Based on observation, interview, and record review the facility failed to implement interventions to prevent pressure ulcer/injuries for 1 of 3 sampled residents (8). Resident 8 experienced harm when they developed avoidable pressure ulcers.This failure placed other residents at risk for development of pressure ulcers, medical complications, and unmet care needs. Findings included . <Resident 8> Review of the facility's policy titled Skin Integrity updated October 2022, documented if a resident admitted with or developed a skin ulcer/pressure ulcer/wound, care would be provided to treat, heal, and prevent, if possible further development of skin ulcers/pressure ulcers/wounds. Review of the annual assessment, dated 02/16/2024, showed Resident 8 had diagnoses which included dementia, contractures (a permanent tightening of the muscles, tendons, skin, and nearby tissues that caused joints to shorten and become very stiff) to the left and right knees and a contracture to the right ankle. The assessment documented Resident 8 was identified as being at risk of developing pressure ulcers and had a Stage II pressure ulcer (a shallow open ulcer with a red or pink wound bed) on their right great toe. Review of Resident 8's care plan dated 11/14/2019, documented Resident 8 was high risk for skin breakdown related to limited mobility, contractures to bilateral feet, left second toe abrasion and fragile skin. The care plan had been updated to reflect a pressure ulcer to Resident 8's second toe on 11/23/2023 and a pressure ulcer to their third toe on 02/28/2024. Review of the care plan showed no interventions specific to Resident 8's care needs were documented regarding treatment and prevention of pressure ulcers to their toes. Review of a progress note dated 11/23/2023 at 10:23 AM, documented a pressure ulcer was found on Resident 8's right great toe due to the second toe being pressed up against it. Review of the 11/23/2023 Braden assessment, (an assessment that explains the risk of getting skin breakdown) documented a score of 13, which indicated Resident 8 was a high risk for skin breakdown. Review of a progress note dated 12/09/2023 at 10:40 AM, documented Resident 8's right great toe was observed to have an indentation from pressure placed on it from direct contact of the second toe. No documentation was found to show that interventions were implemented to prevent further skin breakdown. Review of a progress note dated 12/17/2023 at 10:11 AM, documented Resident 8's right great toe did not have an open wound, but an indentation was present due to continuous pressure against the second toe. The note documented the left side of the second toe was red with no broken skin. No documentation was found to show that interventions were implemented to prevent further skin breakdown. Review of a progress note dated 12/31/2023 at 10:44 AM, documented Resident 8 had a bandage on their right great toe to provide a cushion against pressure caused from the second toe, and the left side of the second toe had a very thin scab. Review of a progress note dated 01/14/2024 at 1:25 PM, documented the area between Residents 8's the right great toe and second toe was dark red, and a double layer of foam dressing had been applied. Review of a progress note dated 01/25/2024 at 11:35 AM, documented Resident 8's right great toe had a foul smell, drainage and yellow slough (a yellowish, moist, stringy substance that can delay wound healing) inside the indentation where the second toe had pressed into the side of the great toe. Review of a progress note on 02/25/2024 at 9:07 AM, documented Resident 8's right great toe, second and third toes had pressure wounds. The wounds were between the toes and were the result of the toes curling up and putting pressure on the insides of the toes, which created open oozing wounds. Review of a progress note dated 02/28/2024 at 2:05 PM, documented two new pressure areas to Resident 8's toes during weekly skin observation assessment. New areas were observed to the inside of the right second toe, and to the inside of right third toe. These areas were caused from the toes crossing over each other. Review of Resident 8's Braden assessment on 02/28/2024, documented a score of 15, which indicated they were high risk for skin breakdown. The assessment showed the resident had an increased risk for skin breakdown from the previous assessment on 11/23/2023. During an observation on 04/09/2024 at 8:55 AM, Resident 8 was sitting in their wheelchair and had socks on both feet. When asked if the nurses had placed anything between their toes prior to the development of the right toe wounds, Resident 8 stated, No, I wish they would have. During an observation of the wound with Staff K, Registered Nurse (RN), on 04/11/2024 at 9:04 AM, Resident 8 was observed with gauze between their toes. The right great toe, second and third toe were all bunched together, with the right great toe and third toe overlapping across the top of the second toe. Pressure ulcers were observed on the inside of the right great toe, inside and outside of the second toe, and on the inside of the third toe. In an interview on 04/12/2024 at 8:30 AM, Staff K, stated Resident 8 had pressure ulcers between their toes and non-adherent strips were placed between them. Staff K added that toe spacers had been ordered but had not yet arrived. Staff K stated nothing had been placed between Resident 8's toes until they had complained about the issue, and a shower aide had reported the