**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident was free from neglect for 1 of 3 residents (Resident 1), reviewed for neglect, when they failed to perform consistent skin assessments as ordered and failed to obtain and implement wound treatment orders when Resident 1 developed a new skin concern. Resident 1 experienced harm when they developed a necrotic (death of tissue) area to the right foot and fifth (little) toe which required hospitalization and surgical intervention of a partial amputation of the right foot (side of foot) including the little toe. Findings included . Review of the facility's policy dated 08/2024, titled, Abuse -screening, training, identification, investigation, reporting and protection, showed the definition for neglect is the failure to provide goods or services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of the Nursing Home Guidelines, The Purple Book, dated October 2015, showed neglect may result from an inaction by an individual or entity with a duty of care for nursing home residents, including the failure to provide goods and services necessary to avoid physical harm. Review of the facility's policy, dated 09/2020, titled, Skin at Risk/Skin Breakdown showed a full body skin evaluation was completed weekly by the licensed nurse. Completion of the skin audit was to be documented. Review of Lippincott Manual of Nursing Practice, Eleventh Edition, showed signs of necrotic tissue in wounds clinically manifest with increased pain, redness, swelling, and warmth to the area, development of bullae (fluid filled sac or lesion), drainage and foul odor. <Resident 1> Review of Resident 1's medical record showed the resident was admitted to the facility on [DATE] with diagnoses to include a fractured right hip, right side hemiplegia/hemiparesis (partial and complete loss of strength to one side of the body) and need for assistance with personal care. Review of the resident's comprehensive assessment dated [DATE] showed the resident's cognition was severely impaired. Review of Resident 1's physician's orders showed the resident had an order dated 09/13/2024, for weekly skin checks every day on Fridays. Review of a nursing progress note, dated 11/07/2024, showed the resident had two new lesions to the outside of the right foot which involved the little toe. Review of a Wound Consultant progress note, dated 11/21/2024, showed wound had closed but remained high risk with direction for nursing to continue the daily wound dressing for extra protection. Review of the nursing progress note, dated 01/19/2025 at 3:30 PM, showed Staff E, Licensed Practical Nurse (LPN), was notified by Staff J, Restorative Assistant (RA), of Resident 1's right foot having a strong, foul odor. Staff E assessed Resident 1's outer right foot to have loose and removed skin, black colored tissue in the wound bed, the little toe (closest to the wound) was dark in color, and the wound had a foul odor. Staff E transferred Resident 1 to a local hospital for evaluation and treatment. During an interview, on 01/22/2025 at 3:04 PM, Staff D, Resident Care Manager (RCM), stated they completed weekly skin assessments on the residents, and the last time they assessed Resident 1's right foot was on 01/05/2025 (14 days prior to significant change). Staff D stated Resident 1 had a callous (a hard, thickened area on skin) to the outer portion of their right foot near the little toe and the surrounding skin was intact. Staff D stated the floor nurses were responsible for completing weekly skin assessments on the residents, and that they tried to routinely monitor pressure wounds and surgical incisions. During an interview on 01/22/2025 at 4:58 PM, Staff O, LPN, stated they worked with Resident 1 on 01/14/2025 and completed the dressing change to their outer right foot. Staff O stated they noted a small open area that was bleeding but the area looked at its baseline otherwise. Staff O stated they did not notify anyone or document the change in skin integrity. During an interview, on 01/22/2025 at 2:30 PM, Staff E, LPN, stated the last time they assessed Resident 1's right foot wounds was on 01/11/2025 (eight days prior to significant change), the area was at baseline with no open areas, and a protective dressing was applied as ordered. Staff E stated when they worked with Resident 1 on 01/15/2025, Resident 1 had refused the dressing change to their right foot due to significant pain and discomfort to the right foot. During an interview, on 01/23/2025 at 12:27 PM, Staff L, Nursing Assistant (NA), stated they worked with Resident 1 on 01/17/2025 and noticed when they assisted the resident to get dressed, the resident's right foot had re-opened. Staff L stated the right foot was swollen, red and warm and they notified Staff F who applied a new dressing. During an interview, on 01/22/2025 at 1:46 PM, Staff F, LPN, stated they worked with Resident 1 on 01/17/2025 and completed the dressing change to their outer right foot. Staff F stated they observed dried serosanguinous [contains both blood and serum (the liquid part of blood)] fluid on the old dressing and a small slit where the drainage was coming from. Staff F stated resident weekly skin assessments were completed by the RCMs. During an interview, on 01/23/2025 at 10:47 AM, Staff H, LPN, stated they usually worked double shifts (two consecutive shifts to equal 16 hours) on the weekends, and they worked with Resident 1 on 01/18/2025 during the day shift (6:00 AM to 2:00 PM). Staff H stated they passed medications for the assigned hall, and did not complete any treatments or dressing changes. Staff H stated the treatments were completed Monday through Friday as they did not have a treatment nurse on the weekends. Staff H stated Resident 1 had a dressing to their right foot, but they never saw the wound. Staff H stated they recalled Resident 1 complained of pain to their right foot during the shift, and the NAs repositioned the resident frequently to keep them comfortable. During an interview, on 01/22/2025 at 2:16 PM, Staff J, RA, stated they worked with Resident 1 on 01/19/2025, after breakfast in their room. Staff J stated Resident 1's right foot did not have a dressing or a sock on it and they observed a bad sore on the outer part of the foot. Staff J stated the wound was on the outer part of the right foot, including the little toe, was dark in color, and there was a foul odor coming from it. Staff J stated they reported it to Staff E. During an interview, on 01/22/2025 at 12:47 PM, a Collateral Contact (CC) at the local hospital stated they had received Resident 1 from the facility, but they had transferred Resident 1 to a hospital in Seattle for further evaluation and treatment by a Podiatrist (medical specialist who help with problems that affect the feet and lower legs). The CC stated the local hospital physician was concerned about potential osteomyelitis (a bone infection that causes inflammation and swelling in the bone) in Resident 1's right foot. During an interview, on 01/23/2025 at 12:57 PM, Staff C, Assistant Director of Nursing (ADNS), stated their investigation regarding the change in condition to Resident 1's right foot showed Staff F assessed the wound on 01/17/2025 to be open, macerated (a breaking down of the skin resulting from prolonged exposure to moisture), and had a piece of loose skin. Staff C stated it did not appear Staff F documented the change to Resident 1's right foot wound nor notify the physician. During an interview, on 01/23/2025 at 4:19 PM, Staff A, Administrator, and Staff B, Regional Nurse, stated that there is indeed a deficiency in the assessment of the resident. During an interview on 01/27/2025 at 10:16 AM, Resident 1's RR, stated Resident 1 was in the hospital and had a partial amputation of their right foot on 01/25/2025. Reference: WAC 388-97-0640(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents received physician ordered medication, had necessary laboratory values (labs) drawn as ordered, and received timely treatment for abnormal labs for 4 of 4 residents (Residents 1, 2, 3, and 5) reviewed for quality of care. This failed practice resulted in harm for Residents 1 and 2 when their treatment was delayed, conditions worsened, and required hospitalization. Residents 3 and 5 were at risk for their condition to worsen and experience inaccurate or a delay in treatment. Findings included . <Resident 1> Review of the resident's medical record showed the resident admitted to the facility on [DATE] with diagnoses to include removal of the left leg below the knee and kidney failure. The 04/19/2024 comprehensive assessment, showed the resident's cognition was intact and required one staff assistance for bed mobility and transfers. Review of Resident 1's 04/12/2024 hospital notes, showed the resident was admitted to the hospital, from the facility, for diagnoses to include hyponatremia (decreased level of sodium [salt] in the blood) and an infected abscess (a painful lump filled with pus that can form anywhere on your body due to an infection or injury) to the left buttock. The discharge notes on 04/18/2024 showed the resident was to have weekly blood draws completed to monitor the hyponatremia and the infection, the first one to be drawn on 04/25/2024. Review of Resident 1's April 2024 Medication Administration Record (MAR) showed orders as follows: • 04/18/2024, obtain weekly labs. Scheduled to be drawn every Thursday morning, first