**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received the necessary treatment and services, consistent with professional standards of practice, to prevent new pressure ulcers from developing by failing to conduct weekly skin assessments for 2 (#R2, and #R12) of 4 (#1, #R2, #R11 and #R12) residents reviewed for facility acquired pressure ulcers. This deficient practice resulted in an actual harm for: 1. Resident #R2, who was a risk for developing pressure ulcers, was discovered to have a Stage 3 pressure ulcer on her left elbow on 2/15/23 at 3:24 p.m. Staff failed to conduct a weekly skin assessment from 02/01/23 to 02/14/23, which delayed the identification and treatment of the wound. 2. Resident #R12, who was at risk for developing pressures ulcers, was discovered with a Stage 2 pressure ulcer on her left and right buttock on 02/06/2023. Staff failed to conduct skin assessments from 12/19/22 to 2/6/2023, which delayed the identification and treatment of the wound. Finding: Review of the facility's policy titled, Wound Care System Requirements, read in part, The facility has a designated Wound Care Nurse, who completes weekly assessment and documentation .Skin checks by licensed staff weekly for all residents .Monthly 100% Skin Audits of all residents by DON (Director Of Nursing) and administrative nurse team completed by the 10th of each month .Weekly wound assessment is being completed, with individual documentation . Resident #R2: Resident #R2 was admitted to the facility on [DATE]. Her admitting diagnosis was End Stage Renal Disease. Other diagnoses in part included, Type 2 Diabetes Mellitus, Contracture of Muscle, Left Hand, Lack of Coordination, Hemiplegia and Hemiparesis Following Unspecified Cerebrovascular Disease Affecting Left Non-dominant Side, Pressure Ulcer Of Right Buttock, Stage 2, and Muscle Weakness. Review of Resident #R2's quarterly MDS (Minimum Data Set) dated 12/09/22 revealed that resident's BIMS (Brief Interview of Mental Status) score of 4 which indicated severe impaired cognition. Further review of the MDS revealed that the resident required extensive assistance with one person physical assist for bed mobility and toileting; and total assistance with two person physical assist with transfers. Review of Resident #R2's care plan revealed she was care planned for impairment to skin integrity related to impaired mobility and incontinence. Pressure wound identified. Interventions included: pressure reducing mattress on bed, pressure reducing cushion to protect the skin while Review of Resident #R2's Braden Scale dated 12/30/22 revealed a score of 13, which indicated that the resident was a moderate risk for the development of a pressure ulcer. Review of the resident's electronic record failed to reveal evidence that weekly skin assessments had been conducted for the month of January 2023. A continued review of the record revealed a monthly skin check was conducted S2DON on 02/01/2023 at 1:00 p.m., indicated that the resident had no new areas of skin impairment. Further review revealed there were no weekly skin assessment conducted until 02/15/2022, which was 14 days after her last skin assessment. A Pressure Ulcer Weekly Wound Evaluation dated 02/15/2023 at 3:24 p.m. revealed that the clinician was notified of the wound on the resident's left elbow by S5LPN on 02/15/2023 at 12:50 p.m. The date the wound was acquired was 02/15/2023. The wound was assessed as a Stage 3 pressure ulcer. The wound was described as the following: wound bed moist, beefy red granulation tissue present. There was 25% granulation tissue and 75% slough tissue in the wound bed with a moderate amount of serosanguineous (yellowish fluid with small amounts of blood) drainage. It measured 2 cm (centimeters) by 2cm by 0.1cm (approximately 3.1-4.0cm in size). There was no peri-wound (tissue surrounding the wound) and the wound edges and shape were attached and flat. The wound was described as a new wound. On 02/28/23 at 1:10 p.m., Resident #R2's wound observation was conducted with S5LPN. The dressing on the resident's left elbow was removed by the nurse. The wound was elongated with an indented dark color wound bed, with edges well approximated. There was no drainage or signs of infection noted. On 03/01/2023 at 5:00 p.m., an interview was conducted with S5LPN. S5LPN stated that on 02/15/2023, the shower aide informed her that Resident #R2 had a dressing on her left elbow. She stated that there was no date, time or initials on the dressing; so therefore, she did not know when or who had placed the dressing on the resident's elbow. She stated that she reported the finding to the S2DON. Resident #R12: Resident #R12 was admitted to the facility on [DATE]. Her diagnoses included in part, Dementia, Congestive Heart Failure, Anxiety, Diabetes Type 2, Morbid Obesity and Depression. Review of Resident #R12's quarterly MDS dated [DATE] revealed she had BIMS of 00, severe impaired cognition. She required extensive assistance with two plus person physical assist for bed mobility and toileting. She also total assistance with two plus person physical assist with transfer. Review of Resident #R12's care plan addressed the resident's potential for impairment/actual impairment to skin integrity related to the resident's impaired mobility status and the need for ADL (Activities of Daily Living) assistance. The interventions did not include weekly skin