resident had breakdown between their toes. In an interview on 04/12/2024 at 11:26 AM, Staff B, Director of Nursing, stated they had many interventions in place for skin breakdown, but not for Resident 8's toes. Staff B added it would have been helpful to have put an intervention in place prior to the skin breakdown. Reference: WAC 388-97-1060 (3)(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to consistently implement effective preventative measures for falls, by evaluating the effectiveness of current interventions and the need for increased supervision for 4 of 4 sampled residents (Residents 31, 33, 36, and 51), reviewed for accidents. Resident 51 experienced harm when they sustained a hip fracture requiring hospital treatment and Resident 36 experienced a pattern of frequent falls. These failures placed residents at risk for repeat falls, major injury, and diminished quality of life. Findings included . Review of the facility titled Fall Evaluation and Management dated 02/2000, showed the facility was to implement a fall management plan based on the resident's medical history and resident evaluation. The policy instructed nurses to complete a Morse fall scale (assessment that scored a residents fall risk) assessment upon admission, with each fall, and with a significant change in condition. A score greater than 45, identified the resident as a high potential for falls and staff should implement appropriate safety interventions for fall management. A score less than 45, identified the resident as a low to moderate potential fall risk and the interdisciplinary team was to determine if safety interventions were needed. The policy further showed nursing staff was to review and update a resident's care plan with newly identified interventions as needed after a fall was sustained. <Resident 51> Review of the admission assessment, dated 03/10/2024, showed Resident 51 admitted to the facility on [DATE]. Resident 51 had diagnoses including dementia and recent thoracic spine fusion (surgical procedure where two or more spine bones are joined together to eliminate movement between them). Resident 51 had moderate cognitive impairment and was able to make their needs known. Review of Resident 51's baseline care plan, dated 03/08/2024, showed they were alert but confused and forgetful. Resident 51 required moderate up to substantial assistance for bed mobility and moderate assistance of one staff for transfers using a front wheeled walker. Falls or risk for falls or fall interventions were not documented on the baseline care plan. Review of the March 2024 through April 2024 facility incident log showed a 03/10/2023 fall entry for Resident 51 with the injury listed as a fracture. Review of Resident 51's progress notes showed they had high anxiety about their admission to the facility, wanted to leave and had family at bedside the first two days. On 03/10/2024 Resident 51 called out for help and was found alone down on the floor lying on their right side. They complained of right hip pain and guarded their hip while grimacing. Resident 51 was then transferred to the hospital for further evaluation and was found to have a right hip fracture. Review of the 03/10/2024 facility fall incident report showed Resident 51 had an unwitnessed fall at 12:45 PM. Resident 51 was found on the floor parallel to their bed lying on their right side while they moaned and complained of right hip pain. Weakness, forgetfulness, admission within the last 72 hours after a spinal procedure were listed as predisposing factors. Resident 51 was noted to have significant complaints of right hip pain, right leg was externally rotated and appeared shorter than the left leg. Staff then used the Hoyer lift to transfer the resident off the floor. Resident 51 was then sent to the hospital for further evaluation and was found to have a right hip fracture. Review of the Interdisciplinary team (IDT) fall review showed Resident 51 overestimated their own ability to self-transfer, attempted to transfer from their recliner and fell onto the floor. Resident 51 had dementia and was adjusting to their new surroundings. The assessment showed the fall on 03/10/2024 was the first fall since their admission to the facility two days prior and the need for initial interventions would be evaluated once the resident returned to the facility. Review of Resident 51 nursing progress note, dated 03/11/2024, showed they did not return to the facility after their hospitalization for right hip fracture. In an interview on 04/12/2024 at 3:35 PM, Staff B, Director of Nursing, stated baseline care plans typically included how much assistance a resident required for their activities of daily living (ADL), but a falls care plan was typically not initiated until the comprehensive care plan was completed (up to 21 days after admission) and the resident's fall risk was determined by completing the Morse fall assessment. Staff B further stated staff had up to five days to implement and re-evaluate safety interventions after a fall occurred. Staff B acknowledged if a resident had increased complaints of pain or showed possible signs and/or symptoms of a fracture such as increased pain, inward or outward limb rotation or limb shortening they should not be moved. Staff B reviewed Resident 51's medical record. Staff B acknowledged Resident 51 was not cognitively intact and had an unwitnessed fall two days after their admission that resulted in a right hip fracture. Staff B further stated that Resident 