one scheduled for 04/25/2024. The box on the 25th was documented with a 5 (a five means see progress notes, progress notes on 04/25/2024 showed need supplies). • 04/19/2024, obtain weekly labs. Scheduled to be drawn every seven days, first one scheduled for 04/24/2024. The box on the 24th was blank. (No nursing note to show why the lab had not been obtained). • 04/24/2024, obtain a Basic Metabolic Panel ([BMP], a blood test that measures eight different substances in your blood [sodium is one of them]). Scheduled to be drawn on 04/27/2024. Lab was drawn. (sodium lab value was low and no documentation to show notification to the provider). • 05/02/2024, obtain labs on 05/03/2024. Lab was drawn. (no documented notification to the provider for the low sodium level). • 05/02/2024, Sugar free Gatorade at bedside every shift for hyponatremia (ordered for the low sodium level from 04/27/2024, five days after lab drawn, when provider reviewed abnormal lab results on rounds 05/01/2024). • 05/06/2024, Sodium Chloride (a fluid that provides sodium replacement), given intravenously ([IV], administered through the veins) for hyponatremia. Review of Resident 1's completed sodium lab draws showed on 04/27/2024 sodium result was 126 milli-equivalents per liter ([mEq/L, a unit of measure], a normal sodium result is 136-145 mEq/L), on 05/03/2024 sodium result was 122 mEq/L, and on 05/07/2024 sodium result was critical at 117 mEq/L. Review of Nursing progress notes showed as follows: • 04/28/2024 at 6:33 AM (one day after labs obtained on 04/27/2024), lab will fax BMP results. (no further notes to show the labs were received or provider was notified, sodium was low at 126 mEq/L). • 05/06/2024 at 10:21 PM, provider called facility after review of 05/03/2024 low sodium level and ordered IV hydration and a follow up BMP lab in the AM. (the orders showed no order had been processed for the BMP lab in the AM on 05/07/2024). • 05/07/2024 at 3:24 PM, resident was observed to be lethargic and pale, called provider, since labs had not been drawn in the AM as ordered, the provider added additional labs. Labs sent to lab at 3:15 PM. • 05/07/2024 at 4:39 PM, lab called facility with critically low sodium results and provider gave an order to send resident to the hospital. • 05/07/2024 at 8:21 PM, call placed to hospital and Resident 1 had been admitted for hyponatremia and would require replacement therapy. During an interview on 05/17/2024 at 1:39 PM, Staff K, Licensed Practical Nurse, stated their process for lab draws were to draw the blood, drive the labs to the hospital to be processed, review the results when they returned to the facility, and update the provider with any abnormal lab values. Additionally, on 05/21/2024 at 12:54 PM, Staff K stated I do not know for sure if the labs ordered on 04/25/2024 were obtained because they needed additional blood drawing supplies from the lab. Staff K assumed the evening nurse would have obtained the supplies and completed the blood draw if it had not been completed prior to their shift ending. Further, Staff K stated they did not recall why the BMP lab was not obtained until late evening on 05/07/2024 and verified there was no lab order for the morning of 05/07/2024. During an interview on 05/20/2024 at 3:25 PM, Staff Q, Resident Care Manager (RCM), stated they did not process the order for Gatorade (a brand of drink used to replace fluids and minerals such as sodium in the body) that was given on 05/01/2024 until the following day on 05/02/2024 when they reviewed the provider's notes. Additionally, Staff Q stated they did not recall why they did not obtain the labs on 04/24/2024 and usually would keep notes as to why something was not done during their shift but could not find any. Staff Q could not recall why the labs on 04/27/2024 were not followed up on. Staff Q did not receive or review the labs obtained on 05/03/2024 and on 05/04/2024 they called the provider with the lab results for the infection but not for the abnormal sodium level. During an interview on 05/16/2024 at 2:38 PM, Staff E, Advanced Registered Nurse Practitioner, stated they would expect nursing to call them for any abnormal lab results. Staff E further stated they received the results as well but did not prioritize reviewing them because they presumed if they were abnormal, the facility would have called. Staff E stated the low sodium lab result for Resident 1 on 04/27/2024 was not called to them and did not review them until their visit with Resident 1 on 05/01/2024 (four days after labs were obtained). Staff E gave new orders to start Pedialyte (a brand of drink used to replace fluids and minerals such as sodium in the body) for oral rehydration and gave the okay to use Gatorade if Pedialyte was unavailable, I can see that didn't happen. Staff E stated follow-up labs were drawn on 05/03/2024 and they did not receive any calls or results until they reviewed the labs themselves late in the evening on 05/06/2024 when the sodium level had dropped to 122 mEq/L. Staff E stated they called the facility on 05/06/2024 in the evening, and gave orders to start IV hydration and repeat labs on 05/07/2024 in the AM. The provider further stated they were not aware the follow up sodium lab had not been drawn until the evening of 05/07/2024, when they received the call that the resident had become lethargic and pale. Additionally, the provider stated the hydration with the drink and IV solution would have presumably corrected the hyponatremia had they been given timely and as ordered. <Resident 2> Review of the resident's medical records showed the resident admitted to the facility on [DATE] with diagnoses to include asthma (a lung disorder characterized by narrowing of the airways, the tubes which carry air into the lungs, that are inflamed and constricted, causing shortness of breath, wheezing and cough) and low blood pressure. The 04/29/2024 admission assessment showed the resident's cognition was intact and required one to two staff assistance for bed mobility and transfers. Review of Resident 2's 04/30/2024 hospital notes, showed the resident experienced a fever and productive cough at the facility and was sent to the hospital to be evaluated, one day after admission. Resident 2 was diagnosed with an infection in their urine, ([bacteremia], the presence of bacteria in your blood, which can be serious and require antibiotics), and pneumonia (an infection that inflames the air sacs in one or both lungs, causing cough, fever, chills, and difficulty breathing). Upon discharge from the hospital on [DATE], the resident was ordered Fluconazole (a brand of antifungal medication) for the pneumonia (next dose on 05/04/2024) daily for seven days and Vancomycin (a brand of antibiotic) IV antibiotics to be given every 12 hours for 11 days (22 doses) for the bacteremia. Review of Resident 2's May 2024 MAR, showed an order for Fluconazole 100 milligrams daily by mouth to start on 05/04/2024. The MAR showed the Fluconazole had not been given on 05/04/2024, 05/05/2024, and 05/06/2024. Three doses were missed. Additionally, the MAR showed an order for Vancomycin IV antibiotics to be given every 12 hours to start on 05/03/2024 in the evening, with no duration noted. Review of Nursing progress notes showed as follows: • 05/04/2024 at 2:20 PM, and 05/05/2024 at 3:23 PM, Fluconazole had not arrived from pharmacy. Resident 2 experienced trouble breathing at rest and had labored breathing. No oxygen required. • 05/06/2024 at 10:00 AM, Fluconazole was on order, at 12:54 PM, no oxygen was required, and lung sounds clear. • 05/07/2024 at 12:40 PM, continuous oxygen required, no breathing issues, and lungs sound clear. First dose of Fluconazole given. • 05/08/2024 at 9:30 AM, Staff H, LPN, documented, Resident 1 does not look well, they were pale, had chills, heart rate at 110 (normal heart rate at rest is 60-100) and respirations at 32 (normal is 12-20). Received orders to send resident out to hospital. Review of the 05/08/2024 hospital admission records, showed the resident had diagnoses of pleural effusions (an excessive collection of fluid in the pleural cavity, the fluid-filled space that surrounds the lungs) and worsening fungal pneumonia (a lung infection caused by fungal spores. It occurs when these spores mix with the air and are inhaled, or when an inactive infection is reactivated). Additionally, the hospital documented Resident 2 had received treatment with Fluconazole since discharged back to the facility on [DATE]. (Resident only received two of the five doses that should have been received). Upon discharge on [DATE], Resident 2 was to continue the IV Vancomycin that was ordered on 05/03/2024. During an interview on 05/17/2024 at 1:39 PM, Staff K stated their process for receiving new medications from the pharmacy would be to input the orders, the orders then go directly to the pharmacy once inputted, and if it was not too late in the day, they would come in that evening or the next day. Staff K stated if the medication did not come in, they would call the pharmacy and they would let them know if the medication was on back order. Staff K stated they would normally call the provider and request a different medication that was available or ask if it was okay to wait to give the medication until it was delivered from the pharmacy. Staff K stated they did not recall why the Fluconazole did not come in until three days later, and they did not recall