assessments. Review of Resident #R12's Braden Scale dated 01/18/2023 revealed a score of 14, which indicated that the resident was a moderate risk for the development of a pressure ulcer. Review of Resident #R12's electronic record revealed a skin assessment dated [DATE] was conducted with no new skin impairments noted. A continued review of the record revealed there were no weekly skin assessments had been conducted for the month of January 2023. Further review revealed a skin assessment was conducted on 02/06/2023, seven weeks after her last skin assessment, which revealed that the resident had a pressure ulcer on her right and left buttocks. A Pressure Ulcer Weekly Wound Evaluation dated 02/08/2023 at 02:08 p.m. revealed that the S18MD was notified of the wound on Resident #R12's left buttock on 02/15/2023 at 12:00 a.m. The date the wound was acquired was 02/06/2023. The wound was assessed as a Stage 2 pressure ulcer. The wound was described as the following: wound bed moist, beefy red granulation tissue present. There was 100% granulation tissue, no slough tissue in the wound bed and a light amount of serosanguineous (yellowish fluid with small amounts of blood) drainage. It measured 1.5 cm (centimeters) by 1 cm by 0.1cm (approximately 1.1-2.0 cm in size). There was no peri-wound (tissue surrounding the wound) and the wound edges and shape were attached and flat. The wound was described as a new wound. A Pressure Ulcer Weekly Wound Evaluation dated 2/8/2023 at 02:13 p.m. revealed that the clinician was notified of the wound on Resident #R12's right buttock on 02/08/2023. The date the wound was acquired was 02/06/2023. The wound was assessed as a Stage 2 pressure ulcer. The wound was described as the following: wound bed moist, beefy red granulation tissue present. There was 100% granulation tissue, no slough tissue in the wound bed and a light amount of serosanguineous (yellowish fluid with small amounts of blood) drainage. It measured 1 cm (centimeters) by 1 cm by 0.1cm (approximately 0.7-1.0 cm in size). There was no peri-wound (tissue surrounding the wound) and the wound edges and shape were attached and flat. The wound was described as a new wound. No wound observation was conducted for Resident #R12 because she was not in the facility during the survey. On 03/01/23 at 6:15 p.m., an interview was conducted with S1DON. S3ADON and S1ADM were present during the interview. S2DON was asked to pull up Resident #R2's skin assessments in the electronic health record. She reviewed the skin assessments and confirmed that the resident did not have any skin assessments conducted for the month of January 2023. She also confirmed that the resident did not have a skin assessment conducted at any time from 02/05/23 to 02/11/23. She stated that the resident had a skin assessment conducted on 02/01/23 and did not have another skin assessment until 02/15/23, 14 days later, when a Stage 3 pressure ulcer was discovered on the resident's elbow. S1DON stated that all residents in the facility were to receive a weekly skin assessment. She stated that there was a built-in report in the EHR (Electronic Health Record) for skin assessments that alerted the nurses when a skin assessment was due. The nurse assigned to the resident was responsible for conducting the skin assessment. She also stated that the S3ADON will run a UDA (User Defined Assessment) report weekly in order to determine if all required assessment had been done. S3ADON confirmed that she was responsible for running UDA report weekly and stated that when assessments were missed she counseled/in-serviced the nurse who did not complete the assessment. When asked if a missed assessment could be completed a day or more after it was late, she said yes. S2DON confirmed that she did not ensure that the missed skin assessments were completed. She confirmed that staff should have noticed the change in the resident's skin before it was noted to be a Stage 3 pressure ulcer. S3ADON did not provide documented evidence of the counseling/in-services conducted with the staff related to the missed skin assessments before the survey was completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interview, the facility failed to ensure residents were free of accident hazards by failing to: 1. properly restrain a resident in her wheelchair during transport in the facility's van for 1 (Resident #1) out of 4 (#1, #R3, #R4, #R5) residents who were transported in the facility's van. 2. provide adequate supervision for 1 (#3) out of 7 (#3, #R6, #R7, #R8, #R9, #R10, #R11) residents who were assessed to be at risk for wandering. The deficient practice resulted in an actual harm for: 1. Resident #1 when S12CNADriver (Certified Nursing Assistant) failed to use the seat/lap belt to properly secure the resident in her wheelchair during transport. On 10/01/22 at 5:29 a.m., S12CNA Driver and Resident #1 were involved in a motor vehicle accident. Resident #1 was transported from the scene of the accident by ambulance to the emergency room where she was diagnosed with a Tibia/Fibula fracture. 