Based on observation, interview, and record review the facility failed to protect resident's rights to be free from abuse when facility policies and procedures to monitor and identify psychological harm were not implemented for 1 of 3 residents (Resident 2) reviewed for abuse. Resident 2 experienced psychological harm and fear when they were verbally abused by a staff member. This failure placed all residents at risk of psychological abuse, and a diminished quality of life. Findings included . Review of the facility Abuse Prevention Policy and Procedure, dated 07/01/2020, directed staff to initiate investigations as soon as a report of abuse was received to rule out or identify abuse and investigations would be completed within five days. Review of the facility policy Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating, dated 09/2022, directed staff to interview the abused resident, reporter, other residents, involved staff, witnesses, physician, and resident representatives when completing an investigation of abuse. The policy showed there would be an assessment and monitoring of the abused resident for emotional support. The policy showed any employee who was accused of abuse was placed on leave with no resident contact until the investigation was completed. The resident would be protected from retaliation from the abuser and would be kept informed of the progress of the investigation. The 3/06/2024 admission Minimum Data Set (MDS, an assessment tool) showed Resident 2 was diagnosed with a stroke with paralysis on their left side and required two person maximum assistance for transfer and physical assistance from staff for showers. Resident 2 was assessed as cognitively intact and able to make their own decisions. A 03/13/2024 facility report to the state agency showed on 03/13/2024 Resident 2 was being assisted to stand by two staff, started to fall, when one staff said, God damn it, mother fu**er and Resident 2 was pushed onto their bed and the two staff proceeded with a bed bath instead of a shower. In an interview on 03/18/2024 at 3:40 PM, Resident 2 stated It was my shower day and they came about 6:00 AM, I was still half asleep and they tried to lift me up and told me to stand. Resident 2 stated there were two caregivers present and Resident 2 started to stand but because of their stroke it was difficult. Resident 2 stated I tried to stand, but they pushed me down and said mother fu**er you are going to break my back. Resident 2 stated I was shocked that they were swearing and they were upset. I did not do anything wrong. I was afraid. They yelled at me and swore and did not even apologize. They just gave me a shower in bed, who does that? They took a washcloth and put it above my face and squeezed water over my head. I was not covered and I was cold and my bed was wet. When Resident 2 was asked how the caregivers made them feel, Resident 2 stated I am afraid that they will come back, and my next shower they will be angry at me because I told on them. Resident 2 was observed with a grimace on their face, eyes wide and had a trembling voice when they stated they were afraid. When asked about what happened after the fall and the shower in bed, Resident 2 stated a nurse came to look at their skin and interviewed them about the incident. Resident 2 stated they were afraid to report the caregiver for pushing them and swearing. Resident 2 stated If it was that easy for [them] to swear at me, there might be others [residents] not capable of complaining, I think [they] could do that to other [residents]. When Resident 2 was asked if the nurses followed up on the days following the fall, Resident 2 said no one talked to them after the first interview Resident 2 stated no one told me anything about an investigation or what happened to the caregivers. Resident 2 stated I am afraid the [caregiver] will come back and be angry at me because I reported them. Resident 2 stated they did not want that caregiver to provide care to them any longer. In an interview on 03/18/2024 at 4:10 PM, Staff D (Resident Care Manager) stated a skin assessment and interview was completed with Resident 2. Staff D stated after an incident a resident should be placed on alert charting to monitor and document for any signs of harm. Staff D stated they thought they placed Resident 2 on monitoring and alert charting. Staff D looked at Resident 2's progress notes and stated documentation was not there to show Resident 2 was monitored for harm after the incident. In an interview on 03/18/2024 at 4:45 PM, Staff A (Administrator) stated an investigation was started, the caregivers were removed from the schedule and were asked to write a statement. Staff A stated Resident 2's allegation could not be substantiated as abuse. Staff A stated the two caregivers returned to work the next day. In an interview on 03/19/2024 at 1:05 PM with Staff A and Staff B (Director of Nursing), Staff B stated they removed the two caregivers from the building on 03/19/2024 and asked them to write a statement of the incident. Staff B stated they did not interview either of the caregivers. Staff B stated both staff returned to work the next day, before the investigation was completed. Staff B stated education or training was not provided before returning to working with residents. Staff A and Staff B were asked if anyone followed up with Resident 2 after the incident. Neither Staff A nor Staff B knew if there was follow up with Resident 2. Staff A and Staff B stated staff was expected to place residents on alert charting to monitor and document the resident status after an incident. Staff A and Staff B were asked if Resident 2 was monitored for harm after the incident was reported, neither Staff A nor Staff B knew if Resident was harmed. Staff A and Staff B were asked to provide the documents of the investigation, Staff B stated the investigation was not finished and the documents were not available. In an interview on 03/20/2024 at 11:41 AM, Staff A stated they would send the incident report. The incident report and documents were not provided until 03/20/20204 at 3:30 PM. Staff A stated their expectation was that both caregivers would be educated to the incident prior to returning to work. Staff A stated Resident 2 should have been monitored for psychosocial harm and documentation of monitoring should be in the medical record. Staff A stated monitoring was not done, but monitoring was important so harm could be identified and interventions could be implemented for the resident's safety. REFERENCE: WAC 388-97-0640(1). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow transfer and discharge requirements for 2 of 2 residents (Residents 4 & 3) reviewed for transfer and discharge requirements. The failure to identify a resident's inability to make complex decisions, coordinate care with the Resident Representative (RR), the physician, and the receiving hospital and provide adequate documents for a safe care transition, placed cognitively impaired residents at risk for harm, unmet care needs, delay in care, lack of advocacy from their RR, and diminished quality of life. Resident 4 experienced psychological harm, applying the reasonable person concept, when they were transported by a taxi driver to the hospital ER, were not able to talk or explain to hospital personnel why they were there or what care they needed, had no advocate present to assist with the transfer, and the facility staff did not contact the ER to provide background information/medical history, and received multiple diagnostic tests that were possibly not required. Findings included . <Facility Policies> The 08/2018 Transfer or Discharge, Emergency policy showed if an emergency transfer or discharge to a hospital was necessary, the facility would notify the attending physician, notify the receiving facility, prepare a transfer form to send with the resident, notify the representative, assist in arranging transportation. The 12/2016 Transfer or Discharge Documentation policy showed When a resident is transferred or discharged , details will be documented in the medical record and appropriate information will be communicated to the receiving health care facility. The policy directed staff to document the basis for transfer or discharged in the medical record including, the specific resident needs that cannot be met, the facility's attempt to meet those needs, the receiving facilities services that are available to meet those needs. The policy directed staff to document notice was provided to the resident/representative and a summary of the resident's overall medical, physical, and mental condition. The policy directed a