**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from neglect for 1 of 11 residents (Resident 35) reviewed for neglect. Resident 35 experienced harm when staff failed to provide Resident 35 water when requested, failed to assess skin excoriation (loss of the top layer of the skin and a portion of the middle layer of the skin due to scratching or an injury) to Resident 35's coccyx (tailbone) and perineum (the area between the thighs that marks the approximate lower boundary of the pelvis and is occupied by the urinary and genital ducts and rectum), and administer pain medications as needed at their end of life per Resident 35's advanced directive (a legal document that outlines preferences for medical care in the event you are unable to communicate your wishes). These failed practices placed the residents at risk for dehydration, additional skin breakdown, and continued pain. Findings included . Review of a policy titled, Abuse Prohibition, dated 10/24/2022, defined neglect as the failure, indifference, or disregard of the Center, its employees, or service providers to provide care, comfort, safety, goods, and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. This includes the failure to implement an effective communication system across all shifts for communicating necessary care and information between the Center, patient, practitioners, and patient representatives. <Resident 35> Review of the medical record showed Resident 35 was admitted to the facility on [DATE] with diagnoses of Clostridium Difficile (a bacteria that causes diarrhea and other intestinal issues), malnutrition, and severe sepsis with septic shock (a life-threatening condition that occurs when the body's response to an infection progresses to a dramatic drop in blood pressure). The 11/11/2024 comprehensive assessment showed Resident 35 was dependent on one to two staff members for activities of daily living; touch assistance/supervision for eating. The assessment also showed Resident 35 had a moderately impaired cognition. <Water> During an observation on 11/13/2024 at 11:38 AM, Resident 35 was lying on their back in bed with their right arm outstretched, reaching towards their water cup on the bedside table. They were calling out ahh and ow. At 11:48 AM, Resident 35 was observed with the back of their hand against the water cup and was calling out water, water. At 11:50 AM, the first observation of staff hearing the resident's request for water, Staff C, Nursing Assistant (NA), walked past the resident's room and did not acknowledge their request for water. At 11:51 AM, Staff E, Director of Rehab/Physical Therapy Assistant (PTA), Staff N, NA, and Resident 52 (a resident that resided in the same hall as Resident 35) were in the hall outside of Resident 35's room, having a conversation. Staff E stated to the resident in the hall, I have a protein café latte for (Resident 35) today, I have it in the refrigerator and will give it to them later as Resident 35 was continuously calling out for water. Resident 52 wheeled themselves into Resident 35's room. Staff E told Resident 52 that was not their room, and the resident responded, I am going to check on them, entered Resident 35's room, and was observed talking to Resident 35 and patting their arm. Staff E and Staff N both left the area without responding to Resident 35's requests for water. At 11:55 AM, as Resident 35 was still calling out for water and reaching for their water cup, Staff C and Staff N were observed outside Resident 35's room, donning gown and gloves to enter the room next to Resident 35. Neither Staff C nor Staff N acknowledged Resident 35's requests for water. At 12:03 PM, Resident 52 was observed putting Resident 35's call light on, exited the resident's room, and stated to Staff O, NA, who was walking past Resident 35's room, Resident 35 wants water, needs water, I can't do it for them. At 12:07 PM, Resident 35 was observed still crying out for water. Staff O, again walked past Resident 35's room. They did not acknowledge the activated call light or Resident 35's requests for water. At 12:11 PM, Staff P, Licensed Practical Nurse (LPN), entered Resident 35's room, as they were continuously calling out for water. Staff P turned off the call light and stated, you need a drink of water? and exited the room without giving the resident water. At 12:16 PM, Staff N entered Resident 35's room with their lunch tray. Resident 35 yelled out water. Staff N stated, you need to wait a minute I have to go gown up. At 12:21 PM, Staff N re-entered Resident 35's room and gave the resident a drink of water, 31 minutes after staff first heard Resident 35 calling out for water. During an interview on 11/13/2024 at 12:50 PM, Staff P stated they went into Resident 35's room earlier that day to answer the call light and were going to get Resident 35 a drink of water. They stated they were going to put ice in their cup, left the room, and got sidetracked. Staff P stated the process for answering call lights was to turn them off when entering the room, then take care of the resident's need. They stated they turned the call light off because they did not want other family members or administrative staff to see that call lights were not being answered. During an observation on 11/15/2024 at 9:47 AM, Resident 35 was lying on their back in bed, their eyes and cheeks and were sunken in. Their mouth was open, their tongue and lips