51 did not return to the facility after they sustained their fracture. <Resident 36> Review of the comprehensive admission assessment dated [DATE] documented Resident 36 had diagnoses including stroke with hemiplegia and hemiparesis (paralysis and weakness) on the left non-dominant side. Resident 36 was cognitively intact, had limited range of motion in both upper and lower extremities on both the left and the right, and required partial/moderate assistance for transferring from a lying to sitting position, sitting to standing, transferring to a chair, toileting, and walking 10 feet. The resident used a walker and wheelchair for ambulation and had no history of falling prior to admission. Review of the baseline care plan, dated 10/26/2023, showed Resident 36 needed minimal/moderate assistance of one staff to move from lying to sitting, transferring to the toilet, moving from sitting to standing, and transferring from the bed to the wheelchair. Review of the care plan, revised on 11/02/2023, showed Resident 36 had a potential ADL performance deficit related to stroke with left-side weakness. Staff were instructed to make sure shoes were comfortable and not slippery, encourage the resident to use the call bell and wait for assistance, and physical and occupational therapy were to evaluate and treat. A review of the facility Incident logs documented the following for Resident 36: -a fall on 11/06/2023 at 10:30PM, -a fall on 11/18/2023 at 4:50PM, -a fall on 11/22/2023 at 10:30PM, -a fall on 11/23/2023 at 5:00PM, -a fall on 11/30/2023 at 2:45AM, -an incident on 12/12/2023 at 10:00AM that resulted in a fracture, and -a fall on 12/22/2023 at 2:00AM. A nursing progress note, dated 11/06/2023 at 10:25 PM, showed Resident 36's call light was activated. The resident was on the floor beside their bed and stated they attempted to self-transfer to brush teeth, then slipped and fell. There was no injury. An IDT fall review completed on 11/07/2023, showed the cause of the fall was Resident 36's mood or mental status; the resident over-estimated their ability to safely transfer without assistance. On 11/06/2023, the care plan was updated to include Resident 36 was high risk for falls related to left sided weakness and gait/balance problems. Staff were instructed to anticipate and meet the resident's needs, make sure the call light was in reach and encourage the resident to use it, the resident needed prompt response to requests for assistance, educate the resident about safety reminders, encourage the resident to participate in activities that promote exercise, strength and mobility, ensure the resident was wearing appropriate footwear, fall evaluation on admit, quarterly and as needed by the licensed nurse, and physical therapy evaluate and treat. An IDT fall review completed on 11/18/2023 documented Resident 36 fell in their room again. The cause of fall was attributed to the resident's mood/mental status; the resident over-estimated their own ability and slid off their bed to the floor. The review documented that the team determined the resident was going to continue to self-transfer, the resident was educated to use their call bell with understanding and the care plan was updated. On 11/20/2023, the fall risk care plan was updated and instructed staff to educate Resident 36 on the importance of using the call light and waiting for assistance, already part of the care plan. Review of Resident 36's nursing progress notes November 2023 through December 2023 showed the following: There was no nursing progress note related to the fall on 11/18/2023. On 11/21 2023, it was noted the resident was to be discharged on 11/24/2023. On 11/22/2023 at 10:10 PM, the resident was found on the floor next to their wheelchair after they fell out of their wheelchair and complained of left hip pain. On 11/23/2023, the resident continued to complain of left hip pain and refused their shower. They told the shower aide they thought they broke their hip when they fell. When questioned, Resident 36 declined to go to the hospital for further treatment. At 5:29 PM, Resident 36 was found on the floor leaning against their nightstand. They reported they were afraid to go home and did not know what they would do if they fell at home. On 11/24/2023 at 2:22 AM, Resident 36 refused transfers with one assist as care planned and stated they were afraid they would fall. The resident complained of left hip pain rated 9 out of 10, the pain was worse with movement, and they winced when returning to bed. At 9:10 AM, the resident again slipped out of bed and did not want to go home and was notified they would not be going home. At 8:29 PM, Resident 36 was reluctant to transfer on their own and did not get out of bed that shift. An IDT fall review completed on 11/23/2023 regarding the fall on 11/22/2023 at 10:10PM documented Resident 36 was forgetful of their left-side deficit from their stroke, the resident was educated to use their call bell for assistance, and the care plan was updated. Review of Resident 36's record showed there was no evaluation done to determine the need for additional interventions after the Resident fell on [DATE], 11/23/2023, and 11/24/22023. The fall on 11/24/2023 was not entered on the facility incident log. On 11/27/2023, Staff B, Director of Nursing entered a progress note that Resident 36 requested an x-ray related to pain in their hip, possibly from the fall that occurred on 11/23/2023. The x-ray was negative for a fracture and concluded Resident 36 