resident transferred or discharged for any reason the receiving facility will receive communication on the basis for transfer/discharge, including specific resident needs that could not be met, facility's attempt to meet those needs, the receiving facility's services available to meet those needs, and all necessary information and documentation to ensure a safe and effective transition of care. <Resident 4> The 03/16/2024 admission Minimum Data Set (MDS, an assessment tool) showed Resident 4 was admitted on [DATE] for rehabilitation after a stroke. Resident 4 was assessed to have unclear speech, rarely/never understood, and sometimes understood others. Resident 4 was not able to use their dominant right side extremities, was unable to speak, was unable to complete a cognitive exam. The MDS showed the staff's cognitive assessment concluded Resident 4 had severe cognitive impairment and could never/rarely make decisions regarding the tasks of daily life. The MDS showed Resident 4 had no delirium, behaviors, or refusals of care. The 03/13/2023 Speech Language Evaluation showed: Resident 4 had a complete loss of speech from their stroke, impaired hearing comprehension, impaired verbal language skills, impaired motor speech, impaired speech intelligibility, and impaired communication exchange in daily activity. Resident 4 was oriented to person only (without awareness of place, time, and situation), had impaired thinking and impaired problem-solving skills. Resident 4's memory was impaired, short-term, long-term, and procedural memory was not assessed due to the impairment. Resident 4 was assessed by the speech therapist to have barriers that would impact discharge, specifically related to cognitive impairment. The 03/12/2024 Care Plan (CP) showed Resident 4 was dependent on staff for dressing, hygiene, showering, mobility in bed, and transfers from one surface to another. Resident 4 used a wheelchair for all mobility and was dependent on staff for mobilization of the wheelchair. The CP showed Resident 4 did not have a plan for behavior interventions. Review of the 03/16/2024 3:37 PM nursing note showed Resident 4 was forcibly trying to get out of the facility entrance and was combative with staff. Staff C (Resident Care Manger) spoke with Resident 4, determined they wanted to leave the facility, contacted the primary representative (RR1), left a voice message for the secondary representative (RR2), and arranged a public taxi to transport Resident 4 to the ER. The facility was unable to provide documentation of why Resident 4 wanted to leave the facility, alternatives offered to meet Resident 4's needs and safety in the facility, reporting the incident to, or involving the physician in, possible resident medical changes, and the details regarding emergent medical or non-medical need to necessitate the transfer to an ER. The facility could not provide documentation of the required information including special instructions or precautions for ongoing care or care plan goals or any other documentation to ensure Resident 4 had a safe and effective transition of care. Review of the 03/16/2024 ER documents showed Resident 4 was dropped off at the curbside by a public taxi, no family members, representatives, or advocates were present, with unclear documentation as to why Resident 4 was sent to the ER. The hospital records showed multiple attempts were made by the hospital staff to call the family and the facility without success. Resident 4 was non-verbal and unable to provide a medical history. After multiple diagnostics the hospital documented Resident 4 was determined to be at their baseline. Resident 4 was admitted to the hospital for placement to a long-term care setting with a diagnosis of failure to thrive and concern for elderly abuse. In an interview on 03/19/2024 at 3:50 PM, Resident 4's RR1 stated they had multiple missed calls on their cell phone from the facility. RR1 answered a call from Staff C who stated Resident 4 was no longer welcome at the facility, argued with a nurse when trying to exit the facility, and the facility was sending Resident 4 to the hospital. RR1 stated they told Staff C they were at work and asked Staff C to hold on the phone. When RR1 came back to the phone, Staff C hung up the phone. RR1 stated they were not provided any details of what occurred and was not part of making decisions for Resident 4's transfer. RR1 stated Staff C did not ask permission or try to solve the problem and was just trying to get [Resident 4] out of there. RR1 stated Resident 4 would not be going back to the facility. In an interview on 03/19/2024 at 4:11 PM, with Collateral Contact, (ER Nurse) who received Resident 4 from the ER triage, stated a taxi dropped Resident 4 off outside the ER and left. Resident 4 had some papers and written on one of the pages was a note summarized as Hi my name is (Name), I left (facility) against medical advice (AMA), please help me. The CC saw a signed AMA form. The CC tried to communicate with Resident 4 thru writing and determined Resident 4 could not hold a pen or write with either their right dominant hand or their left hand. The CC stated Resident 4 was not able to state why they were at the ER or where they came from or how the ER was supposed to help them. In an interview on 03/19/2024 at 4:36 PM, Resident 4's RR2 stated they received a voicemail on 03/16/2024 from Staff C. The cell phone voicemail was transcribed into text and was provided as a document. The documented message stated Resident 4 wanted to leave the facility, Staff C stated they could not keep them at the facility, Staff C could not reach RR1 and wanted someone to come pick up Resident 4, Staff C stated they tried calling the hospital and the hospital would not take Resident 4, Staff C stated they tried to get an ambulance company to transport Resident 4 to the hospital but there was no medical necessity for transport, Staff C stated Resident 4 was going to leave the facility and they would rather not put them out on the street and could not keep Resident 4 at the facility as it was not a prison. In an interview on 03/20/2024 at 11:59 AM, Staff A (Administrator) stated Resident 4 answered yes and no questions by nodding or shaking their head but was non-verbal. Staff A stated the MDS assessment showed Resident 4 was unable to complete specific cognitive tests and did not determine Resident 4's cognitive capacity. Staff A stated the AMA incident was not reported to the state agency, was not on the facility incident reporting log, an incident investigation was not initiated, the discharge documentation was not thorough. Staff A stated they needed to collect more information on the incident. Staff A stated Resident 4 was assisted by Staff C to get a public taxi and Resident 4 was sent with paperwork to the local ER. Staff A reviewed the incident details and stated Resident 4 had an unsafe discharge. In an interview on 03/22/2024 at 10:44 AM, Staff C stated on 03/16/2024 Resident 4 was at the facility exit door trying to leave. Resident 4 was wearing a gown and in a wheelchair and throwing punches at staff. Staff C stated they talked with Resident 4 to try to understand what was going on. Staff C stated that Resident 4 wanted to leave the facility and offered to help them do so safely. Staff C stated they called RR1 multiple times. When Staff C reached RR1 they explained Resident 4 wanted to leave, was very upset, and Staff C did not have a discharge plan for Resident 4. Staff C stated RR1 agreed to have Resident 4 sent to the ER by taxi. Staff C stated they tried calling RR1 again to provide an update and was not able to reach RR1. Staff C stated they pushed Resident 4 out of the locked facility door and the taxi driver had a wheelchair transport van. Resident 4 was placed in the taxi van and strapped in by the driver. Staff C provided the taxi driver with an envelope that contained contact information for Resident 4, a list of medications, and the AMA form to give to the ER staff. Staff C stated they wrote on the documents that Resident 4 requested to go to the ER, was discharged AMA from facility. Staff C did not send an escort for Resident 4's safety. Staff C stated they did not call the ER after Resident 4 left in the taxi. Staff C stated they did not discuss with the ER Resident 4's care needs, the situation of why they were being transported, and did not follow up to ensure Resident 4 arrived at the ER in the public taxi. Staff C stated they should have called the ER staff to discuss why Resident 4 went to the ER. In an interview on 03/22/2024 at 10:59 AM, Staff A stated they understood the discharge of Resident 4 was not