notifying the provider. During an interview on 05/17/2024 at 12:33 PM, Staff E stated they were unaware Resident 2 had not received three of the four doses of Fluconazole prior to being sent to the hospital. Staff E presumed if all doses had been given as ordered the infection may not have worsened. Staff E stated the hospital should have been made aware of the missing doses upon transfer, this could have changed Resident 2's treatment plan during their hospital stay, but considering the hospital's documentation, that was not done. Staff E further stated Vancomycin should have been continued to complete the 11 days (22 doses) that was ordered. Staff E was informed at that time that only 15 doses of the 22 doses had been administered and stated, that would be a perfect reason why Resident 2 is running fevers. Staff E further stated their expectation was for staff to report timely lab results and administer medications as ordered. <Resident 3> Review of the resident's medical record showed the resident was admitted to the facility on [DATE] with diagnoses including hypothyroidism (the thyroid gland cannot make enough thyroid hormone to keep the body running normally) and end stage renal disease (kidney function has declined to the point that the kidneys can no longer function on their own). The comprehensive assessment dated [DATE] showed the resident had moderately impaired cognition and required assistance of one-two staff members for activities of daily living (ADLs). Record review of a nursing progress note dated 05/13/2024, showed Staff B, was advised by Staff E to send Resident 3 to the hospital for evaluation of a thyroid crisis (when the thyroid gland releases a large amount of thyroid hormone in a short amount of time) after Staff E had reviewed the critical thyroid stimulating hormone (TSH) lab results obtained on 05/10/2024. The lab results showed an elevated TSH level at 45.5 milli-international units per liter ([mIU/L], a unit of measure) (normal range is 0.5-5.0 mlU/L). Record review of the hospital discharge instructions dated, 05/13/2024, showed Resident 3 had been discharged back to the facility with new orders to change Levothyroxine (a brand of medication used to treat hypothyroidism) from 88 micrograms ([mcg], unit of measure) every morning to 122 mcg every morning. Record review of the May 2024 progress notes showed no documentation of the discharge instructions, or the dose change on the Levothyroxine order from the hospital visit on 05/13/2024. Record review of Resident 3's May 2024 MAR showed Levothyroxine 122 mcg was not started until 05/17/2024 (four days after the medication change was ordered). During an interview on 05/17/2024 at 12:34 PM, Staff E stated they did not receive any notification from the facility of a critical lab value for Resident 3 on 05/10/2024. Staff E stated they noted the lab in the office on 05/13/2024 and immediately called the facility for a transport out to the hospital for evaluation of a thyroid crisis. Staff E further stated their expectation was for staff to update them with any critical lab values as soon as they received them. During an interview on 05/17/2024 at 3:08 PM, Staff B stated the TSH lab for Resident 3 was drawn on 05/09/2024 and was not called into Staff E when the critical results came back on 05/10/2024. Staff B stated their expectation was for staff to immediately notify the provider with critical labs/change in conditions and document in the resident's medical record. Staff B stated when a resident returned from the hospital it was the Resident Care Managers (RCM) responsibility to review hospital discharge instructions if they were in the building. Additionally, Staff B stated if the RCMs were gone during the time of readmission, it would be the responsibility of the nurse on the floor to review for any changes, that did not get done. Staff B further stated staff did not follow the correct process for resident 3. <Resident 5> Review of the resident's medical records showed the resident admitted to the facility on [DATE] with diagnoses to include atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to stroke, heart failure and other complications) and a fracture of the right leg. The 05/03/2024 comprehensive assessment, showed the resident had severe cognitive impairment and required assistance of two staff with bed mobility, toileting, and transfers. The assessment further showed the resident received Coumadin, an anticoagulant (a high-risk medication that prevents or breaks down blood clots). Review of the resident's 05/15/2024 hospital discharge summary, showed the resident was sent to the hospital due to an unwitnessed fall out of their bed. During the hospital visit, Resident 5 was found to have an elevated international normalized ratio ([INR], a test that measures how long it takes for your blood to clot and monitor if the anticoagulant was working], when elevated, it indicates that your blood is taking longer to clot and there is an increased risk of bleeding). Review of Nursing progress notes specific to the Coumadin orders, showed on 04/30/2024 at 11:27 AM, the order was to give Coumadin 2.5 mg every evening and recheck INR on 05/03/2024 (should have received Coumadin on 04/30/2024, 05/01/2024, and 05/02/2024). A note on 05/03/2024 at 11:57 AM showed, hold the Coumadin for two days (hold on 05/03/2024, and 05/04/2024, and resume 2.5mg ([mg] a unit of measure) on 05/05/2024) and recheck INR on 05/06/2024. Review of Resident 5's April 2024 through May 2024 MARs, showed no Coumadin was administered on 05/02/2024, 05/03/2024, 05/04/2024, and 05/05/2024. The MAR further showed there were no Coumadin orders entered for 05/03/2024. During an interview on 05/21/2024 at 12:54 PM, Staff K stated their process was to draw the INR's the morning they were due, call the provider with the results, and obtain new orders. The provider's order would be documented under the nursing progress notes titled Coumadin note. Staff K verified they obtained the Coumadin orders on 04/30/2024 and 05/03/2024 and processed them. When Staff K was questioned about the accuracy of the orders, Staff K reviewed the order from 04/30/2024 and confirmed they had entered the order incorrectly and Resident 5 should have had a dose of Coumadin on 05/02/2023. Staff K continued to review the order for the 05/03/2024 INR and confirmed they did not process an order for Coumadin, and they should have, causing the resident to miss a 2.5 mg dose that should have been given on 05/05/2024. Staff K further stated the INR results were accurate but the information the provider was given from previous orders, for ordering the next dosing of Coumadin, would have been inaccurate. During an interview on 05/17/2024 at 3:10 PM, Staff B, Interim Director of Nursing Services (IDNS), stated their expectation would be for the nurses to give the medications as ordered and if that was not possible, they would expect the nurses to call the provider for additional directions. Staff B stated when medication orders were input into the system, they did not go directly to the pharmacy, the orders needed to be printed and faxed over to the pharmacy. Staff B stated they were unaware the nurses were not following the correct process. Additionally, Staff B would expect the nurses to process the orders correctly and right when they were received. Staff B further stated if the nurses had issues in obtaining medications timely, they would expect that communication from the nurses . Reference: WAC 388-97-1060(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to notify the provider (physician or nurse practitioner) following a resident's complaint of new onset chest pain for 1 of 2 residents (Resident 22) reviewed for change in condition. The failure to notify the provider in a timely manner resulted in harm to Resident 22 when they experienced distress, delay in treatment, and prolonged pain. Findings included . Review of the facility policy titled, Managing Acute Condition Change (MACC), revised on 02/2018, showed the Resident Care Manager (RCM) or charge nurse would assess the resident experiencing an acute change. The facility would notify the physician and family/responsible party without delay when a change in condition had been identified. <Resident 22> Review of the electronic medical records showed Resident 22 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation (an irregular and often very rapid heart rhythm) and a history of a heart attack. The 09/15/2023 comprehensive assessment showed the resident required extensive assistance of two staff members for transfers, dressing, and toileting. The assessment also showed the resident had an intact cognition. A concurrent observation and interview on 12/12/2023 at 9:44 AM, showed Resident 22 in their room, sitting hunched forward in their motorized wheelchair. Resident 22, with grimaced expression, complained of constant, stabbing chest pain that radiated to their right side, mid-back area. Resident 22 stated several years ago they experienced a heart attack that presented as pain in the right shoulder and was concerned that their current pain was a heart attack. They stated their pain started three to four days ago, but the pain during the previous night was excruciating. Resident 22 stated the pain was so intense during the night, that they put their call light on for help. A nurse answered the call light and looked at their back. Resident 22 stated