had degenerative changes and osteoarthritis of the left hip. Review of a nursing progress note, dated 11/30/2023, documented Resident 36 fell in their bathroom at 2:45AM, hit their arm on the sink which caused an abrasion and landed on their left hip. The resident then crawled to the door and was found by a nursing assistant. This note was struck out (a line drawn through the entry) on 12/04/2023 and noted as incorrect documentation. A 12/02/2023 nursing progress note documented Resident 36 had adequate safety awareness but appeared to backslide recently and had several falls from over-estimating their abilities. They were encouraged to get up and ambulate only when staff were present. On 12/04/2023 at 8:08 AM, a nursing progress note documented Resident 36 fell in their bathroom, hit their arm on the sink that caused an abrasion and landed on their left hip. An IDT fall review completed on 12/04/2023 regarding the fall that occurred on 11/30/2023 documented the resident fell in their room. The cause again was that Resident 36 over-estimated their ability to safely ambulate without assistance. Resident 36 was again encouraged to use their call light and wait for staff assistance. The care plan was updated to include 1:1 activities related to the resident not wanting to leave their room. The IDT team concluded the resident was alert and oriented and would likely continue to self-transfer. On 12/12/2023 at 3:56 AM, the nursing progress note showed the resident asked for an early dose of pain medication for pain rated 10 of 10 (on a scale of zero to 10, zero being no pain and 10 being the worst pain), then requested to go to the emergency room for pain medication. Resident 36 was told there was less than one hour before their next dose of pain medication was due, and the resident stated they would tough it out until the next dose. The resident was told to put on their call light if they wanted to go to the hospital. On 12/12/2023 at 1:01 PM, Staff B documented Resident 36 continued to complain of left hip pain and had several falls, the last one occurred on 11/30/2023. When assessed, the resident's left leg was externally rotated and this was not new, but the resident grimaced when attempts were made to straighten or move the left leg. An Xray of the left hip and femur were to be obtained. On 12/13/2023 at 10:24 AM, a nursing progress note showed Resident 36 had an acute fracture of their left femur at the neck (top part of the thigh bone.) The resident was transferred to the local hospital. An incident report completed on 12/13/2023 showed Resident 36 stated they thought they slept wrong, and my legs kind of slid off the bed and I felt a pop at the same time. Predisposing factors for the incident included the resident had a history of self-transfers and had been previously educated to not self-transfer. Under other information, it was documented there had been no immediate fall noted since 11/30/2023, the resident states that likely occurred the night of 12/07/23 or 12/08/23. There were no witnesses. The investigation documented that when interviewed, Resident 36 stated that on 12/11/2023, they had tried sleeping on their left side and in doing so, their legs slid off the mattress and they felt a pop at that time. There were no entries on the incident log for Resident 36 on 12/07/2023 or 12/08/2023 and no nursing progress notes. Review of a nursing progress note, dated 12/21/2023, showed Resident 36 returned from the hospital after surgical repair of their hip fracture. A 12/22/2023 at 2:00AM nursing progress note showed Resident 36 was found on the floor sitting against the door frame after a fall. Resident 36 stated they got up themselves because no one answered their call light. Resident 36 stated they caught the wheel of their walker on a chair, started to fall, the guided themselves to the floor and scooted to their door. An incident report dated 12/22/2023 showed Resident 36 was notified they required two staff and a gait belt to assist them when being transferred. When asked why they were up without assistance, Resident 36 reported they were independent when at the hospital and thought they were also independent at the facility. The report documented the care plan was reviewed and updated, the current plan of care would continue, and interventions would be implemented as indicated. In an interview on 04/12/2024 at 2:56 PM, Staff G, Nursing Assistant Registered, stated residents that were at risk for falls had a laminated star sign that was placed on their door and that was how they were aware of a resident's fall risk. Other residents might have a sign in their bathroom that instructed staff to not leave a resident unattended in the bathroom. They stated they had access to each resident's care plan, and there might be communication on the board in the breakroom if there were changes for a resident. Staff G stated they remembered Resident 36 and believed most of their falls occurred on the evening shift. Staff G stated they did not remember being told to do anything different after Resident 36 kept falling, they just remembered the resident being forgetful and thinking they were able to do more than they were capable of. In an interview on 04/12/2023 at 3:35PM, Staff B stated care plans were usually reviewed the next day after a resident fell, but they had five days to do so. Staff B stated Resident 36 had initially been doing well working with therapy, but when discussions about discharge started it seemed that was when