safe. Staff A stated there should have been a call to the ER to transfer care and inform the ER of the incident. Staff A acknowledged the facility's failed practice. <Resident 3> A 03/15/2024 Significant Change MDS showed Resident 3 was admitted on [DATE] with a urinary tract infection, kidney failure on dialysis, bowel incontinence, and urine retention with an indwelling catheter to the bladder. Resident 3 required physical assistance from staff for all mobility, hygiene, toileting and catheter care. A review of the 03/25/2024 nursing note showed Resident 3 had an antibiotic resistant UTI and was positive for COVID-19 (a highly transmissible infectious virus that causes respiratory illness and in severe cases can cause difficulty breathing and could result in impairment or death). A review of the 03/25/2024 nursing notes showed no documentation of an assessment of Resident 3's change in condition which required a transfer to the hospital emergency room. A review of the 03/25/2024 facility to hospital transfer form showed Resident 3 was sent to the emergency room for altered mental status. A 03/25/2024 facility report to the state agency by Staff A (Administrator) showed Resident 3 was given their roommate's medications, became heavily sedated, and was transported emergently to the hospital. Review of the 03/25/2024 facility investigation summary showed Resident 3 was administered a potent medication for opioid dependance, a blood pressure lowering medication, an antianxiety medication, and four other medications not prescribed to Resident 3. Review of the 03/25/2024 9:26 AM nursing note showed Staff C attempted to contact the hospital ER for 30 minutes and was unable to give report to hospital ER staff to hand off care safely. In an interview on 03/27/2024 at 1:26 PM, Resident 3's RR stated they arrived at the facility on 03/25/2024 to visit Resident 3. The RR stated they were told Resident 3 was sent to the hospital earlier that morning because Resident 3 was given their roommate's medications in error. The RR stated none of Resident 3's contacts were notified of the transfer to the hospital or the medication error. In an interview on 03/27/2024 at 4:57 PM, Staff C stated nurses are expected to make a call and provide report of the resident status to the receiving facility. Staff C stated they did not connect with hospital staff and did not provide information to the hospital ER staff to transfer care of Resident 3's care. In an interview on 03/27/2024 at 4:57 PM, Staff A stated nurses are expected to notify the Resident's representative and the hospital staff when transferring a resident to the hospital. Staff A stated there was no documentation to show the RR for Resident 3 was informed of the emergency transfer to the hospital as expected. Staff A stated Staff C should have, but did not, contact the hospital staff to provide a verbal transfer of care. Refer to F760- Residents are Free from Significant Medication Errors REFERENCE: WAC 388-97-0120(3)(a)(b). .

Based on interview and record review the facility failed to ensure 1 of 3 residents (Resident 3), reviewed for medication administration was free from a significant medication error. Resident 3 experienced harm when a staff nurse, who had not completed the facility required competency review for medication administration, did not follow standard practices for medication administration when they administered potent medications belonging to another resident to Resident 3 which resulted in the resident entering a comatose state (a life-threatening change of condition), emergency transfer to the hospital, and admission to the intensive care unit. These failures placed all residents at risk of harm, significant injury, and potential death. Findings included . Review of a facility policy titled Administering Medications, dated 04/2019, showed medications are administered in accordance with the prescriber's orders. The nurse staff administering medications would verify the resident's identity before giving medications using the photo in the medical record or verifying the resident identity with other facility staff. The nurse staff would check the medication label to verify the right resident, right medication, right dosage, with time and right route before giving the medication. Medications ordered for a particular resident may not be administered to another resident. New nurse staff are not permitted to prepare or administer medication until they have been oriented to the medication administration system used by the facility. The charge nurse must accompany new nurse staff on the medication rounds for a minimum of three days to ensure established procedures are followed and proper resident identification methods are learned. A 03/25/2024 facility report to the state agency by Staff A (Administrator) showed Resident 3 was given their roommate's medications, became heavily sedated, and was transported emergently to the hospital. Review of the 03/25/2024 facility investigation summary showed Resident 3 was administered a potent medication for opioid dependance, a blood pressure lowering medication, an antianxiety medication, and four other medications not prescribed to Resident 3. In an interview on 03/27/2024 at 4:20 PM, Staff F (Licensed Practical Nurse) stated they went into Resident 3's room, woke the resident from sleeping, placed the medication cup on the bedside table, asked Resident 3 to verify their name, started a conversation, then Resident 3 took the cup of medications and swallowed them. When finished Resident 5 (the roommate to Resident 3) asked about when they would receive their medications. Staff F asked their name and identified the medication error. Staff F reported to Staff E (Resident Care Manager) who told Staff F to monitor Resident 3. Staff F told Staff D (Resident Care Manager) about the specific medications administered in error. Staff D immediately assessed Resident 3 as difficult to arouse and called 911 for emergency medical services. In an interview on 03/27/2024 at 4:50 PM, Staff C (Staff Development Coordinator) stated Staff F was a new employee, had two training days on the medication cart with other nurse staff, and did not have a competency review completed before independently administering medications to residents. Staff C provided Staff F's timecard and stated Staff F worked five shifts independently before the medication error occurred on 03/25/2024. Staff C stated all nurses should have a competency review prior to independently administering medication. In an interview on 03/27/2024 at 5:00 PM, Staff A and Staff C acknowledged the wrong medications were given and Resident 3 had a life-threatening decline in condition related to the significant medication error. Refer to F622- Transfer and Discharge Requirements. REFERENCE WAC: 388-97-1060(3)(k)(iii). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 44> According to the 12/29/2023 Quarterly MDS, Resident 44 had a diagnosis of an irregular heartbeat. This MDS showed Resident 44 received AC medication during the assessment period. Review of the February 2024 MAR showed Resident 44 received AC medication two times daily. Review of the 12/23/2023 at high risk for readmission d/t polypharmacy CP showed Resident 44 was on a high-risk AC medication with an intervention to monitor high risk medications. This CP did not specify what to assess or monitor regarding AC medication use. Review of Resident 44's February 2024 POs showed an active order for an AC medication to be administered twice daily. There were no indications to assess or monitor for signs and symptoms of active bleeding related to AC medication use. Review of Resident 44's February 2024 MAR showed they had received the AC medication twice daily. During an interview on 02/26/2024 at 10:13 AM, Staff E stated Resident 44 was receiving an AC medication and they were not monitoring for signs of active bleeding, but they should to ensure Resident 44 was not having adverse side effects from the medication and staff would know how to care for her while on a blood thinner medication. <Sleep Medications> <Resident 85> Review of the February 2024 POs showed Resident 85 received a medication for sleeping daily. Review of the February 2024 MAR showed no documentation to assess and/or monitor the sleeping hours to determine if the medication was effective or not. In an interview on 02/26/2024 at 1:56 PM, Staff G reviewed Resident 85's record and stated there should be indications to monitor Resident 85's hours of sleep to determine if the medication was helpful, but there was none. Staff G stated the monitoring of a resident's sleeping hours was