the nurse told them there was a red spot on their back and it was probably from the belt that was used with the sit to stand mechanical lift (used for transfers). The night nurse put a pad over the red spot, but that did not help the pain. The resident stated they spoke to Staff H, Licensed Practical Nurse (LPN), that morning and was told the night nurse left a note for the Nurse Practitioner to see the resident the next day (12/13/2023). Resident 22, with tears in their eyes, stated they wanted to see a doctor right away because they suffered so much in bed that previous night but didn't want to go against what Staff H had told them. Resident 22 stated they requested pain medication during the night and again that morning but was told there was nothing else to give them, just their scheduled Tylenol (a medication used to treat minor aches and pains). During an interview on 12/12/2023 at 10:07 AM, Staff H stated Resident 22 had complained of pain that morning. They stated the night nurse felt it was from the sit to stand belt and put a dressing over a red spot on their back. Staff H stated they were monitoring Resident 22 and had put them on the schedule to see the Nurse Practitioner the following day - if the resident was still complaining of pain. Staff H stated the resident was not placed on alert charting and no vital signs (measurements of the body's most basic functions, including body temperature, blood pressure, respirations, and pulse) were obtained. Staff H stated the last blood pressure was taken on 12/10/2023. An observation on 12/12/2023 at 1:35 PM, showed Resident 22 in bed, lying on their back with a washcloth over their eyes. Resident 22 did not respond when spoken to. An observation on 12/13/2023 at 10:47 AM showed Resident 22 sleeping in bed, curled into the fetal position on their left side. Resident 22 did not respond when spoken to. During an interview on 12/14/2023 at 10:26 AM, Collateral Contact 1 (CC1), Nurse Practitioner (NP), stated the facility should have notified them on Tuesday (12/12/2023), when Resident 22 first complained of chest pain, especially with their history of a heart attack, I should have gotten a phone call. CC1 stated they were not notified of pain, just a request for nausea medication, and when they saw Resident 22, late afternoon of 12/13/2023, they had no complaints of nausea, but I absolutely should have been notified by phone regarding the chest pain. CC1 stated knowing now that Resident 22 had shingles, they would still have expected to be notified; the resident only had Tylenol for pain and the type of pain caused by shingles would not have been relieved by Tylenol. CC1 stated, had the facility notified them of the complaints of chest pain, the resident would have been seen at the emergency room and would have received treatment and pain management for the shingles. During an interview on 12/19/2023 at 12:10 PM, Resident 22's Representative, Collateral Contact 2 (CC2) stated they had received a text message from the resident stating they were having pain that felt like their heart attack in the past. CC2 stated it was more concerning that Resident 22 would state that, as it was usual for them to complain of that type of pain. Review of Resident 22's care plan, dated 09/28/2023, showed an intervention for pain as Anticipate the resident's need for pain relief and respond immediately to any complaint of pain, initiated on 06/14/2023. Review of the December 2023 Medication Administration Record (MAR), showed Resident 22 had an order for Tylenol 1000 milligrams (mg) three times a day, initiated on 11/06/2023. Additional review showed Resident 22 had new orders dated 12/14/2023 for Ibuprofen (an anti-inflammatory medication used to treat mild to severe pain) 400 mg twice a day as needed for five days, Lidocaine HCL External Gel 2% (a topical medication used to treat pain), apply to right upper back/chest topically as needed for shingles pain, may use twice a day. The MAR showed an order was placed on 12/15/2023 for Lidocaine External Patch 1.8% (a patch containing medication used to relieve the pain caused by shingles [a viral infection that causes a painful rash]). During a follow up interview on 12/19/2023 at 1:44 PM, Resident 22 stated I wasn't afraid to have a heart attack, I was afraid the staff wouldn't chase that (possibility that chest pain was a heart attack) .I wanted to be sure I wasn't having a heart attack. During an interview on 12/20/2023 at 4:03 PM, Staff B, Director of Nursing, stated that if a resident complained of excruciating pain, and the nurse felt an SBAR (a communication tool to provide prompt and appropriate communication to a provider) was needed for additional pain medications, there should have been a phone call to the provider at that time. Staff B further stated their expectation was to notify the provider with a change in a resident's condition. Reference: WAC 388-97-0320(1)(b)(c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure care and services that addressed skin infections and accurate blood pressure treatments were provided in accordance with professional standards of practice for 2 of 5 residents (Residents 44 and 13) reviewed for quality of care. This failure resulted in actual harm to Resident 44 when they experienced unnecessary pain, emotional distress and a decline in their medical condition, and caused unmet care needs and placed Resident 13 at risk for negative health outcomes. Findings included . <Resident 44> Review of the electronic medical records, showed Resident 44 was admitted to the facility on [DATE] with diagnoses including cellulitis (a bacterial infection of the deep layer of skin) of the right lower leg, lymphedema (swelling caused by a blockage of the drainage of lymph fluid) of the right and left lower legs, heart disease, obesity, and depression. Resident 44's most recent comprehensive assessment, dated 10/31/2023, showed they required extensive assistance of one to two caregivers for bed mobility, transfers, dressing and toileting and were cognitively intact. During an observation and interview with Resident 44 on 12/13/2023 at 11:08 AM, the resident showed their right leg to be significantly larger than their left leg. The right lower leg from the knee down was disfigured with red rough, dry, scaly skin and fluid was draining from many breaks in the skin. The top of the foot was covered with a gauze wrap bandage and the ankle area was dark brown in color with areas of thick hard lumps and multiple thick folds in the skin. Resident 44 stated the lymphedema had gotten worse in the right leg after the foot got a bad infection which required a hospitalization and intravenous antibiotics prior to coming to the facility. The resident stated, under the bandage on the top of the right foot, there were several large deep wounds from the cellulitis and the nurses were changing the dressing on it every day. During the same interview, Resident 44 stated they were being seen by a United Wound Healing (UWH) consultant physician assistant (PA-C) who was supposed to come that day to assess the wound and lymphedema but was told they were ill and would not be coming. Resident 44 stated they were worried that the right leg had yet to be wrapped with bandages for the lymphedema to help with the pain and swelling since they were admitted , and felt the right foot was getting much more swollen, hard, and painful every day. During an interview with Resident 44 on 12/19/2023 at 12:10 PM, they stated their right foot was bothering them because of the lymphedema pain and began crying. They stated their lower right foot and leg felt like a brick and they could hardly move the right foot because it was painful and heavy feeling. They stated it was getting more and more difficult to move and participate in therapies because of this. Resident 44 stated, I just don't understand why no one has done anything yet to decrease this fluid and swelling with lymphedema wraps. Resident 44 stated the wound consultant had told them they had ordered vascular studies, x-rays and blood work ups on their previous visits and needed the results of those before they could safely order the lymphedema wrap treatments. During an observation of a dressing change to the right foot with Staff K, Licensed Practical Nurse (LPN), on 12/19/2023 at 1:05 PM, showed the top of the right foot open in many areas with multiple stages of healing ranging in colors from red to yellow to black and covered the whole top of the foot. Staff K took off the old dressing, cleansed the wounds with saline spray, placed a Xeroform dressing (a petrolatum based fine mesh gauze that has antimicrobial properties) over the wounds, covered them with an absorbent dressing and a gauze wrap. Resident 44 questioned Staff K about the current treatment orders, stating the last nurse who changed the dressing told them they were just following what the treatment order was in November, because there were no current orders on the December Treatment Administration Record (TAR) sheets. Staff K responded, yes there is, it's still the every other day treatment with the xeroform dressing as before. Review of the December 2023 TAR for Resident #44 on 12/19/2023 at 2:00 PM showed there were no orders written for a dressing change to the right foot and lower leg for the licensed staff to follow. Review of the Physician Assistant Certified (PA-C) wound consultant's documentation on 12/20/23 at 2:30 