2. Resident #3, who was assessed as an elopement/wander risk, was found in an empty on the floor and sustained bruising and a puncture wound to the left temporal (near the ear) region of her head. Findings: Resident #1: Facility failed to provide a the following documents upon completion of the survey: policy for the use of the facility's van; manufacturer's instruction for the van's restraint system; transportation log; competencies for all transport personnel prior to exit in-service for all staff related to transportation guidelines and occupant safety. Resident #1 was admitted to the facility on [DATE] with diagnoses that included Diabetes Mellitus Type II, End Stage Renal Disease, Muscle Weakness, Abnormalities of Gait and Mobility, Dysphagia, Anxiety, Dyspnea, Depression, Congestive Heart Failure, Obesity, Dementia and Peripheral Vascular Disease. Review of Resident #1's quarterly MDS (Minimum Data Set) dated 07/12/22 revealed the resident had a BIMS (Brief Interview for Mental Status) score of 14 indicating the resident was cognitively intact. Further review revealed the resident was ambulatory with 1 person assistance and utilized a wheelchair. Review of Resident #1's significant change MDS dated [DATE] revealed the resident had a BIMS score of 08 indicating resident had recall memory deficits. Further review revealed the resident was used a wheelchair and did not ambulate with impairment to one side lower extremity. Review of S12CNADriver's handwritten statement dated 10/01/22 revealed in part: transporting Resident #1 to dialysis. I wheeled Resident #1 outside to the van around 5:25 a.m. I put the lift gate down and got inside the van and lifted the swift for the seat belt. I grabbed the three of them, I hooked on the bar on her wheelchair and the other two on each side above the leg rest. Then the last one I hooked right behind under the seat on the middle bar .I was coming up to the turning lane and put my right signal on and a truck turned in front of me. Then his passenger was on the phone with 911 and asked me did I need an ambulance, I said yes for my resident. Review of the hospital emergency room (ER) visit notes dated 10/01/23 read in part . resident presented to the ER at 6:32 am on 10/01/22 with complaints of pain to the right leg via emergency medical services. X-rays of the right leg were obtained with impression: Mildly displaced fracture of the distal fibular metaphysis and tibial diaphysis. ER disposition was admit. Review of Resident #1's facility incident report completed by S2DON dated 10/01/22 read in part .Incident location - Out of facility/during transport. Incident description-S12CNADriver reported to S16PADIM while transporting Resident #1 to dialysis, a car turned in front of her van causing a car accident. Resident #1 was transported to hospital from the scene of the accident. Review of investigation records provided facility completed by S17ADM revealed in part Summary of events: resident diagnosis - left tibia/fibia fracture. Resident was involved in a vehicle accident with the facility transportation vehicle she was being transported to dialysis on October 1, 2022 at 5:45 a.m. Staff member S12CNADriver was the driver the facility van at the time of the accident and was the only staff member with the resident. Resident #1 was transported to the hospital via ambulance with a medical stretcher. On 10/01/22, the resident was seated in a wheelchair and locked-in/wheelchair braced as per transportation guidelines in the facility transportation vehicle and the vehicle sustained a head on collision due to fault of another driver. The resident sustained a tibia/fibula fracture of the left leg, resident was transported to hospital where the resident had surgery to repair the fracture. Facility completed an in-service for all nursing staff in regards to resident transportation guidelines and occupant safety. Review of the facility's Supervisor's Incident and Investigation Report revealed in part .S16PADM was notified at 5:50 a.m., on 10/03/22 about a traffic accident. Another vehicle hit the facility van head on with S12CNADriver, employee, and Resident #1 in the vehicle while being transported to dialysis. Louisiana Uniform Crash Report completed by (local police department): the driver of vehicle #2, facility van, was driven by S12CNADriver, license information, valid, license class Regular driver license, type non-CDL (Commercial Driver's License). Passenger in vehicle #2 was Resident #1, seat position-other enclosed cargo area, air bag did not deploy, type of medical transport-EMS (Emergency Medical Service) ground, Injury status-possible injury. Review of facility's Employee Corrective Action Form revealed in part: Employee was transporting Resident #1 in the facility van. Employee did not put the seat belt/safety belt on Resident #1 while transporting causing serious bodily injury. Action: Termination of employment. Signed by S16PADM on 10/05/22. Review of Resident #1's nursing notes revealed in part: 10/06/22 6:15 pm - Resident return from hospital via AASI, alert, awake, no c/o pain. Further review revealed that note did not address the status of the resident's leg. Review of the hospital written discharge instructions dated 10/06/22 revealed in part WBAT (Weight Bearing as tolerated) to RLE (Right lower extremity) for transfers, activity/mobility with assistance and diagnosis at time of discharge MVC (motor vehicle crash), multiple fx (fractures). Surgical / Procedure 10/03/22 - Rt (right) tibia I & D (incision and drainage), IM (Intramedullary) nail with casting (added for above question nothing found in documentation I have of a cast applied) On 02/27/23 at 11:10 a.m., an interview was conducted with Resident #1. When