very important to identify if the medication was effective, but they missed that. Refer to F655- Baseline Care Plan. Refer to F842- Resident Records - Identifiable Information. REFERENCE: WAC 388-97-1060(1). <Anticoagulant (AC) Monitoring> <Facility Policy> According to the November 2019 Anticoagulation - Clinical Protocol facility policy, residents on AC therapy would have a person-centered CP that included possible signs and symptoms of bleeding, and food and drug interactions. The policy showed the physician would order measures to address any complications, including holding or discontinuing the AC medication as indicated. <Resident 60> Review of Resident 60's 02/22/2024 Physician Order (PO) summary showed a 12/20/2023 PO for an AC to be administered to Resident 60 twice daily. This medication was prescribed for Resident 60's irregular heart rhythm. There was no assessment or additional orders to monitor for adverse side effects such as bleeding or bruising. Review of Resident 60's 04/06/2023 Comprehensive CP showed no CP related to Resident 60's use of the AC medication. There were no goals, interventions, or directions for staff to monitor Resident 60 for adverse side effects. There were no instructions for staff to follow if Resident 60 had an adverse reaction to their AC medication. In an interview on 02/27/2024 at 10:49 AM, Staff E (Resident Care Manager - RCM) confirmed Resident 60 did not have orders or a CP to monitor Resident 60 and their use of the AC medication. Staff E stated it was important to monitor residents who took AC medications to ensure the dosage was appropriate and to monitor residents for adverse side effects. Staff E stated nurses should be monitoring residents for bleeding and bruising. Based on observation, interview, and record review, the facility failed to identify and provide care and services in accordance with the resident's goals and professional standards of practice in the areas of splint use and monitoring impacts of blood thinners and sleep medications for 4 of 20 residents (Residents 191, 60, 85, & 44) reviewed for quality of care. Resident 191 experienced harm when their left hand became swollen and self-reported a severe level of pain when the facility failed to implement measures to monitor the resident's circulation and blood flow to their broken left arm after wound treatment and reapplication of the hard splint. These failures placed residents at risk for unmet needs, decline in medical status, and a decreased quality of life. Findings included . <Splint/Cast> <Facility Policy> Reveiw of the facility policy titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol, revised April 2018, showed the nursing staff would assess and document a resident's significant risk factors for developing pressure ulcers including immobility. The policy showed the impact of specific treatment choices made by the resident/resident representative would be reviewed. <Resident 191> According to the facility census, Resident 191 was admitted to the facility on [DATE] for skilled nursing and rehabilitation services following hospitalization. The 02/16/2024 hospital discharge summary showed Resident 191 was discharged to a skilled nursing facility with a splinted left arm after sustaining a left radial (forearm bone) fracture. Review of the facility's 02/16/2024 admission Nursing Database showed Resident 191 was assessed to be alert, oriented with intact memory, and had clear speech during communication. The skin assessment of this record showed Resident 191 has a skin tear on their left forearm. On 02/20/2024 at 11:31 AM, Resident 191 was observed lying in bed, their left arm in a half-cast fiberglass (a hard plaster material) splint wrapped in a cotton dressing and secured by an elastic bandage; the left arm was resting on top of the resident's chest area. Resident 191 stated they had a bad fall, landed on their left arm and broke it. Resident 191's left hand was observed to have two rings on their fingers; a cloth sling was tucked on the left side the resident (partially lying on the sling) and was not supporting the fractured arm. When asked if the resident was aware they were lying on the sling, Resident 191 stated it was supposed to help the staff to have something to hold on to during repositioning in bed but they [staff] did not use it [cloth sling] anyways .they just yank my arm whichever way they want and it really hurts . Review of Resident 191's medical records on 02/20/2023 showed the 02/16/2024 admission Nursing Database (head-to-toe assessment) completed by the admission nurse did not identify the presence/use of a left arm splint. The facility records did not show any monitoring for swelling and/or blood circulation of Resident 191's left hand/fingers. Resident 191's baseline Care Plan (CP) did not capture the presence/use of a left arm splint and the risks involved with having an immobilization device in place. The CP showed no indication for use of the cloth sling or any staff instructions on how to use and apply the sling correctly. In an interview on 02/22/2024 at 8:40 AM, Staff W (Admissions Nurse) stated they conducted the head-to-toe assessment during admission and were responsible for creating the baseline (CP). When asked how the staff determine what needed to be included in the CP, Staff W stated they based the resident's CP from their initial assessment of the resident and from there, the staff would pick and choose from the CP library which was built-in the facility's electronic health records software. The 2023 February Treatment Administration Record showed a 02/16/2024 order to perform daily treatment and dressing change to Resident 191's left forearm fall-related skin tear and to place the splint back in place after wound care. In an observation and interview on 02/22/2024 at 9:14 AM, Resident 191 was in bed and the cloth sling was off, and scrunched to the side; their left hand was swollen (almost twice the size of their right hand) and purplish in color. The two rings on the resident's left fingers appeared tight on the knuckles. Resident 191 stated the nurse who applied the splint put in on too tight. Resident 191 stated their left hand turned pale, cold, and swollen throughout the night and was very painful and they could not extend their arm out without causing severe pain. Resident 191 stated they told the nurse on duty in the morning who adjusted/loosened the splint for them but the swelling had not yet subsided. Resident 191 stated they did not want to remove their rings because of their fear of losing them. In a joint observation and interview on 02/22/2024 at 9:23 AM, Staff K (Licensed Nurse) saw the condition of Resident 191's left hand and stated having a splinted/casted arm was a high risk condition because a resident could lose their arm if not assessed or monitored accordingly. When asked if there was any indication to monitor Resident 191's left hand for swelling, Staff K stated there should be, but there was none. Staff K stated it was important to have monitoring in place because swelling was hard to track if not recorded in the resident's medical record, .swelling could happen pretty fast and was dangerous for a splinted/casted arm. Staff K stated there were no indications to elevate Resident 191's left arm to help decrease the swelling; there were no instructions written specifically for the use of the cloth sling; and that Resident 191 was not presented with the risk and benefits for wanting to keep their rings on which could further impair circulation and potentially severe the resident's limb. In an interview on 02/22/2024 at 8:58 AM, Staff H (Resident Care Manager) stated the baseline CP was important to be complete, accurate, and identify the needs of newly admitted residents so the nursing staff could provide safe care. Staff H referred to the baseline CP initiated for Resident 191 on admission and stated the presence of a left arm splint was not captured. Staff H stated there was no assessment or monitoring in place to check for Resident 191's skin for pressure points or the resident's left hand/fingers for any changes in color, movement, sensation, or blood return on the nail beds to ensure Resident 191 had adequate blood flowing to their left arm from being splinted. <Resident 85> According to the 02/05/2024 admission Minimum Data Set (MDS - an assessment tool), Resident 85 had diagnoses including heart failure. This MDS showed Resident 85 used an AC during the assessment period. Observations on 02/20/2024 at 11:18 AM, and on 02/22/2024 at 10:29 AM showed Resident 85 had a faded bruise on their right hand. Resident 85 stated they had bruises on