PM, showed they first assessed the wounds on 10/31/2023 and were to assess and treat the wounds once a week after that until healed or the resident was discharged . Review of the PA-C's wound consultant's notes, dated 10/31/2023, showed Resident 44 had a history of lymphedema to both their legs since a motor vehicle accident many years ago with fractures and crushing injuries to the lower back and right lower extremity. The wound provider measured both the right and left lower legs which showed a significant increase in size to the right leg and found four areas of concern identifying them as wounds 1 through 4. Wound 1 was identified as lymphedema to the bilateral lower legs and described the lower right leg as swollen with the hard [NAME] raised areas and fissures (splits and cracks in the skin) seen with severe chronic lymphedema. Wound 2 was described as the right back to front of the foot and ankle, measured as 24 centimeters (cm) width by 16 cm length by 0.1 cm depth. The wound was described as full thickness involvement (damage extends below all layers of the skin into the subcutaneous tissue or beyond, (into the muscle, bone and tendons) with the wound base showing 51-75% slough (yellow/white material of dead tissue separating from living tissue) and 11-25% eschar (brown/black dry dead tissue within a wound). Wound 3 was described as the right lower leg, full thickness involvement, measured as 24 cm x 18 cm x 0.1 cm with the wound base as 26-50 % eschar and 26-50% epithelial (pink or pearly white healing skin tissue). Wound 4 was described as the right side of the foot, full thickness involvement, measured as 4 cm x 4 cm. x 0.1 cm with 51-75% slough and 11-25% eschar. On 10/31/2023, the consultant PA-C ordered the following for the facility to follow through with until their next weekly visit. * Baseline vascular studies for appropriate compression for central lymphatic dysfunction and bilateral lower leg lymphedema. Bilateral lower extremity (BLE) venous ultrasound and arterial ultrasound with ankle/brachial index (ABI) (analyzes the quality of blood flow in the ankle arteries). * Imaging CT scan (computed tomography scan) (an imaging test that helps detect diseases and injuries) CT anterior and posterior (A/P) vascular assessment/baseline for central lymphatic dysfunction/lymphedema (a CT scan with an injection of dye to produce pictures of blood vessels and tissues). * Treatment orders, cleanse wounds with wound cleaner, apply skin prep (a protective barrier to protect the skin from adhesive dressings) to the peri wound (the tissue surrounding a wound) and allow to dry, apply xeroform gauze to open areas, cover with super absorbent dressings, change the dressings every other day and as needed. * Pain control 30 minutes prior to wound treatment, please administer as needed (PRN) pain medication and/or topical anesthetic. * Apply lotion to all areas of dry skin. * Pressure relief, offloading repositioning per facility protocol. * Protein supplement with meals twice daily until wound closure. Review of physician visit notes, nursing progress notes, Medication Administration Records (MARs) and TARs from 10/31/2023 through 11/07/2023 showed no documentation that appointments were made for either ultrasound vascular studies or CT scan imaging for baseline studies as ordered by the PA-C contracted wound care consultant for appropriate compression of the lower extremity lymphedema. Resident 44's TAR's showed from 10/25/2023 through 10/30/2023 the facility nursing staff followed admission orders to clean the right lower leg blisters and open areas with normal saline, apply Xeroform over open wounds and cover with absorbent dressings and wrap with Kerlix (a gauze bandage roll) every day and as needed (PRN). These treatment orders continued from 10/31/2023 through 11/04/2023, though did not show to apply skin prep to the peri wound and did not change to every other day dressing changes from every day as ordered by the PA-C on 10/31/2023. Review of the PA-C wound consultant notes dated 11/07/2023, showed after assessing and treating the wounds the following were ordered for follow up by the facility staff. * To obtain an x-ray of the right foot to rule out concerns of osteomyelitis in the muscle/tendon level wound on the right foot. * Continue to pursue vascular studies for baseline evaluation to manage the bilateral lower extremity lymphedema. Review of the PA-C wound consultant notes dated 11/14/2023, showed after assessing and treating the wounds the following were ordered for follow up by the facility staff. * An X-ray of the right foot was done on 11/07/2023 and stated there was a non-specific notation about concerns of bone infection and it was negative for any fractures. The nursing staff were to contact radiology for an addendum to ensure there is no bony involvement. * Vascular studies, bilateral lower extremities venous ultrasound and arterial ultrasound with ABI's. * Imaging. CT scan A/P vascular assessment/ baseline for central lymphatic dysfunction/lymphedema. * More aggressive pain control routinely and topical (top of skin) and systemic (medication by mouth) pain control prior to dressing changes and UWH visits. Topical lidocaine 4% to the wound bed of right foot prior to dressing changes. Dressing treatment continues with every other day dressing changes and PRN. Review of Resident 44's physician visit notes, nursing progress notes, MAR's and TAR's from 11/07/2023 through 11/21/2023 showed no documentation that appointments were made on the third week request for ultrasound vascular studies and CT scan imaging for baseline studies as ordered by the PA-C wound consultant for appropriate compression of the lower extremity lymphedema. In addition, the review did not show that the nursing staff contacted the radiology department for an addendum to ensure osteomyelitis (infection of the bone) was found in the x-ray. Review of the November 2023 TAR's showed from 11/05/2023 through 11/28/2023 wound treatment orders remained the same as the previous orders. There were no orders written to apply the topical lidocaine 4% to the wound bed prior to dressing changes for pain relief, to apply skin prep to the peri wound and again did not change the dressing change order to every other day. Review of the PA-C wound consultant notes dated 11/21/2023, showed after assessing and treating the wounds, they found the wounds to be healing the past three weeks, but the resident was having increased pain during dressing changes. The following were ordered for follow up by the nursing staff. * Imaging x-ray right foot and inflammatory lab work up to rule out osteomyelitis. * Unknown if the CT scan has been obtained for medical necessity of lymphedema management. * Skin care treatment every day and as needed. Cleanse legs with warm water and mild soap. Massage a thin layer of A&D ointment (a Vaseline based ointment) to legs and non- covered areas on the feet. Ensure no moisture gets between the toe web spaces. After cleansing and drying the legs, apply a thick layer of unscented shaving foam to BLE. Soak with warm towels for 15/20 minutes. Wipe away the cream and scaling skin. Pat dry and complete wound treatment. * Systemic and local pain control (topical lidocaine 4% to wound bed right foot prior to dressing changes. Same treatment orders as previous every other day and as needed order. * Offloading with right foot footwear. * Consider a lower dose of systemic pain control prior to dressing changes and wound discomfort. Review of physician visit notes, nursing progress notes, MARs and TARs from 11/14/2023 through 11/28/2023 showed no documentation that appointments were made on the fourth week request for ultrasound vascular studies and CT scan imaging for baseline studies as ordered for appropriate compression of the lower extremity lymphedema. In addition, the review did not show that the nursing staff had contacted radiology for an addendum to the 11/07/2023 x-ray or ordered a new x-ray of the right foot to rule out osteomyelitis. Review of Resident 44's November 2023 TARs from 11/05/2023 through 11/28/2023 showed there were no changes to the treatment orders and none of the PA-C wound consultant orders to cleanse the legs, apply the A&D ointment to the legs and feet, apply the shaving cream or soak the legs for 15/20 minutes and wiping away the scaling skin were present. In addition, there were no orders to apply the topical lidocaine 4% to the wound bed prior to dressing changes for pain relief, to apply skin prep to the peri wound and again did not change the dressing change order to every other day. Review of a facility Registered Nurse (RN) Staff O, wound evaluation note, dated 11/28/2023, showed new orders were received to treat the top of the right foot cellulitis area by cleaning with an antimicrobial wound cleaner, apply skin prep to peri wound and allow to dry, cover with super absorbent dressings and change the dressing every other day and PRN. Review of the PA-C wound consultant notes, dated 12/05/2023, stated unable to locate any repeat x-ray or inflammatory lab work ordered for osteomyelitis rule out. Unable to locate any pain control med changes from recommendations made on last visit from hospital in western part of state. Lymphedema assessment of a chronic skin condition that is stalled. The following orders were again requested for follow up by the nursing staff. *Ensure pain control is in place routinely