the resident began falling and did not use their call bell. The resident's care plan was updated on 11/30/2023, to include 1:1 activities in their room to distract them from falling. Staff B stated they had not been notified that Resident 36 had increased pain and that the resident had told staff they thought they broke their hip after the 11/22/2023 fall. Staff B expected staff to notify them when any resident had increased pain after a fall. Staff B stated they did not consider the incident when the resident heard a pop on 12/12/2023 a fall; the resident repositioned themselves in their bed, their legs came off the bed and they heard a pop. When asked if the resident's care planned interventions were reassessed after Resident 36's falls, Staff B stated there would not be documentation showing care plan interventions were reassessed. <Resident 33> According to the 10/25/2023 quarterly assessment, Resident 33 had diagnoses including cervical spinal stenosis (narrowing of the spinal canal in the neck that may cause pain, tingling, numbness, and muscle weakness below the area of narrowing), and dementia (loss of thinking, remembering, and reasoning that interferes with a person's daily life and activities). Resident 33 had a range of motion impairment to bilateral upper extremities and required moderate assistance of staff for bed mobility. The assessment further showed Resident 33 had a memory problem but was able to verbalize their needs. Review of the October 2023 through April 2024 facility incident log showed a 11/15/2023 fall entry for Resident 33 with the injury listed as a fracture. Review of Resident 33's nursing progress notes showed: - 11/01/2023 at 3:08 PM, Resident 33 had slight to moderate range of motion limitation in their elbows and moderate range of motion limitations in their shoulders. Resident 33 required extensive verbal/visual cueing and prompting to stay on task. - 11/11/2023 at 10:40 AM, Resident 33 showed increased confusion, accusatory and paranoid behaviors towards staff. Staff would obtain a urine sample to determine the root cause of the behaviors. - 11/13/2023 at 8:45 AM, Resident 33 showed unusual paranoid and suspicious behaviors times two. A urine sample was collected that morning and was negative for a bladder infection. Staff would continue to monitor behaviors and implement interventions as indicated. - 11/15/2023 at 10:25 PM, yelling was heard from Resident 33's room. Resident 33 was found on the floor next to their bed and complained of right hip pain. Resident 33 was assisted to their bed with use of the Hoyer mechanical lift (machine that allows a person to be lifted and transferred with minimal physical effort). Resident 33 continued to complain of right hip pain and was unable to straighten out their right leg due to pain. Resident 33 was then transported to the hospital for further evaluation. - 11/16/2023 at 2:28 AM, a call was received from the hospital which stated Resident 33 had a right hip fracture and required surgery. There were no nursing progress notes or other monitoring documentation found for Resident 33 between 11/13/2023 8:45 AM and 11/15/2023 10:25 PM. Review of the 11/15/2023 facility fall incident report showed Resident 33 had an unwitnessed fall out of bed at 10:35 PM. Resident 33 was found on the floor and complained of right hip pain, no lower extremity inward or outward rotation was noted at that time. Staff transferred Resident 33 back to bed using a Hoyer lift and reassessed them for injuries, Resident 33 was now unable to straighten their right leg due to hip pain and winced in pain if their right hip was touched or right leg was repositioned. Resident 33 was then sent to the hospital for further evaluation and was found to have a right hip fracture. The facility incident report contained no resident or staff interviews. The investigation showed Resident 33 had their call light within reach, but it had not been activated and was last seen by staff at 9:30 PM (one hour and five minutes prior to their fall). The incident report summary showed the fall appeared to be an isolated incident, and staff were educated on positioning residents in bed, completing a post fall assessment and showed the care plan had been updated. Review of Resident 33's care plan, dated 10/30/2017, showed they required maximal assistance of one staff member for bed mobility. A behavioral care plan initiated 10/31/2017 identified Resident 33 had occasional delusions with an intervention for staff to monitor behavioral episodes and attempt to determine the underlying cause. The 10/31/2017 behavioral care plan did not show any new behavioral interventions were added for Resident 33's increased confusion, paranoia, suspicious or accusatory behaviors which occurred November 2023. The Dementia care plan further showed Resident 33 had cognitive loss, short term memory issues, confusion, and was disoriented at times. A pain care plan initiated 10/30/2017 showed Resident 33 had limited range of motion to their right arm and an artificial elbow joint with an intervention for staff to monitor for increased risk for falls. The falls care plan initiated 10/31/2017 showed Resident 33 was at risk for falls related to confusion, deconditioning, and inability to walk with interventions for staff to anticipate the resident needs, ensure the call light was within reach, quarterly fall evaluations, and to follow the facility fall protocol. Review of the care plan showed no new fall interventions were added