their hand for a while related to the AC medication. Review of the February 2024 Medication Administration Record (MAR) showed Resident 85 received the AC medication as ordered for an abnormal heartbeat. Review of the CP showed there was no CP for AC medication for Resident 85. In an interview on 02/26/2024 at 1:56 PM, Staff G (RCM) reviewed Resident 85's record and stated there should be a PO from the provider to monitor Resident 85 for bleeding and bruises but staff did not obtain one. Staff G stated CPs for all high-risk medications were very important to direct staff to provide care for the resident but they did not have CP for AC medication and to monitor the side effects. In an interview on 02/27/2024 at 2:33 PM, Staff B (Director of Nursing) stated there should be a PO to monitor Resident 85 for any new bruising related to AC medication and a CP developed for AC medication monitoring but did not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 10> According to the 01/26/2024 Quarterly MDS, Resident 10 was able to make themselves understood and was able to understand others. The assessment showed Resident 10 required physical assistance with moving to and from a lying position, turning side to side, and positioning their body while in bed. Resident 10 required maximal assistance with lower body dressing and putting on/taking off footwear. The MDS showed Resident 10 had a diagnosis of weakness or complete paralysis of one side of their body, affecting their dominant right side. According to the MDS, Resident 10 was at risk for developing PUs. Review of a 11/15/2023 PO for Resident 10 showed an order to complete weekly skin assessments. These PO's showed a 02/08/2024 order that directed staff to monitor Resident 10's right second medial toe blood filled scab every shift, this being the first notation of the wound in Resident 10's records. A PO initiated on 02/13/2024 directed nursing staff to treat Resident 10's right medial second toe wound. These orders did not show any pressure reduction methods in place for Resident 10's toe. Record review of Resident 10's revised 12/12/2023 at risk for impaired skin integrity CP, showed Resident 10 would not develop new skin breakdown. This CP showed interventions for a LN to complete weekly skin checks, and for staff to provide assistance with repositioning. This CP did not have the right second toe medial PI documented on it. The CP did not identify the right great toe positioning that caused constant pressure to the second toe therefore they did not have interventions in place to reduce the pressure to this area. Review of a 01/10/2024 weekly skin assessment showed Resident 10's skin was intact and showed Resident 10 had no skin irregularities. Review of a 02/14/2024 weekly skin assessment showed Resident 10 had a skin irregularity to their right medial second toe and the irregularity was not new. This skin assessment only noted a skin irregularity to Resident 10's right second toe but did not document an assessment of the wound itself to include measurements, color, if there were any signs of infection or drainage noted. Review of Resident 10's weekly skin assessments showed the skin assessment was not completed, as ordered by the Physician, on 01/17/2024, 01/24/2024, 01/31/2024, and 02/07/2024. Observations on 02/21/2024 at 8:53 AM, 10:48 AM, and 12:22 PM, on 02/22/2024 at 9:02 AM, 11:51 and AM, 02/23/2024 at 9:13 AM, 02/27/2024 at 8:45 AM, and 1:54 PM, and on 02/28/2024 at 12:53 PM showed Resident 10 lying in bed on their back with the head of the bed elevated 90 degrees and blankets draped over their toes. On 02/21/2024 at 12:48 PM Resident 10 stated they had a wound that developed to their right second toe which caused them pain at times. A wound care observation and interview on 02/27/2024 at 10:52 AM showed Resident 10 lying in bed on their back. Staff F (Licensed Practical Nurse) stated Resident 10's right big toenail was pressed against the right second medial toe causing pressure to the right toe where the wound had developed. The right second medial toe wound measured 1.3 cm wide by 2 cm in length and presented as a circular dark purple area with open skin rolled around the wound edges. Staff F stated Resident 10 often refused care and stated refusals should be documented in Resident 10's medical records, and staff should notify the RCM of refusals. Staff F stated they did not document the refusals but should have. Staff F stated the RCM was aware of Resident 10's frequent refusals of care. Review of Resident 10's records showed a 02/27/2024 provider note stating they were informed of a new wound to Resident 10's right second toe on 02/26/2024 and that it appeared their right great toenail had rubbed the right second toe causing the DTPI. This note showed Resident 10 was at risk of delayed wound healing due to unstable blood sugars and right-sided hemiplegia (weakness or complete paralysis of one side of their body.) During an interview on 02/26/2024 at 10:09 AM Staff E (RCM) stated Resident 10's weekly skin assessments were not completed on 01/17/2024, 01/24/2024, 01/31/2024, and 02/07/2024, but they should have been. Staff E stated the weekly skin assessments were important to prevent new skin issues and note any skin issues before they caused the resident to develop a PI/PU. Staff E stated Resident 10's right great toe turned toward their second toe causing the toenail to press into the side of the second toe. Staff E stated there was not any pressure reduction methods in place between Resident 10's right great toe and their second toe prior to development of the PI, but there should have been. Staff E stated they placed the original PO for the wound treatment but was unable to state when the PI developed due to the incomplete weekly skin assessments and no NPN's documenting when the wound developed. Staff E stated Resident 10 did not have a CP for their right second toe medial PI, right sided hemiplegia, or adult failure to thrive (lack of motivation/ability to perform Activities of Daily Living (ADLs) on own with impaired physical function, malnutrition, depression, and cognitive impairment being the 4 main symptoms), but they should have so staff knew how to care for Resident 10. During an interview on 02/26/2024 at 11:43 AM Staff A (Administrator) stated there was no investigation logged or completed for Resident 10's facility acquired PI, but there should have been. During an interview on 02/27/2024 at 11:13 AM Staff E stated they investigated Resident 10's records further because they thought it was the podiatrist that cut their toe when trimming Resident 10's toenails. Staff E stated the podiatrist did not cut the resident, and the wound was a PI caused by the toes pressing together.<Resident 17> Review of the 09/21/2023 Quarterly MDS showed Resident 17 had no memory impairment and diagnoses included a brain bleed with impaired mobility to one side of their body, end stage kidney failure, and diabetes. The assessment showed Resident 17 was at risk for developing PUs and did not have any current PUs. Review of a 02/07/2024 Significant Change MDS showed Resident 17 developed one Unstageable PU and one DTPI. <Heel DTPIs> Review of a 01/03/2024 incident report showed Resident 17 complained of pain to their right heel. The incident report showed staff identified a wound measuring 1.0 cm by 1.0 cm. A 01/04/2024 NPN showed Resident 17 had a DTPI to their right heel. A 01/09/2024 Physician progress note showed resident with a new [DTPI] to left inner heel . [left lower extremity] was directly on the edge of calf bolster (a device used to protect a resident's legs from injury while in a wheelchair). This progress noted showed Resident 17 had conflicting appointments during the time the facility's contracted wound team was in the facility and the physician instructed the RCM to contact wound team for a consult at a non-conflicting time. There were no progress notes indicating facility staff contacted the wound team for a consult. There were no assessments in Resident 17's record indicating Resident 17 was assessed by the contracted wound team as ordered by the provider. A 01/11/2024 PO instructed staff to provide treatment to Resident 17's left lateral heel. Review of Resident 17's revised 01/12/2024 CP showed Resident 17 had a skin tear to their right lateral heel. This CP showed Resident 17 would wear bilateral foam boots at all times. This CP did not identify a right heel DTPI or any skin impairment related to Resident 17's left heel. The CP did not instruct staff to assess, measure, or document the condition of the right heel. The CP directed staff to provide the