and when doing dressing changes. *Ensure vascular studies are done at the earliest convenience to ensure most appropriate lymphedema management is initiated. Vascular studies BLE arterial ultrasound BLE venous ultrasound ABI's- baseline lymphedema evaluation. *Skin care treatment every day and as needed the same as ordered on 11/21/2023. *Systemic and local pain control (topical lidocaine 4% to wound bed right foot prior to dressing changes. Same treatment orders as previous every other day and as needed order. *Offloading Right foot footwear The 12/05/2023 PA-C documentation further stated, based on today's evaluation, wound healing potential is guarded, and may be delayed. Overall, this patient is at a high risk for complications related to the problems addressed today. Review of physician visit notes, nursing progress notes, MAR's and TAR's from 11/28/2023 through 12/20/2023 showed no documentation that appointments were made on the fifth week request for ultrasound vascular studies and CT scan imaging for baseline studies as ordered. In addition, the review did not show that the nursing staff had ordered a new x-ray of the right foot to rule out osteomyelitis. Review of a wound evaluation note written by Staff O, dated 12/12/2023, showed new orders were received to treat the top of the right foot cellulitis area by cleaning with an antimicrobial wound cleaner, apply skin prep to peri wound and allow to dry, cover with super absorbent dressings and change the dressing every other day and PRN. Review of Resident 44's November 2023 and December 2023 TAR's showed from 11/28/2023 through 12/20/2023 there were no orders written to treat the wounds on the right leg. Review of Resident 44's (MAR's) from 11/01/23 through 12/20/2023 showed an order for two Tylenol, eight hour extended release tablets (1300 milligrams (mg) twice a day as needed for pain. The record showed the resident recieved the Tylenol 19 times from 11/01/2023 through 11/30/2023 and 11 times from 12/01/2023 through 12/20/2023. Review of the MAR showed an additional order was added on 12/05/2023 for Oxycodone (a narcotic pain medication) 5 mg every 12 hours as needed for pain, and to administer one tablet every Tuesday morning at 6:00 am prior to UWH providing treatments. One dose was documented as given on 12/12/2023. Review of Resident 44's care plan, dated 10/25/2023, showed a problem listed for acute pain related to left lower extremity cellulitis with wound infection and an actual skin impairment to the right lower extremity related to cellulitis. There were no interventions listed for the treatments provided including use of a topical pain medication for dressing changes, off-loading of the right foot for comfort, or providing a nutritional supplement with meals to promote healing. During an interview with Resident 44 on 12/21/2023 at 10:12 AM, they stated the wound consultant PA-C had not been in to see them for the past two Tuesdays, 12/12/2023 and 12/19/2023, and they were really worried about the lymphedema getting worse and being so painful. Resident 44 stated they continued to get the dressings changed to the right foot about every day, though no other type of treatment such as leg soaks or any type of lotion or cream had been applied. Resident 44 stated they had not been out of the facility for any vascular studies and could only remember having one x-ray of the foot and one blood draw since admission. Resident 44 stated staff had not been elevating the right foot or providing any type of footwear for protection of the foot. During an Interview with the Director of Nursing (DON) on 12/21/2023 at 10:40 AM, when asked about the PA-C wound consultants orders, they stated they would locate them and provide them to the survey team. At approximately 11:30 AM, the DON provided information on the last orders written on 12/12/2023 by Staff O. The information provided showed no further evidence that the PA-C's orders were followed up on for the 11/07/2023, 11/14/2023, 11/21/2023 and 12/05/2023 consultant orders for treatments and diagnostic studies. <Resident 13> Review of the facility policy titled Drug Regimen Review Policy and Procedure, dated 04/2019, showed the pharmacy was to review each resident's medication regime to ensure that risk and problems were identified and acted upon in a timely manner. Review of the electronic medical record showed Resident 13 was admitted to the facility on [DATE] with diagnoses including heart failure and hypertensive chronic kidney disease (high blood pressure caused by damage to the kidneys). The 09/21/2023 comprehensive assessment showed the resident required extensive assistance of one to two staff members for dressing, toileting, bed mobility, and transfers. The assessment also showed the resident had a severely impaired cognition. Review of Resident 13's medication orders showed an order, dated 07/25/2023, for amlodipine besylate (a medication that lowers blood pressure) oral tablets, give 7.5 mg by mouth one time a day, please hold for SBP (systolic -the top number of the blood pressure - measures the pressure in the arteries when the heart beats, blood pressure) < 100 (less than 100 millimeters of mercury [mmHg] - a measurement to record blood pressures). Review of a pharmacy recommendation, dated 07/26/2023, showed a pharmacy recommendation to add blood pressure readings to Resident 13's MAR for the amlodipine order. There was no documentation that the recommendation was completed. A second pharmacy recommendation dated 11/30/2023 showed the same recommendation with provider in agreement (signed 12/01/2023). Review of Resident 13's MARs showed the following: August 2023: Amlidopine was given 24 times, held four times. There were three documented blood pressure readings in the medical record - the documented readings did not correspond to the held medication dates. September 2023: Amlidopine was given 26 times, held four times. There were nine documented blood pressure readings in the medical record - the documented readings did not correspond with the held medication dates. October 2023: Amlidopine was given 24 times, held three times. There were four documented blood pressure readings in the medical record - the documented readings did not correspond with the held medication dates. November 2023: Blood pressure readings were added to the MAR on 11/8/2023. Amlidopine was administered 11/1/2023, 11/2/2023, 11/3/2023, and held on 11/6/2023 with no blood pressure readings recorded in the medical record. During an interview on 12/20/2023, Staff H, Licensed Practical Nurse, stated prior to the addition of the blood pressure readings to the MAR in December, the blood pressure was recorded by the nursing assistants and Resident 13 was administered the medication based off that reading. During an interview on 12/20/2023 at 2:36 PM, Staff G, Resident Care Manager, stated the licensed nurse should have documented a blood pressure reading somewhere in the medical record if they had held or administered the medication. During an interview on 12/20/2023 at 2:56 PM, Staff C, Senior Regional Support Nurse, stated they expected the licensed nurse to document the blood pressure in the medical record. Staff C stated they expected the Director of Nursing would have addressed the first pharmacy recommendation in July 2023. WAC-388-97-1060(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide adequate supervision and interventions to ensure the safety of 1 of 2 residents (Resident 26) reviewed for falls. This failure resulted in actual harm to the resident who experienced two falls within 10 hours, that resulted in a major injury; the first fall resulted in a head trauma with a laceration; the second fall resulted in a pelvic fracture. Findings included . Review of the facility's policy titled, Accident/Incident, revised 10/2022 showed a plan to prevent re-occurance is initiated at the time of the incident. <Resident 26> Review of the medical record showed Resident 26 was admitted to the facility on [DATE] with diagnoses including dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), delirium (a serious change in mental ability that causes confused thinking and lack of awareness), kidney failure, and muscle weakness. The 09/22/2023 comprehensive assessment showed the resident required physical assistance of one staff member for toileting and transfers. The assessment also showed the resident had a severely impaired cognition. An observation on 12/18/2023 at 9:04 AM, showed Resident 26 asleep in their bed, lying on their right side. The resident had their glasses on and there was a laceration on the top of their forehead. The resident's hair was observed with thick bloody flakes. During an interview on 12/18/2023 at 12:24 PM, Staff I, Nursing Assistant (NA), stated the resident had two different falls with injuries the night before. Review of the nursing progress note, dated 12/17/2023 at 12:12 AM, showed Resident 26 was found in their room, lying on the floor by their roommates' bed and bathroom door. The resident had two lacerations, one to their forehead and the other on the left side of their head. The resident yelled out when they moved their right-side lower extremity. Staff received an order to send the resident to the hospital for evaluation. Further review of the nursing progress notes at 4:03 AM, showed the resident returned from the emergency department (ED), at 3:40 AM with four staples to the top of