since October 2021. Review of a 11/16/2023 hospital progress note showed Resident 33 had advanced dementia and was essentially noncommunicative. The notes documented Resident 33 sustained a fall out of bed that resulted in right hip pain and imaging confirmed a right hip fracture. In an interview on 04/12/2024 at 3:35PM, Staff B reviewed Resident 33's care plan and acknowledged staff education was the only intervention completed for their unwitnessed fall that resulted in a right hip because Resident 33 already had several fall interventions in place prior to their fall on 11/15/2023. <Resident 31> Review of the admission assessment, dated 02/07/2024, showed Resident 31 admitted to the facility on [DATE] and required moderate up to maximal assistance for most activities of daily living including dressing, transfers, and toileting. The assessment showed Resident 31 had a history of falls prior to admission and sustained two or more falls since their admission to the facility. Resident 31 had moderate cognitive impairment but was able to make their needs known. Review of the 01/24/2024 Morse fall assessment identified Resident 31 as a high fall risk related to a history of falls, weakness, and overestimates/forgets limitations. Review of the 01/24/2024 baseline care plan showed Resident 31 was a high fall risk related to a history of fainting and falls, with interventions of a perimeter mattress and bed against the wall initiated. The baseline care plan further showed Resident 31 required moderate assistance of two staff for toileting and transfers. Review of the 01/25/2024 Staff D, Medical Doctor, progress note showed Resident 31 was hospitalized after they sustained a fall at home on [DATE] and was down about 24 hours. Review of the January 2024 through April 2024 facility incident log showed the following entries for Resident 31: - 01/28/2024 fall at 8:07 PM - 01/30/2024 fall at 5:00 AM - 01/31/2024 fall at 12:57 PM - 02/01/2024 fall at 2:45 PM - 02/03/2024 fall at 6:00 PM - 02/07/2024 fall at 4:30 AM - 02/16/2024 fall at 9:52 AM Resident 31 had seven falls listed on the incident log in 19 days. Review of January 2024 through April 2024 nursing progress notes showed Resident 31 was confused, forgetful and safety education was ineffective related to poor cognition: - 01/28/2024 at 7:40 PM, was found on the floor in front of their wheelchair when they attempted to self-transfer into bed. Resident 31 did not call for staff assistance. - 01/30/2024 at 7:48 AM, was found sitting on the floor undressed with a soiled brief rolled up under them. Resident 31 stated they needed to use the bathroom and had not activated their call light. - 01/31/2024 at 12:55 PM, sitting on the floor in the dining room. Fall unwitnessed by staff in the dining room. - 02/01/2024 at 3:45 PM, was found sitting on the floor in their room. - 02/03/2024 at 6:14 PM, Resident 31 self-propelled out of the dining room and fell in the hallway. Resident 31 stated they slipped out of their wheelchair. - 02/07/2024 at 5:18 AM, Resident 31 was found sitting on the floor leaning against their bed wrapped in blankets with wet clothing sitting next to them. Resident 31 stated they slid to the floor to remove their wet clothing. - 02/07/2024 at 1:32 PM, a nursing assistant observed resident slide to the floor from bed without hitting their head. - 02/09/2024 at 9:50 PM, was found sitting on the floor in the bathroom. Resident 31 stated they slid to the floor from their wheelchair. Staff educated not to leave resident unattended in the bathroom. - 02/14/2024 at 11:30 PM, found sitting on the floor with back against the bed. - 02/16/2024 at 9:43 AM, found sitting on floor next to wheelchair. Resident 31 stated they needed to use the bathroom. Resident 31 was found on the floor 10 different times in 19 days. Review of facility fall incident reports showed incident reports completed for seven of 10 falls: - 01/28/2024 at 8:07 PM, Resident 31 was found on floor with their back against wheelchair, attempted to self-transfer into bed. Memory deficit, confusion, gait imbalance, and impaired memory listed as predisposing factors. Was previously educated to not self-transfer. The call light was within reach but not activated. The care plan was updated to add frequent visual checks for safety. - 01/30/2024 at 5:00AM, Resident 31 was found on the floor with a soiled brief behind them and stated they needed to void. Confusion, impaired memory, incontinence, overestimation of physical abilities and only 1 wheelchair break locked was listed as predisposing factors. The care plan was updated to add nonskid socks while in bed. - 01/31/2024 at 12:57 PM, Resident 31 slid off their wheelchair onto the floor in the dining room. Noisy environment and impaired memory were listed as predisposing factors. Resident 31 thought their legs got tangled up which caused them to slide to the floor. Velcro was added to wheelchair cushion to keep it from sliding. - 02/01/2024 at 2:45 PM, Resident 31 was found sitting on the floor in their room and stated they slid down when they tried to reach for something. Confusion, impaired gait/memory, weakness/fainting were listed as predisposing factors. Falling star was placed outside of room to help staff identify as a high risk for falls. - 02/03/2024 at 6:00PM, Resident 31 slid out of their wheelchair and sustained a large abrasion to their back. The wheelchair was assessed. - 02/07/2024 at 4:30 AM, Resident 31 slid off the bed while it was in a low position, found