treatment as ordered and did not have an intervention to include the facility's contracted wound team in Resident 17's care. Review of Resident 17's wound and skin assessments showed a 02/02/2024 weekly skin audit. This audit showed [left] heel continued with treatment . There were no other wound or skin assessments in Resident 17's record indicating staff were monitoring and assessing Resident 17's right and/or left heel. Review of a 02/15/2024 PO directed staff to cleanse Resident 17's left lateral heel, apply a medicated treatment and cover with a bandage. The diagnosis for this PO was indicated as a DTPI for the right lateral heel. There were no clarifying POs in Resident 17's record to indicate if Resident 17 had a DTPI to the right heel, left heel, or both. In an interview on 02/27/2024 at 11:55 AM, Resident 17 stated they obtained the DTPI on their right heel from it resting on their wheelchair footrest. Observation on 02/28/2024 at 11:27 with Staff C (Regional Nurse Consultant) showed Resident 17 lying in bed on their back. Staff C removed Resident 17's socks. There was no dressing observed to Resident 17's right or left heel. A small, nickel sized darkened discolored area was noted to Resident 17's right lateral heel and a large, golf ball sized darkened discolored area was noted to Resident 17's left lateral heel. Both of Resident 17's feet were observed to be dry and had large pieces of flaky skin. Staff E peeled large pieces of skin from the discolored area to Resident 17's left heel. Underneath the dry skin, a large, darkened discolored area remained. Staff C pressed on the discolored area of Resident 17's left heel and could not determine if the area was blanchable (process to determine if there is adequate blood flow to compressed skin) or not. At that time, Resident 17 stated they had no feeling in their left foot and could not feel Staff C pushing on their foot. In an interview on 02/28/2024 at 11:50 AM, Staff C stated they could not determine what the area on Resident 17's left foot was. Staff C stated the area needed to be evaluated by the facility's contracted wound team. Staff C stated all DTPI's and areas of skin impairment should be measured and assessed per the facility's policy. Staff C confirmed there was missing documentation regarding monitoring, measuring, and assessing Resident 17's right and left heel. <Tailbone PU> Review of a 01/08/2024 incident report showed Resident 17 was found to have a 4 cm by 8 cm open area to their tailbone area. Review of Resident 17's revised 01/12/2024 CP showed Resident 17 had an unstageable open area to their tailbone. The CP showed Resident 17 was provided with an air mattress for pressure relief, Resident 17 was to turn and reposition every two to three hours, and staff were to provide the treatment as ordered. The CP did not identify how the PU would be monitored. A 02/11/2024 PO instructed staff to cleanse the tailbone wound daily, apply a medicated dressing, and cover with a foam bandage. Review of Resident 17's skin and wound evaluations showed an evaluation was completed on 01/09/2024 and showed the tailbone PU area measured 12.9 cm, was 6.2 cm long and 3.3 cm wide. The evaluation was incomplete and did not address the location of the wound. The next evaluation was not completed until 01/29/2024, nearly three weeks later, and showed the PU increased in size with the area measuring 24.6 cm, length was 9.4 cm and width was 4.2 cm. The remaining evaluations were completed on 02/06/2024 and 02/15/2024. Record review on 02/28/2024 showed no further evaluations were completed for Resident 17's tailbone PU. In an interview on 02/27/2024 at 12:10 PM, Staff E stated the tailbone PU was evaluated weekly on Mondays. Staff E confirmed there were missing assessments and stated maybe the resident was out, maybe we missed [the assessments]. Staff E stated the contracted wound team assessed Resident 17's PU by looking at the weekly photographs and measurements obtained by Staff E. Staff E stated the contracted wound team called Staff E at the end of the day on Monday's with recommendations for Resident 17's wound. Staff E stated the recommendations were not formally documented. Staff E could not provide any documentation showing the contracted wound team assessed Resident 17's PU. In an interview on 02/28/2024 at 12:26 PM, Staff C confirmed there was no record of the contracted wound team assessing or evaluating Resident 17's PU. Refer to F609 - Reporting of Alleged Violations Refer to F610 - Investigate/Prevent/Correct Alleged Violation REFERENCE WAC: 388-97-1060 (3)(b). Based on observation, interview, and record review the facility failed to ensure 3 of 5 sampled residents (Residents 32, 10, & 17) reviewed for Pressure Ulcers (PUs)/Pressure Injuries (PIs), received prescribed pressure reducing measures and repositioning on a consistent basis. Resident's 32 and 10 experienced harm when they developed facility acquired PUs. This failure placed all residents at risk for PI/PU development, and a diminished quality of life. Findings included . <PU Staging Guide> Review of the facility provided guided titled, Gentell PI Staging and Care Plan Considerations, dated 2019, showed a PI/PU was defined as damage to the skin and underlying tissue usually over a bony prominence. The guide showed PI/PUs could present as intact skin or an open ulcer and might be painful, and these injuries occurred as a result of intense and /or prolonged pressure or pressure in combination with shearing. A Deep Tissue Pressure Injury (DTPI) presented as intact or non-intact skin that was non-blanchable deep red, maroon, or purple discoloration, or epidermal (outer, protective layer of skin) separation revealing a dark wound bed or blood-filled blister. Stage II PU was defined as a partial thickness loss of skin with exposed dermis (sensitive connective tissue layer under the outer layer of skin) presenting as a shallow open ulcer with a red or pink wound bed, without slough or bruising. A Stage III PU was defined as full thickness loss of skin, in which fat tissue was visible in the ulcer and rolled wound edges were often present. Slough and/or eschar might be visible and obscure the extent of tissue loss which would then be defined as an Unstageable PU. <Facility Policies> Review of the facility policy titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol, revised April 2018, showed nursing staff and the practitioner would assess and document an individual's risk factors for developing PIs/PUs such as immobility, recent weight loss, and a history of PUs. The policy showed the nurse would describe and document a full assessment of a PU including location, stage, length, width, and depth, and the provider would assist the staff in identifying the type of PI/PU. Review of the facility policy titled, PI Overview, revised March 2020, showed PI/PU referred to damage to the skin and/or underlying soft tissue usually over bony prominence. A PI would present as intact skin and could be painful. A PU would present as an open ulcer, the appearance would vary depending on the stage and could be painful. PI/PU's occurred as a result of intense and/or prolonged pressure or pressure in combination with shear. Shearing occurred when layers of skin rubbed against each other or when the skin remained stationary, and the underlying tissue moved and stretched and angulated or tore the underlying capillaries and blood vessels causing tissue damage. DTPI presented as a persistent non-blanchable deep red, maroon, or purple discolored area of skin. Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration, or epidermal separation revealed a dark wound bed or blood-filled blister. Pain and temperature change often preceded skin color changes. Review of the facility policy titled, [Facility] Living - Weekly Skin Audit Guidelines, revised 08/25/2020, showed weekly skin audits would be completed on all residents by a licensed nurse. This policy showed that all new PI's required implementation of weekly wound assessments to be done by a licensed nurse <Resident 32> According to the 01/18/2024 Admission/5-day Minimum Data Set (MDS- an assessment tool), Resident 32 admitted to the facility on [DATE], had no memory impairment and had diagnoses including diabetes (high blood sugar), malnutrition, and depression. According to this assessment, Resident 32 required extensive assistance with bed mobility and was at risk for developing PUs. According to the 01/12/2024 nursing admission skin assessment, Resident 32 admitted with no PU. A 01/12/2024 Braden scale (a tool identifying the risk for forming PUs) showed Resident 32 was at high risk for developing PUs. The 01/12/2024 Skin Care Plan (CP) showed Resident 32 had the potential for alteration in skin integrity. Nursing interventions included instructions to staff to keep skin clean and dry, report any new skin impairments to nurses, and for nurses to complete weekly skin assessments. Review of a nutritional assessment, dated 01/16/2024 upon admission, completed by the Registered Dietitian (RD), showed Resident 32 was at high risk for skin break down. A 01/19/2024 Care Conference note showed Resident 32 stated my butt hurts when sitting up in the chair. A 01/23/2024 weekly skin audit showed Resident 32's skin was intact and Resident 32 had no PUs. Review of the 01/30/2024 Nursing Progress Note (NPN) showed Resident 32 had an open area that measured as 1.0 cm (centimeter)X 0.5 cm X 0.5 cm on their tailbone area. This note showed Resident 32 preferred to lay on their back and did not want to be on their sides due to shoulder pain. A 01/30/2024 Physician Order (PO) directed staff to apply a barrier cream to Resident 32's buttocks after every incontinent episode. Review of the February Treatment Administration Record (TAR) showed Resident 32 received treatment to their buttocks as ordered. On 02/01/2024 the Skin CP was revised to include a small open area to Resident 32's tailbone. Interventions included an air mattress. A 02/12/2024 PO directed staff to cleanse a wound, apply medication, and cover with a dressing daily. This order did not specify the site for the wound treatment. The 02/19/2024 PO directed staff to apply a treatment to the open wound on Resident 32's tailbone area. Review of the Resident 32's records showed the resident's tailbone wound was assessed by a contracted wound provider on 02/18/2024 now measuring 0.6 cm X 0.3 cm X 0.1 cm. The wound provider recommended that staff reposition Resident 32 every two to three hours per facility protocol and recommended an RD evaluation for interventions. Observations on 02/20/2024 at 9:39 AM, 11:57 AM, and 2:11 PM, on 02/21/2024 at 9:04 AM, 11:30 AM, and 1:52 PM, on 02/22/2024 at 8:10 AM, 10:23 AM, and 1:33 PM, on 02/23/2024 at 8:51 AM, 11:07 AM, and at 1:20 PM showed Resident 32 lying on their back on airmattress in their bed. In an interview on 02/21/2024 at 10:23 AM, Resident 32 stated they had a sore on their bottom. Resident 32 stated they did not want to get up in their wheelchair (w/c) because their bottom hurt. Resident 32 stated,staff were too busy to help me to get up in w/c and reposition me in my bed. In an interview on 02/22/2024 at 11:07 AM, Staff I (Certified Nursing Assistant - CNA) stated they tried to reposition Resident 32 in bed at times but Resident 32 refused to be on their side. Staff I stated they did not document the refusals. Staff I stated they should have documented the refusals and notified the RCM. Observation on 02/27/2024 at 12:52 PM showed Staff P (Licensed Practical Nurse- Wound Nurse) providing wound care to Resident 32. Resident 32's tailbone wound was covered with a bordered gauze dressing. Staff P removed the dressing, assessed the wound that measured 2.0 x 0.5 x 0.3 cm. The wound had mild clear color drainage with no odor. Staff G (Resident Care Manager - RCM) joined the wound nurse to assess the wound. Staff G stated the wound base was covered with slough (dead cells) and was a Stage 3. In an interview on 02/26/2024 at 1:29 PM, Staff G stated they expected staff to reposition residents every two to three hours in bed and in their w/c to reduce the risk for PUs. Staff G stated staff should document if residents refused care and notify RCM and Social Services to follow up. Staff G Stated they knew Resident 32 was at high risk for developing PUs but staff missed implementing interventions to prevent PUs. Staff G stated they did not follow the contracted wound provider's recommendations on 02/18/2024 to reposition Resident 32 or obtain an evaluation from the RD. Staff G stated they should have notified the RD about Resident 32' PUs but they did not. In an interview on 02/26/2024 at 2:16 PM, Staff Q (RD) stated they assessed residents upon admission, quarterly and as needed. Staff Q stated they reviewed residents with weight loss and PUs issues in a weekly nutrition meeting with nurse managers. Staff Q stated they were unaware of Resident 32's PU and did not assess Resident 32 after they developed a PU. In an interview on 02/27/2024 at 2:28 PM, Staff B (Director of Nursing) stated monitoring, early identification of skin impairments, and implementing PU prevention timely were important to maintain skin integrity and to prevent new PUs from developing. Staff B acknowledged the nurses did not follow the instructions for preventative measures which resulted in Resident 32's new PU on their tailbone. Staff B stated it was very important for staff to update resident's CPs according to the assessment, to follow the provider's recommendations, and to ensure residents were free from new PUs and pain related to PUs, but they did not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 66> According to 12/09/2023 Significant Change MDS, Resident 66 was assessed to have moderate memory impairment. The assessment showed Resident 66 had difficulty with hearing. The MDS showed Resident 66 had diagnoses of right hip fracture, history of unspecified falls, hemiplegia (weakness or complete paralysis of the entire one side of the body) affecting their left side, repeated falls, and generalized muscle weakness. The assessment showed Resident 66 required maximum assistance with transfers from chair to bed and bed to chair since diagnosis of Covid -19 (a highly contagious respiratory illness) and Shingles (a contagious painful, burning skin rash). Review of Resident 66's Activity of Daily Living CP revised on 10/17/2023 showed Resident 66 required one person assistance with dressing, transfers, and mobility. Resident 66's communication CP dated 10/03/2023 showed Resident 66 preferred communicating face to face, speaking clearly and concisely with the TV off, and limiting other background noises due to hearing deficit. Resident 66 was assessed to be a high fall risk related to history of falls with serious injury and incontinence on 10/03/2023 with interventions to keep bed in lowest position and resident required one person assist with all transfers. Resident 66 had a 10/16/2023 AD medication CP with an intervention to monitor for unsteady balance. Resident 66's Restorative Nursing Program CP dated 11/17/2023 showed they required one person assist and walker with ambulation (prior to significant change). Resident 66 had a Covid-19 CP dated 11/27/2023 showing they were on isolation precautions and to keep their door closed. Review of Resident 66's NPNs showed an 11/27/2023 provider note stating Resident 66 was a high fall risk and their reason for admission was due to falls. An 11/28/202 skilled NPN showed Resident 66's gait was unsteady, they had poor balance, and they were positive for Covid and were on isolation precautions. A 12/01/2023 NPN showed Resident 66 was on isolation precautions for positive Covid 19 and Shingles. A 12/07/2023 NPN showed Resident 66 had returned from the hospital after the surgical repair of the right hip fracture. Review of an 11-29-2023 Fall Risk Assessment showed Resident 66 was confined to a chair and oriented, required hands on assistance to move from place to place, was unable to independently come to a standing position, and required an assistive device such as a wheelchair. This fall risk assessment showed Resident 66 had one to two falls within the last six months and scored 13 which defined them as a moderate fall risk. Review of a 12/01/2023 fall IR showed Staff FF (CNA) went to answer Resident 66's call light that was on and asked them what they needed from the doorway. Staff FF was in the hallway outside of Resident 66's room putting on personal protective equipment due to Covid -19 isolation precautions when they heard a loud noise. Resident 66 was observed to be on the floor near their bed. The CNA notified the nurse on duty who went to assess Resident 66 immediately and noted the call light was within reach but not used or on. The IR showed Resident 66 had predisposing complications of gait imbalance (unsteady) while walking and recent illness (Covid 19 and Shingles). The IR showed the fall was unwitnessed. During an interview on 02/21/2024 at 8:38 AM Resident 66 stated they had a fall on 12/01/2023 breaking their right hip which required surgical repair. Resident 66 stated they required two CNAs for assistance at the time due to general weakness from Covid and that two CNAs had helped them to the