their head. Review of the hospital ED report dated 12/17/2023 at 3:19 AM, showed Resident 26 had a head injury and scalp laceration. The hospital discharge instructions titled Head Injury, Adult, showed complications after a head injury may occur within the first 24 hours after the injury and an adult should stay with them to observe and monitor for any changes in condition. Review of nursing progress notes dated 12/17/2023 at 9:12 AM, showed Resident 26 experienced a second fall. The Resident was found in their room, on the floor, lying on their left side, between their wheelchair and bathroom. The resident told staff they fell, and their arm and head were hurt. Staff called 911 and Resident 26 was transferred to the ED. Additional review of the nursing progress notes at 1:39 PM, showed the resident returned from the ED and had a right pelvic fracture and a possible hip fracture. Review of the resident's Neurological (pertaining to the brain, spinal cord and nerves) Assessment flow sheet (a form used to assess, monitor, and record neurological signs and symptoms following a head trauma) showed instructions to complete neurological checks every 15 minutes, four times, then every 30 minutes, four times, then hourly, four times, followed by every four hours, four times, then every shift for 72 hours. The assessment consisted of the resident's level of consciousness (level of alertness and awareness), pupil response (pupil size and reaction to light exam to evaluate brain activity), motor functions, to include hand grasps and extremities, pain response, vital signs, and observations. The first entry was recorded on 12/16/2023 at 11:10 PM at the time of the first fall, with level of consciousness, vital signs and pain response documented. The next eight entries were documented as Hospital. On 12/17/2023, the three remaining hourly checks at 3:55 AM, 4:55 AM, and 5:55 AM, showed Refused. Documentation at 9:55 AM and 1:55 PM showed Hospital; 5:55 PM and NOC (night shift) showed Refused. On 12/18/2023, Dayshift showed Refused. The 12/18/2023 Evening shift showed resident vital signs were documented. The 12/18/2023 NOC showed no documentation. The 12/19/2023 Day and Evening shifts showed Refused. The 12/19/2023 NOC and 12/20/2023 Day and Evening shifts showed resident vital signs documented. Out of 25 opportunities for complete neurological checks there were four entries for level of consciousness, four entries for pain response, six entries for vital signs and no documentation of pupil responses, motor functions, or observations of Resident 26. During an interview on 12/18/2023 at 12:42 PM, Staff H, Licensed Practical Nurse, (LPN), stated the resident had two different falls over the weekend. Staff H stated they were to resume the original plan of care, the resident was not to bear weight, and required supervision. Staff H stated the resident was a high fall risk and the resident has fallen in the past when they self-transferred from their bed to their wheelchair or from their wheelchair to their bed. Staff H stated the fall preventions put in place for the resident were a fall mat and staff were to remind the resident they were to use their call light. Staff H stated that they would glance into the resident's room when they walked by to see if they were attempting to get out of their bed. An observation on 12/18/2023 at 12:49 PM, showed Resident 26 was lying on their right side in their bed. Their privacy curtain was closed, and they were not visible from the hallway. During an interview on 12/18/2023 at 2:09 PM, Staff F, NA, stated they were working when Resident 26 returned from the ED after the resident's second fall. Staff F stated they were to redirect the resident to not get out of their bed. Staff F stated the resident requested to use the bathroom and Staff F advised the resident to use their brief and to stay in their bed. Staff F stated the fall preventions they used were a fall mat, bed in the lowest position, privacy curtain left open, and kept the resident's wheelchair away from them. During a follow-up interview on 12/21/2023 at 9:14 AM, Staff F stated on the morning of 12/17/2023 at 8:00 AM, Staff L assisted them with providing care to the resident and placed the resident into their wheelchair for breakfast by their bedside tray table. Staff F stated that they left the room and 15 minutes later they found the resident on their floor. Staff F stated prior to this fall, they had checked on the resident twice since 6:00 AM. Staff F further stated they should have stayed with the resident during their breakfast; it was not safe to leave the resident. During an interview on 12/18/2023 at 3:28 PM, Staff N, NA stated they were informed the resident had two falls over the weekend. Staff N stated the new fall interventions were to observe the resident more often. An observation on 12/18/2023 at 3:30 PM, showed Resident 26 was lying in their bed and their privacy curtain was pulled closed and they were not visible from the hallway. During an interview on 12/19/2023 at 9:09 AM, Staff G, Resident Care Manager (RCM), stated that prior to the falls, the resident would be in their wheelchair in the hall. Staff G stated since the fall with the pelvic fracture, the resident had been declining. The resident was now on bedrest and was eating less. Review of the physician orders dated 12/17/2023 at 2:00 PM, showed the resident was non-weight bearing to their right lower extremity. There was no physician order for bedrest. During an interview on 12/19/2023 at 1:09 PM, the Resident's Representative stated they were informed the resident experienced two falls over the weekend after they slipped out of their wheelchair. The Resident's Representative stated they received a call every few weeks or so that the resident had fallen. They stated the resident received staples to their head from the first fall and then a second fall in the morning resulted in a fractured pelvis. The Resident's Representative stated these were the most severe injuries the resident experienced during a fall. During an interview on 12/20/2023 at 12:33 PM, Staff M, LPN, stated they were the nurse on shift when Resident 26 had their first fall on 12/16/2023. Staff M stated they were alerted by Staff W, NA, that the resident was found on their floor between their roommate's bed and the bathroom door. Staff M observed the resident on the floor with a gash on their forehead and a large puddle of blood on the floor. They rolled the resident onto their back and the resident yelled out that their right leg was in pain. 911 was called and the resident was taken to the ED. Staff M stated they were not sure how the resident came to be on the floor with the injuries. Staff M stated when the resident returned from the ED they were placed into their bed and went to sleep for the night. Staff M stated the resident did return with staples to their forehead from the fall. Staff M stated upon their return to work the following night, 12/17/2023, they were informed the resident had a second fall during the morning that resulted in a pelvic fracture. Staff M stated when a resident returned from the hospital, the protocol included completing an assessment, obtaining vital signs, and performing neurological checks. Staff M stated that neither shift completed an assessment for the resident. Staff M stated the fall prevention that was in place was the fall mat. An interview on 12/21/2023 at 8:24 AM, Staff L, Registered Nurse (RN), stated they were notified Resident 26 had a fall during the night. Staff L stated they and Staff F, NA proceeded to get the resident dressed and into their wheelchair for breakfast on the morning of 12/17/2023. Staff L stated the resident was afraid of falling and stated don't let me fall, when they were getting them ready in the morning. Staff L stated the resident's bedside tray table was up against the wall, with the resident in their wheelchair for breakfast. Staff L stated they left the residents room at 8:25 AM and they were alerted by Staff F at 8:45 AM that they had found the resident on their floor in their room. During an interview on 12/20/2023 at 2:33 PM, Staff B, Interim Director of Nursing (DON), stated that the expectation for staff when a resident returned from the emergency department, were to review the emergency department paperwork, perform neurological checks and assessments, obtain vital signs, review orders, and notify family and providers. During a second interview on 12/21/2023 at 9:48 AM, when asked if the resident was left in a safe position, alone in their wheelchair without supervision, and a known head injury, Staff B declined to answer. Reference WAC: 388-97-1060(3)(g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that 1 of 3 residents (Resident 1) reviewed for indwelling urinary catheters (a hollow, partially flexible tube that collects urine from the bladder and leads to a drainage bag), was referred to a urologist for evaluation of the continued need for the urinary catheter. Resident 1 experienced harm when after nine months of use, they experienced a urethral (a tube that connects the urinary bladder to an opening for the removal of urine from the body) erosion (a place where surface tissue has been gradually destroyed) pressure injury (localized damage to the skin as well as underlying soft tissue sometimes related to medical devices). Findings included . Record review of the facility's policy titled, Indwelling