wrapped in blankets and stated they wanted to take their wet clothes off. The call light was within reach but had not been activated. - 02/16/2024 at 9:52 AM, Resident 31 was found sitting on the floor next to their wheelchair and stated they needed to use the bathroom. The call light was within reach but had not been activated, neither wheelchair brake was locked, and the resident was barefoot. Review of Resident 31's care plan, dated 01/29/2024, showed they were a high fall risk related to poor balance, poor communication, poor comprehension, and unsteady gait. The facility identified seven non injury falls and implemented the following interventions: 01/29/2024- frequent visual checks, 01/30/2024- nonskid socks on while in bed, 01/31/2024- provide activities that promote exercise and strength, 02/12/2024- bring to nurses station for safety monitoring if up in wheelchair, 02/05/2024- pharmacy consult to evaluate medications, falling star placed outside of room to help staff identify hall fall risk, ensure call light is within reach when in room, proper footwear when up for the day and nonskid socks on when in bed as allowed. A 02/05/2024 intervention showed Resident 31 would sometimes sit or lay on the floor for comfort and instructed staff to allow them to stay on the floor if they were found sitting and appeared safe and uninjured. Review of Resident 31's nursing progress notes from January 2024 through April 2024 showed: - Resident 31 was very confused and is only oriented to self, has very poor safety awareness and has fallen here several times with no injuries. Resident will most likely continue to fall as they do not believe they have any mobility issues. - Resident 31 was very confused and needs monitoring, does not redirect well, does not use call light appropriately. - Resident 31 does not remember the redirection after just a few minutes, needs almost constant supervision, tries to transfer by self very quickly, education is not effective, and collapses to floor without warning during transfers. - Resident 31 was a fall risk and tried to self-transfer many times during a 24-hour period, does not participate well during transfers, loses concentration and folds to the floor during transfers. - Resident 31 was noncompliant/unable to understand the call light system. - Resident 31 was unable to use call light appropriately, attempts to self-transfer and ends up sitting on the floor. - Resident 31 overestimating their abilities and has poor balance resulting in high fall risk, with several falls since admit. In an interview on 04/11/2024 at 8:40 AM, Staff B, Director of Nursing acknowledged there were no fall incident reports for Resident 31 for the 02/09/204 or 02/14/2024 falls. In an interview on 04/11/2024 at 11:43 AM, Staff C, Licensed Practical Nurse, stated a fall occurred when there a resident had a change in plane (change in position resulting in coming to rest on the ground or at a lower level) and a fall packet should be filled out. Staff C further stated that a new intervention should be implemented, and care planned right after a fall occurred because the same incident could reoccur if a new intervention was not added. In a follow up interview on 04/11/2024 at 12:10 PM, Staff B, stated any change in plane was considered a fall and they expected staff to complete a fall packet each time that occurred. Staff B further stated they expected staff to implement a new fall safety intervention as soon as possible after a fall. Reference WAC 388-97-1060 (3)(g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record reviewthe facility failed to provide cueing and meal assistance, monitor for significant weight loss, and risk of skin integrity for nutrition for 1 of 1 sampled residents (29). The resident experienced harm when they had an unplanned severe weight loss, nutritional decline, and breakdown of skin integrity with wound development. This failure placed other residents at risk for unplanned weight loss, medical complications, and unmet care needs. Findings icluded . <Resident 29> Review of the 03/25/2024 significant change assessment, showed Resident 29 had diagnoses which included stroke, anemia, and ataxia (impaired coordination). The assessment also documented Resident 29 had moderate cognitive impairments, required partial to moderate assistance from staff with eating, had experienced significant weight loss, and was at risk for developing pressure ulcers. Review of skin care plan, the 01/25/2024, showed Resident 29 was at risk for skin breakdown related to incontinence, and low body weight. The care plan documented on 03/10/2024, the resident had suspected deep tissue injuries (SDTI, purple or maroon localized areas of discolored intact skin or a blood-filled blister caused from pressure) to the coccyx, and moisture associated skin damage (MASD, inflammation or skin erosion caused by prolonged exposure to moisture such as urine or stool). An air mattress was added as an intervention on 03/11/2024. Review of nutrition care plan, dated 01/11/2024, showed Resident 29 was a nutritional risk and the interventions instructed nursing staff to give a substitute meal or a supplemental drink if less than 50% of meal consumed. Review of the nutrition/hydration review, dated 03/13/2024, documented Resident 29 had two SDTI's on their coccyx (tailbone) and that an air mattress had been added. Resident 29 was consuming 45 percent (%) of their meals and the cause of the pressure ulcers was decreased nutritional