were dry and cracking. Their bottom lip was adhered to their bottom teeth and had a white film over it. Resident 35 stated yes when asked if they were thirsty and if they were in pain. Resident 35 was not able to state where their pain was located. <Skin> Record review of a NA assignment sheet, dated 11/10/2024, showed the NA had documented on their sheet that Resident 35 had extreme skin breakdown. Record review of a nursing progress note, dated 11/10/2024 at 9:29 PM, showed Staff Z, LPN, documented Resident 35 had an excoriated perineum that had an open area on the vulva (external female genital organs) that was bleeding that evening when the NA was providing incontinent care. During an interview on 11/15/2024 at 11:46 AM, Staff C stated they had reported Resident 35's skin maceration (the process of skin softening and breaking down due to prolonged exposure to moisture) to Staff F, Unit Manager (UM), on 11/11/2024. Staff C stated that morning, they were performing personal cares for Resident 35 and their skin was just wiping off. They stated Staff M, Registered Nurse (RN)/Infection Preventionist (IP) had been passing by Resident 35's room during the cares, and they asked Staff M to look at the macerated skin. Staff M advised them to use warm water to remove the thick paste that was covering the wound, but did not assess the wound. During an interview on 11/15/2024 at 12:18 PM, Staff F stated Resident 35 had the maceration from incontinence and sweating. They stated they were informed of the maceration on Tuesday (11/12/204) or Wednesday (11/13/2024). They stated they were informed of redness by maybe an aide but did not assess the areas. During an interview on 11/16/2024 at 9:07 AM, Staff M stated they were asked to look at Resident 35's perineum on either 11/11/2024 or 11/12/2024. They stated they were called into the resident's room by two NAs to assess the areas of concern. Staff M stated there was a thick layer of what looked like powder that had gotten wet, caked on Resident 35's perineum. Staff M stated there was so much powder and wet stool, they were unable to see any of the wound area. Staff M stated they did not assess the wound area. Review of a nursing progress note, dated 11/14/2024 at 7:15 AM, showed Staff B, Senior Director of Nursing, and Staff F assessed Resident 35's perineum and buttocks area, four days after the initial report of skin breakdown. Resident 35 had front peri area that is inflamed and reddened in color with erosion (occurs when the skin's outer layers break down) of skin folds, bilateral (both sides) buttocks have superficial (occurring on the surface) open areas . During an interview on 11/16/2024 at 2:24 PM, Staff Z stated they had reported the perineum concerns to the Registered Nurse that was on duty that night so they could assess Resident 35's condition. <Pain> An observation on 11/15/2024 at 10:01 AM, showed Staff C, Staff Q, NA, Staff O, and Staff R, LPN, outside Resident 35's room, putting on gowns and gloves. The staff entered the room and began to perform incontinent care for Resident 35. Observation of the resident's perineum showed severely macerated (softening and breakdown of the skin due to prolonged exposure to moisture or fluid) tissue that was bright red. As Staff C cleaned the perineum with cleansing wipes, Resident 35 squeezed their eyes shut, cried out in pain, made a fist with their left hand, and repeatedly punched Staff Q in the right forearm. Staff O stated they were training Staff R and stated to Staff R that they kept up on Resident 35's pain medication and were able to administer pain medications every eight hours as needed (provider order showed pain medication was to be given every six hours as needed). Staff O stated they were going to get Resident 35 an oxycodone (a medication used to treat moderate to severe pain) since it was time for their next dose (their last dose had been given at 3:23 AM). Staff O did not administer Resident 35 a pain medication, despite stating they would. Review of a provider progress note, dated on 11/14/2024 at 9:30 AM, showed Resident 35's provider had assessed them for an acute visit due to decreased activity, worsening pain, and progressive skin changes to their perineum. The provider note showed the resident was unable to feed themselves and had significant pain with repositioning. Resident 35 was observed laying in bed on left side with mouth open, dry mucous membranes. Patient unable to reposition self, due to weakness. The assessment showed their skin was macerated and erythematous (abnormally red skin due to inflammation) rash on buttocks, inner thighs, and bilateral labia (the folds of skin at the outer part of a woman's sexual organs), superficial sloughing (shedding) of dermal (skin) layer on buttocks bilaterally, roughly two to three centimeters (a unit of measurement) in circumference. Resident 35 had a new diagnosis of dermatosis (disease of the skin) of perineum consistent with atopic dermatitis (a condition of the skin that causes inflammation, redness, swelling, and cracking of the skin) reaction from their current conditions of c-diff colitis(inflammation of the large intestine), recurrent diarrhea/watery stools and sweat. Record review of a Nurse Practitioner (NP) provider note, dated 11/15/2024 at 9:30 AM, showed Resident 35 was seen to follow up on concerns of moisture associated skin damage [(MASD) a general term for inflammation of skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, or sweat] of the genital area. The resident was unresponsive and quietly moaning (indicative of discomfort or pain). They were lying in bed, mouth open with dry mucous membranes. Resident 52 was unable to reposition themselves due to weakness and was moaning. Their genitourinary (organs of the urinary and genital system) area was excoriated, and red. New medications were ordered for pain, to be administered every two hours as needed, and anxiety, to be administered every four hours as needed. Review of the November 2024 Medication Administration Record, showed Resident 35 had received one dose of Tylenol (an over the counter medication to treat mild to moderate pain) on 11/15/2024 at 1:41 AM with ineffective results. They received one dose of oxycodone (a prescription pain medication used to treat severe pain) on 11/15/2024 at 3:23 AM, despite Staff O stating they would give a pain medication at 10:01 AM that morning. The facility did not provide Resident 35 any additional medications for pain control prior to them passing away at 9:00 PM, 17.5 hours after their last dose, despite the NP noting Resident 35 had been moaning that morning and had ordered additional medications for pain and anxiety. Record review of Resident 35's Advance Directive dated 12/12/2023, showed it is my desire that pain alleviation or control procedures or medication be administered and continued, and that as long as I live, I be kept as pain-free and comfortable as is reasonably possible. During an interview on 11/19/2024 at 10:27 AM, Staff B stated the process for change in condition did not happen for Resident 35. The new medications for pain and anxiety should have been pulled right away from the Pyxis (a medication dispensing system) and given. Advance Directives were reviewed upon admit by social services and that information should have been communicated to the unit manager. Staff B stated the provider should have been contacted sooner to address those concerns. During an interview on 11/19/2024 at 12:11 PM, Staff A, Administrator, stated they would have expected the staff to administer Resident 35 water, even if we had to have staff sit with (them). They stated the process for any skin change was to report it immediately to the licensed nurse, unit manager, and provider. They stated the process for Advance Directives included a review by Staff B to ensure that all the orders were being followed; that is (their) department and (their) duty. Staff A stated the facility did not follow their processes. 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 provide an environment that was free from avoidable accident hazards for 1 of 5 residents (Resident 4) reviewed for accidents with injury. This failed practice placed the residents at risk for avoidable accidents when Resident 4 experienced actual harm when their fifth toe on their right foot was broken while being pushed in their wheelchair. Additionally, the facility failed to ensure a safe smoking area and storage of smoking paraphernalia (items or equipment associated with a particular activity, hobby, or lifestyle) for 3 of 3 residents (Residents 13, 27, and 45) reviewed for safe smoking. The failure to ensure a safe smoking environment and storage of smoking paraphernalia placed the residents at risk for dissatisfaction with their smoking activity experience and injury. Findings included . Review of a policy titled, Accidents/Incidents, revised 03/01/2024, showed an accident was defined as any unexpected or unintentional incident that may result in injury or illness to a resident. After an accident occurred, the licensed nurse (LN) would report the accident and assist with a timely investigation to determine the cause. They would take immediate post-accident measures, implement appropriate interventions, update the care plan and communicate with the resident/representative, and complete nursing documentation and change of condition. Any incident that would be considered an allegation of abuse/neglect would be managed according to facility abuse prohibition policy. The LN would evaluate the resident, notify the physician, report the physical findings/extent of injuries, and obtain orders if necessary. The LN would create an event report in the medical record and document the accident in the resident's chart. All accidents would be reported to the supervisor. All accidents would be investigated to determine if the accident had been reported timely, investigated, and interventions were implemented. <Injury> <Resident 4> Review of the medical record showed Resident 4 was admitted to the facility with diagnoses including diverticulitis (inflammation of pouches in the colon that can cause abdominal pain, fever, nausea, vomiting, and sometimes bleeding), epilepsy (a brain disorder that causes people to have repeated seizures), and anxiety. The 10/24/2024 comprehensive assessment showed Resident 4 required substantial/maximal assistance of one staff member for activities of daily living (ADLs), including transfers and mobility. Resident 4 was able to make their needs known. During a concurrent observation and interview on 11/13/2024 at 3:21 PM, Resident 4 stated their right foot little toe was hurt from the accident that occurred two or three days ago, maybe Sunday. Resident 4 stated they were in their wheelchair that morning and someone had pushed them to