Urinary Catheter, dated 02/2019, showed that: - residents who enter the facility without a catheter will not be catheterized unless medically necessary, - a resident who enters the facility with an indwelling catheter is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates catheterization is necessary. Conditions may include urinary retention that cannot be treated or corrected medically. Record review of the facility's policy titled, Skin at Risk/Skin Breakdown, dated 09/2020, showed that newly identified skin impairment (abrasion, excoriation, pressure sore, rash, or skin tear), the licensed nurse will notify the physician, notify the resident representative, document findings in the resident's record and identify interventions to promote healing and or resolution the skin impairment. Review of a December 2010 Wound Management and Prevention article titled Indwelling Urinary Catheter-Associated Urethral Erosion in Elderly Men, showed that medical devices such as indwelling urinary catheters have caused pressure injuries called urethral erosion. Urethral erosion in men ranges from a partial-thickness wound involving a small area of the glans (tip) penis to a full-thickness pressure injury, or erosion, cleaving (splitting) the glans or penile shaft. <Resident 1> Review of Resident 1's medical record showed they were admitted from another long term care nursing facility on 03/09/2022 with diagnoses to include Parkinson's disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), benign prostatic hyperplasia (BPH, a condition where benign (non-cancerous) nodules enlarge the prostate gland (the gland that produces the liquid in which sperm are expelled from the penis), and obstructive uropathy (a condition where urine cannot flow normally through the urinary tract). Review of the 03/15/2022 comprehensive assessment showed Resident 1 was cognitively intact, was incontinent of bladder and bowel and did not have an indwelling urinary catheter. Review of a discharge summary from the previous nursing facility dated, 03/08/2022, showed that Resident 1 had BPH with urinary retention, was medicated with tamsulosin (a medication that works by relaxing the muscles in the prostate and bladder so that urine can flow easily), and would need to see a urologist (a medical provider that specializes in diagnosing and treating diseases of the urinary system) for follow up on a yearly basis. Review of Resident 1's physician orders from 03/09/2022 to 09/22/2023 showed no orders or referrals for a urology consult. Review of an acute physician exam, dated 10/02/2022 at 11:10 AM, showed Resident 1 was observed in no acute distress, comfortable and the resident denied any problems with urination. The plan for Resident 1's BPH was to continue with the tamsulosin medication. Review of a provider progress note, dated 12/22/2022 at 8:42 PM, showed Resident 1 was sent to the hospital for a change in condition. Review of a post hospital physician exam, dated 12/27/2022 at 12:53 PM, showed Resident 1 was readmitted to the facility on [DATE] after an acute hospital stay for a urinary tract infection (UTI, an infection of any part of the urinary system) with an indwelling urinary catheter. Review of a 12/29/2022 at 8:50 PM nursing communication to the physician showed that Resident 1 returned from a hospital stay with a foley (a type of urinary catheter) catheter and recommended a physician order to discontinue the foley catheter with a voiding (the act of urinating) trial and post void residual (the amount of urine that remains in the bladder after urination) assessment. Review of a 01/04/2023 at 12:59 PM nursing progress note showed the physician talked to Resident 1 about their catheter and void trial today and the resident wanted to keep the catheter. Review of a physician progress note, dated 01/04/2023 at 1:07 PM, showed Resident 1 refused to have their foley [catheter] removed, the resident said they felt better with the catheter; the resident was educated on the increased risk for recurrent UTI's secondary to the continued use of the foley [catheter] and [Resident 1] stated they would take the risk. Review of the medical record showed no order/referral for Resident 1 to see a urologist (a physician who specializes in the study or treatment of the function and disorders of the urinary system). Review of a 09/03/2023 at 4:11 PM nursing progress note showed documentation that no urine was collected in the resident's catheter bag between 6:00 AM and 12:00 PM and a scan of Resident 1's bladder showed 390 milliliters (ml) residual urine in the bladder (a volume of less than 50 ml is considered adequate bladder emptying; in the elderly, between 50-100 ml is considered normal. In general, a volume greater than 200 ml is considered abnormal and could be due to incomplete bladder emptying). The catheter was changed and after removal thick, light green discharge came from the urethra and a urine sample was sent to the lab for analysis. The resident was diagnosed with a UTI on 09/06/2023 and antibiotics were ordered. Review of a nursing progress note, dated 09/15/2023 at 6:33 AM, showed Resident 1 was sent to the hospital for a change in condition, was diagnosed with a UTI, sepsis (a bacterial infection in the bloodstream or body tissues) and respiratory failure. The resident was admitted to the intensive care unit. Review of an in-hospital wound report with photo, dated 09/15/2023 at 5:29 PM, showed Resident 1 was assessed to have a pressure injury on their penis from the chronic indwelling foley catheter. The photo showed a 2-inch split in the penis tip from the urethra on the inferior (low or lower in position) aspect of the glans penis. Medical record review showed no documentation of the pressure injury to Resident 1's penis. Review of a nursing progress note, dated 09/19/2023 at 12:54 PM, showed Resident 1 was readmitted to the facility. During a concurrent interview and observation on 09/19/2023 at 3:05 PM showed Resident 1 in their bed, alert and oriented. There was a covered urinary catheter bag secured on the left side of the bed frame. Resident 1 stated they got the catheter sometime after they moved to the facility and was not aware of any injury to their penis. Staff E, Nursing Assistant (NA) and Staff F, NA, provided catheter care (a process to clean a urinary catheter tube where it exits the body) for Resident 1. The injury was observed and the resident denied any discomfort in the area. During an interview on 09/19/2023 at 3:45 PM, Staff B, Interim Director of Nursing, stated they had not read Resident 1's hospital report yet nor were they aware of a pressure injury to the resident's penis. During an interview on 09/21/2023 at 10:30 AM, Staff G, Physician Assistant-Certified (PAC)/Contracted Wound Specialist, stated they consulted on Resident 1's skin in June 2022 and had not received a referral from the facility to assess a pressure injury on the resident's penis. Staff G stated that chronic foley catheter use can cause a mucosal membrane pressure injury to the male urethra. During an interview on 09/22/2023 at 11:45 AM, Staff J, NA, stated they had provided catheter care for Resident 1 and the injury to their penis had been there for several months. During an interview on 09/22/2023 at 12:05 PM, Staff D, Licensed Practical Nurse, stated that Resident 1 had no erosion on the top of their penis when they were admitted . Staff D recalled that when Resident 1 returned from the hospital with the foley catheter, the resident refused to let the physician have it removed. [Resident 1] probably should have gone to a urologist at that time. Staff D stated they were aware of the injury to the resident's penis but did not remember when it happened, and it should have been documented in the resident's record. Staff D stated they were not sure if a physician had been notified about the injury either. During an interview on 09/22/2023 at 12:34 PM, Staff H, Registered Nurse /Resident Care Manager (RCM), stated when residents were admitted with a foley catheter they would need an appropriate diagnosis and we would do a voiding trial to see if the resident still needed the catheter. Staff H stated residents with chronic urinary catheters were usually referred to a urologist. Staff H stated they started the RCM position recently, had Resident 1 on their case load and was not aware if they had been seen by a urologist. During an interview on 09/22/2023 at 1:00 PM, Resident 1's Representative (RR1) stated they did not think the resident needed the catheter because it increased the risk of infections, and the resident was urinating just fine before the catheter was placed. RR1 stated Resident 1 told them they wanted to keep the catheter because it was easier that way and they would not have to wait for staff to change their brief. RR1 stated Resident 1 had been to a urologist in the past, but not since admitted to this facility. RR1 was asked if they were informed by the facility of Resident 1's pressure injury to their penis and stated, No. I had no idea. How horrible, that just makes me sick. RR1 was crying and appeared very upset. During a telephone interview on 09/22/2023 at 1:50 PM Staff I, Medical Doctor, stated they completed a readmission evaluation for Resident 1 earlier that day. They stated they were not aware of a pressure injury to the resident's penis as he was not informed and did not see the pressure injury. Reference WAC 388-97-1060(3)(c)