sink. Resident 66 stated they were standing at the sink while the two CNAs went outside of their room into the hallway when their legs got tangled up and they fell. Resident 66 stated the CNA and nurse came back into the room after they fell. During an interview on 02/26/2024 at 9:09 AM Staff E (RCM) stated when a resident was assessed to be a fall risk, they expected staff to remain with the resident during cares, especially standing. If there was a concern that a resident, who was assessed to be a high fall risk and had a history of falls with serious injuries, would attempt to self-transfer they would implement a one-to-one caregiver to always stay with the resident. Staff E stated Resident 66 was positive for Covid and Shingles just prior to their fall and had experienced a change in condition causing them to have an increase in general weakness overall which should have been updated on Resident 66's CP to direct staff to stay with them while standing and providing care, but it was not. During an interview on 02/27/2024 at 9:19 AM Staff R (CNA) stated they were expected to stay with resident that were assessed to be a high fall risk while providing cares. Refer to F609 - Reporting of Alleged Violations Refer to F610 - Investigate/Prevent/Correct Alleged Violation REFERENCE WAC: 388-97-1060 (3)(g). Based on interview and record review, the facility failed to ensure supervision was provided to residents at the care level they were assessed to require for 2 of 3 residents (Resident 66, & 31) reviewed for falls. Resident's 66, who had a change in condition and increased weakness, experienced harm when they fell when left unsupervised resulting in a fractured right hip and to Resident 31, who required extensive assistance from staff with toileting, was left on the toilet without supervision resulting in a fall with a skin tear and left foot fracture. These failures placed all residents at potential risk for avoidable falls, injuries, and a diminished quality of life. Findings included . <Facility Policy> Review of the facility policy titled, Assessing Falls and Their Causes, revised March 2018, showed residents must be assessed upon admission and regularly afterward for potential risk of falls and that any relevant risk factors must be addressed promptly. This policy showed appropriate interventions taken to prevent future falls would be recorded in the residents Electronic Health Record (EHR). Review of the facility policy titled, Accidents and Incidents - Investigating and Reporting, revised July 2017, showed the Incident Reports (IR) for the facility would be reviewed by the Safety Committee for trends related to accidents or safety hazards in the facility and to analyze any individual resident vulnerabilities. <Resident 31> According to the 01/24/2024 admission 5 Day Minimum Data Set (MDS- an assessment tool), Resident 31 admitted to the facility on [DATE], and was assessed with no memory impairment, and demonstrated no rejection of care. Resident 31 received pain medications, antianxiety (AA), and antidepressant (AD) medications on seven of seven days during the assessment period. Resident 31 had a history of falls. The MDS showed Resident 31 used a wheelchair (w/c) for mobility and required extensive assistance from staff with toileting and one person assistance with transferring from bed to w/c and w/c to bed. During the admission assessment, a fall risk evaluation was completed on 01/18/2024 with a score of 12, showing Resident 31 was a fall risk. Review of the 01/18/2024 Fall Care Plan (CP) showed Resident 31 was a fall risk related to a history of falls, AA, and AD medications. Nursing interventions instructed staff to keep Resident 31's call light within reach, keep their bed in the lowest position except during care, and update the fall risk assessment post fall and quarterly. The CP directed staff, Do not leave the resident unsupervised in bathroom (BR)/on bedside commode. Review of the undated [NAME] (communication guide for CNAs about individual resident's needs) directed staff Do not leave the resident unsupervised in BR/on bedside commode. Review of a 01/27/2024 provider note showed Resident 31 was a fall risk and recommended staff keep Resident 31's bed in the lowest position to decrease the risk for injury related to falls. Observations on 02/20/2024 at 10:21 AM and 1:18 PM, on 02/21/2024 at 8:50 AM, 10:02 AM, and 1:20 PM, on 02/24/2024 at 10:22 AM and 2:43 PM showed Resident 31 lying in their bed. The bed was not observed in the lowest position and was 24 inches from the floor (standard bed height). In an interview on 02/22/2024 at 8:50 AM, Resident 31 stated they needed help to go the BR for bowel movements (BM). Resident 32 stated sometimes they had to wait for more than 35 minutes to get help. Resident 31 stated a couple of weeks ago, I fell in the BR and broke my toe. Resident 31 stated their broken toe was very painful at times and pain medications helped to relieve their pain. Review of the 02/07/2024 Nursing Progress Note (NPN) showed Resident 31 was observed lying on the floor in the BR with a skin tear to their left elbow measuring 1.0 centimeter (cm) X 2.0 cm and posterior left forearm measured 1.5 cm X 2.5 cm. Resident 31 denied any pain at that time. Staff notified the Physician and provided first aid to Resident 31. Review of the investigation showed Resident 31 had a fall on 02/07/2024 at 7:05 PM in the BR in their room. In a statement, the assigned Staff S (Certified Nursing Assistant - CNA) documented Around 7:01 PM, Staff S put the resident in the BR to use the toilet, gave the call light to call the staff when finished and Staff S waited outside the BR door for privacy. Around 7:05 PM Staff S heard a scream and went to see the resident in the BR. Staff S noticed Resident 31 lying on the floor inside the BR with skin tears on left arm and elbow. The 02/08/2024 investigation note showed Resident 31 was alert, forgetful, and required education on safety, transfers, and call light usage. A copy of the 02/08/2024 left foot X-rays report attached with the investigation showed Resident 31 had a non-displaced fracture at the base of their left great toe. There was no documentation in Resident 31's record showing Resident 31 complained of foot pain or staff communication with the provider about the foot pain which resulted in a Physician Order (PO) for an X-ray on 02/08/2024 related to left toe fracture. Review of the 02/09/2024 PO directed staff to splint (a device to support and protect the broken bone) Resident 31's left great toe by taping second toe to their great toe, to check capillary refill the toenail beds every shift, and to keep splint intact for 21 days. Observations on 02/21/2024 at 11:00 AM, 02/22/2024 at 12:23 PM, and 02/23/2024 at 3:33 PM showed no splint taped Resident 31's left second toe to their left great toe. In an interview on 02/23/2024 at 11:23 AM, Staff J (Licensed Practical Nurse - LPN) stated Resident 31 refused to have the splint on their left great toe and Staff J documented the refusals on treatment administration record. Staff J stated they did not document the communication with the provider in Resident 31's record. Staff J stated they should have documented in Resident 31's record but they did not. Staff J stated they did not notify the RCM and Social Services (SS). In an interview on 02/26/2024 at 2:19 PM, Staff H (Resident Care Manager) stated Resident 31 had poor safety judgement and was forgetful at times. Staff H stated the CP instructed staff not to leave the resident alone in the BR, but staff left the resident unsupervised in the BR and caused Resident 31 to have a fall with fracture. When Staff H was asked about the documentation about Resident 31's left toe fracture, Staff H reviewed Resident 31's record and stated they did not document Resident 31's complaint of foot pain or communication with the provider for an X-ray order. Staff H stated they were unaware of Resident 31's refusals of left great toe splinting as ordered by the provider. Staff H stated staff should have notified the RCM, SS, and the provider and documented in Resident 31's record, but they did not. In an interview on 02/27/2024 at 2:38 PM, Staff B (Director of Nursing - DNS) stated they expected staff to assess the resident at admission, post fall and quarterly and update the CP as needed. Staff B stated to update and follow the CP was very important to provide the necessary care to residents. Staff B stated the facility was aware of Resident 31's fall risk and left the resident alone in the BR and caused a fall with fracture. Staff B stated staff should not have left the resident alone in the BR.