intake and decreased mobility. Resident 29's weight was 97.8 pounds (lbs.) on 02/13/2024 and on 03/06/2024 89lbs, a 9.0 % loss. No additional nutritional interventions were implemented. The weekly skin evaluation on 03/19/2024 documented the area to Resident 29's tailbone was changed from SDTI's to MASD. A review of the weight record for Resident 29 documented the following: 01/07/2024 102lbs. 01/11/2024 95lbs. 02/13/2024 89lbs. 12.75% loss in one month 03/05/2024 90.5lbs. 11.2% loss in two months 04/02/2024 88.5lbs. 13.2% loss in three months Review of Resident 29's medical record found no nutritional interventions had been implemented for the significant weight loss until 04/09/2024. On that date a liquid supplement was added to be given twice daily. During an observation of the wound on 04/09/2024, with Staff K and Staff L, Nursing Assistant, Staff K stated Resident 29 had a stage III pressure ulcer (an ulcer that extends through the skin into deeper tissue and fat, but does not reach the muscle, tendons, or bone). The pressure ulcer contained slough and was approximately the size of a pea, the surrounding tissue was red and blanched. During an observation of a meal service on 04/10/2024 showed the following: 12:29 PM, Resident 29 attempted to take a bite of their food with their fork and was unable to do so independently. The resident attempted to use spoon and fork and was unable to get the food onto their utensils. There were two aides at this table assisting residents to eat their meal. This table was used for residents who needed assistance with their meals. 12:32, the resident had taken a bite of their beets and was now trying to use a butter knife to eat with. 12:36 PM, the resident was unable to take a bite of their food and attempted to use the butter knife again. Resident 29 put the knife down and ate a piece of meat with their fingers. 12:39 PM, The resident was able to take a bite of rice with their fork. When the resident attempted to take a bite of their egg roll, they were unable to and began eating bites of broccoli with their fork. 12:42 PM, the resident attempted to cut up their egg roll with a spoon. 12:47 PM, the resident picked up their egg roll and put it down. The resident was not cued or assisted during the meal service. 12:54 PM, Resident's spouse gave them a bite of their egg roll, 25 minutes after the meal had begun. Resident 29 ate approximately 40% of their food and was not cued or helped during the meal service and was not provided a liquid supplement as instructed on their tray card. During an observation of the breakfast meal on 04/11/2024 showed the following: 7:59 AM, Resident 29 was in the dining room and had toast, eggs, fruit juice and water. Resident 29 consumed bites of their toast. 8:02 AM, Resident 29 attempted to take a bite of their eggs with their fork and dropped the fork on the table, picked up the fork and attempted to get a bite and was unsuccessful. 8:05 AM, Resident 29 continued trying to use their fork for their eggs and decided to take a bite of toast instead. 8:08 AM, Resident 29 tried to use their fork again and put it down and drank some juice. 8:16 AM, Resident 29 was able to take some bites of their eggs. The resident then decided to use their spoon for their eggs and was unable to. Resident 29 consumed a piece of toast, half of their eggs and three quarters of a cup of their juice. Resident 29 was not cued or helped during the meal service. In an interview on 04/12/2024 at 8:40 AM, Staff L stated they reported to the nurse if the resident did not consume any of their meal or supplement, otherwise the nurse could look at the meal intake that was charted. Staff L stated if a resident had poor intake an alternate meal or supplement would have been offered. Staff L added that Resident 29 required supervision and cueing with their meals as they were confused and became distracted with their utensils. In an interview on 04/12/2024 at 9:10 AM, Staff B, Director of Nursing, stated Resident 29 was underweight upon admission to the facility, and had been doing well until they had a stroke, and now required more assistance. Staff B stated the initial assessment showed the wound was MASD but has developed into a pressure ulcer. In an interview on 04/12/2024 at 12:34 PM, Staff O, Speech Therapist, stated Resident was confused and would benefit from cueing and supervision with meals. In an interview on 04/12/2024 at 12:57 PM, Staff M, Registered Dietician, stated once a resident had poor intake or weight loss, nutritional interventions would be added to increase the resident's protein. After discussion of Resident 29's pressure ulcer and weight loss, Staff M stated the resident's weight was significantly down on 03/05/2024, and it would have been helpful to have added protein. In an interview on 04/12/2024 at 2:15 PM, Staff B stated when a resident had significant weight loss or wounds, the Registered Dietician (RD) is notified via email. Staff B stated the RD had access to place orders into the system and can do so at any time. Staff B stated the expectation was for interventions to be placed the same week that a change had occurred. Staff B added that Resident 29 was in the hospital from [DATE] through 03/19/2024 and it would have been helpful for the supplement to have been initiated earlier to assist with weight loss and skin breakdown. Staff B stated nursing was also able to initiate a supplement and did not have to wait for the RD to do so. Reference: WAC 388-97-1060(3)(h).