back from an appointment. The facility documented that TD 1 further explained that he harnessed all four points of Resident 3's wheelchair, but he missed the lap belt strap.

A review of resident 3's medical record was completed on 7/30/24.

Facility staff completed a quarterly Minimum Data Set (MDS) assessment of Resident 3. The Assessment Reference Date was 4/3/24. As part of the MDS assessment, a facility staff member conducted a Brief

Interview for Mental Status (BIMS), for which Resident 3's score was 11. Per the Centers for Medicaid Services (CMS) MDS 3.0 Resident Assessment Instrument Manual, a BIMS score of 11 represents moderately impaired cognition. Facility staff also assessed Resident 3 as requiring substantial to maximum assistance with mobility and that the resident used a wheelchair.

On 4/22/24 at 12:26 PM, a facility nurse documented a Nursing Note in Resident 3's medical record. The nurse documented that Resident 3 had a fall in the transport van while returning from a doctor's appointment.

The nurse documented that Resident 3 had an injury to her left knee and that the resident was sent to the emergency room .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 3 465101 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465101 B. Wing 07/30/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hurricane Health and Rehabilitation 416 North State Street Hurricane, UT 84737

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 On 4/24/24 at 9:06 AM, a facility nurse documented a Nursing Note in Resident 3's medical record. The nurse documented that as Resident 3 was being transported to the facility, the resident was propelled out of Level of Harm - Actual harm the wheelchair, hitting the front seats. The nurse documented Resident 3 sustained a right leg injury and was transported to an acute care hospital. The nurse documented that an x-ray revealed Resident 3 sustained a Residents Affected - Few right femur fracture.

Note: Based on hospital radiology reports, Resident 3 sustained a left femur fracture.

On 5/1/24 at 5:27 PM, a facility nurse documented a Nursing Note in Resident 3's medical record that the resident had readmitted to the facility. The nurse also documented Resident 3 had a large left arm bruise, two left hip sutures, one left knee suture, and that Resident 3 was to have weight bearing as tolerated.

Resident 3's medical record included the resident's hospital discharge documentation that was dated 5/1/24. Per the hospital discharge documentation, upon Resident 3's presentation to the emergency room for the evaluation of the resident's left knee pain, x-ray results revealed the resident an acute left distal femoral shaft fracture. Resident 3 was initially hospitalized in the intensive care unit for close monitoring and treatment.

On 7/30/24 at 11:28 PM, an interview was conducted with the Transportation Supervisor (TS). TS stated that

on 4/22/24, TD1 called the facility to inform them that a resident had slid from the wheelchair during transport because TD 1 had to break hard. TS stated the incident occurred on the road just next to the facility. TS stated on 4/22/24, when the transportation van entered the parking lot, he was present along with a physical therapist, a nurse and the operations manager. TS stated when the van door was opened, it was apparent

the resident had not been secured properly and the lap belt was not on. He stated Resident 3 was in notable pain and paramedics were called.

On 7/30/24 at 1:48 PM, an interview was conducted with the facility's Operations Manager (OM). The OM explained that on 4/22/24, the day of incident involving Resident 3, the facility immediately updated and revised their process for ensuring transportation staff were trained and monitored. The OM stated the facility retained all prior training and included an observed daily check off for every transport to ensure the transportation driver did not forget anything before the facility van moved. The OM stated the onboarding process included new training on how to secure residents in the transportation van, as well as a post-training examination. The OM also stated that if an employee, who had been used to transport residents, had not provided transportation services within the previous 30 days, an observed check off would be required to ensure the drivers skills remained acceptable.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 3 465101