asked about the accident that happened on 10/01/22, she stated that she was going to dialysis, something happened, can't really remember it all, she went to the hospital and was there for 2 days, might have been longer than that, I don't remember. She can't recall how long it had been since she was walking, but stated when she came in the facility she was walking, but it had been a good while since had walked. Put in proper POD, complete sentences. On 02/27/23 at 12:10 p.m., an interview was conducted with S1ADM (Administrator) and S2DON. Both S1ADM and S2DON confirmed the facility van used during the MVA (motor vehicle accident) was totaled and no longer in their possession. S1ADM confirmed the facility had obtained a new transportation van that has yet to be used as they are still waiting on registration documents. S1ADM stated that the facility had been using an ambulance or a 3rd party contractor for resident transport since the accident. S1ADM confirmed he did not have the transportation log or manufacturer's instruction manual for the van's restraint system, as it was left in the van that had been involved in the MVA. On 02/28/23 at 4:35 p.m., an interview was conducted with S2DON (Director of Nursing), reviewed the form titled Employee Corrective Action form and confirmed it was a form for S12CNADriver. She confirmed the resident identified on the report was Resident #1. She stated she could not give a reason for the termination of S12CNADriver, because she was not involved with the termination of S12CNADriver. She was only told by S16PADMN that the employee was terminated on 03/01/23 at 10:48 a.m., a phone interview was conducted with S12CNADriver. She stated she would call her attorney to see if she could provide an interview about the accident that occurred on 10/01/2022. On 03/01/23 at 11:03 a.m., a second phone interview was conducted with S12CNADriver. She stated she had spoken with her attorney who advised her not to provide an interview. Resident #3 Review of the hospital ER (Emergency Room) visit notes dated 1/16/23 read in part, The resident presented to the ER for evaluation of fall .patient is a fall risk, she wandered off and was found on the floor, it appears she had hit her head on the left temporal region where there is a bruise and a puncture wound . Further review revealed that Resident 3 was recently admitted to the hospital for a subarachnoid, intraparenchymal and subdural hemorrhage (bleeding on the brain) and was discharged to the facility on 1/13/23. An interview was conducted on 2/27/23 at 3:00 p.m. with S3ADON. She stated that S11CNA had just put the resident in her bed and when she went back to check on the resident and discovered the resident was not in bed. She stated the Business Office Manager informed her and the CNA that she had seen the resident walking by her office earlier going towards the therapy room. They went down the hall to the therapy department but the resident was not in the therapy department. They started looking for the resident in the rooms on the hall. The resident was found in an empty room on the floor. She stated the resident was assessed and had a bruise to her left eye. S3ADON confirmed that the resident was at risk for wandering and confused at times. She also confirmed that the resident was not able to ambulate without assistance. When asked what interventions were put in place addressing the resident's wandering, she stated, I'm not sure. I don't remember. An interview was conducted on 2/28/23 at 10:45 a.m. with S11CNA. She stated that she put the resident in her bed after lunch between 12:30-12:45 p.m. She then went to the dining room to get another resident to put to bed. When she passed by the resident's room, she noticed the resident was not in her bed. She checked in the resident's bathroom and the resident was not in her bathroom. She stated that the DON's (Director of Nurses) office was across from the resident's room and the door was open. She asked the DON and the ADON (Assistant Director of Nurses) if they had seen the resident leave her room. She stated that they told her they did not see the resident. She asked the nurse and the nurse stated that she did not see the resident. She asked the Business Office manager if she had seen the resident and the Business Office Manager told her that she had seen the resident walking towards the therapy department. S11CNA stated that she, the ADON and the Business Office Manager began looking for the resident. They did not find the resident in the therapy department, so they looked in the empty rooms down the hall. The resident was found in one of the empty rooms next to the bed and chair on the floor. She confirmed that the resident was confused most of the time, not able to use the call bell to call for assistance or not able to walk without assistance. She stated that the night CNAs (Certified Nursing Assistant) had reported to her that the resident would frequently wander and needed to be monitored. S11CNA confirmed on the day that the resident fell (1/16/23), she was the only CNA working on that hall. On 2/28/23 at 11:00 a.m., an observation was made on Hall A of Resident 3's room which was across from the DON's office and was also visible from the nurse's station. On 2/28/23 at 1:50 p.m., an interview was conducted with S1DON. She confirmed that S11CNA was the only CNA assigned on Hall A where the resident resided.