the bathroom. Resident 4 stated they hit their foot on their roommate's bed. They stated their foot hurt and no one had looked at it. At 3:50 PM, Staff E, Director of Rehab/Physical Therapy Assistant (PTA) was attending to Resident 4's roommate. They came to Resident 4's bedside and removed Resident 4's right sock. The fifth toe showed blue/purple discoloration at the base of the toe that was one inch in length. The bruising was on both the top and side of the foot. Resident 4 stated to Staff E, I asked you to look at my foot earlier because it hurt and was bumped on their roommate's bed. Staff E responded, you asked me to remove your shoe. During an interview on 11/18/2024 at 8:49 AM, Staff E stated Resident 4 had told them that morning (11/13/2024) that their foot was sore. They stated they removed Resident 4's shoe, did not remove their sock, and asked the resident to wiggle their toes. Staff E stated Resident 4 was able to wiggle their toes and told the resident they were fine. During an interview on 11/18/2024 at 2:33 PM, Staff L, Registered Nurse (RN), stated the injury to Resident 4's foot was reported to them the same day the State Surveyor had reported it to the Administrator (11/13/2024). Staff L stated when they received the report, they assessed the foot and noted purple bruising on the outer side of the fifth toe. Resident 4 reported they had pain with palpation (the process of using one's hands to check the body). Staff L stated they administered pain medication, completed a risk management form, and reported it to the administrative staff. Staff L stated they notified the provider and an order for an X-ray had been placed. Staff L stated they were not notified of any accident or injury until after the State Surveyor had reported it. During an interview on 11/19/2024 at 8:43 AM, Staff F, Unit Manager, stated they were informed of the injury by Staff L. They stated the process was for staff to inform the nurse when an accident/injury had occurred. The licensed nurse would complete a change in condition form to notify the provider of the injury. Staff F stated Staff L completed the form and notified the provider electronically with a change in condition form the night they were told of the injury. Review of the medical record showed an x-ray had been obtained on 11/14/2024, one day after the Resident 4 reported the injury. The x-ray report showed a fracture of the fifth proximal phalanx (smallest toe). During an interview on 11/19/2024 at 10:19 AM, Staff B stated they were unable to determine who injured Resident 4's toe. They stated Staff F had assessed the resident's injury by removing both socks and comparing the feet but was unsure what day that occurred. Staff B stated Staff F reported no concerns at that time. Staff B stated it took a few days for the bruising to show. They stated they assessed the resident on 11/14/2024, saw the bruising, and ordered an x-ray. Staff B stated the process was for staff to report accidents, injuries, and pain to ensure those concerns were followed up on. Staff B stated the process was not followed. During an interview on 11/19/2024 at 12:34 PM, Staff A, Administrator, stated the process should have been for Staff E to report the injury as soon as Resident 4 informed them of the incident. Staff A stated Staff E should not have assessed the resident's injury, as that was not the process, nor their role. Staff A stated any injury should also be immediately reported to the provider, especially if there was pain and/or swelling. Staff A stated the process was not followed. <Smoking> Review of the policy titled Smoking, revised on 05/01/2024, showed smoking would be permitted in the designated area only, have a non-combustible container for cigarette disposal, and the outdoor smoking area would protect residents from weather conditions. The policy further showed smoking supplies to include tobacco, and lighters would be stored at the nursing station. <Resident 13> Review of the medical record showed Resident 13 with diagnoses including diabetes (a group of diseases that result in too much sugar in the blood), heart disease and absence of left lower leg. The 09/18/2024 comprehensive assessment showed Resident 13 was independent for ADLs, able to use a manual wheelchair for mobility, and had an intact cognition. Review of the Resident 13's smoking evaluation, dated 08/29/2024, showed they were allowed to smoke independently. The evaluation also showed they were aware of the designated smoking area, reviewed the smoking policy, and their smoking supplies would be maintained by staff and stored at the nursing station. During an interview on 11/13/2024 at 9:53 AM, Staff J, RN, stated Resident 13 would go outside to smoke multiple times per day. During an interview on 11/13/2024 at 9:55 AM, Resident 13 stated they were a current smoker and went outside to smoke five times a day. Resident 13 stated when the weather was good, they would smoke in the designated smoking area, however when the weather was raining, snowing, or hot sun, they would not smoke in the designated smoking area as there was no protection from the elements. Resident 13 stated they always kept their cigarettes and lighter in their room or with them at all times. Resident 13 stated they disposed of their used cigarettes in their empty cigarette pack and put them into their trash can in their room. An observation on 11/13/2024 at 11:31 AM, showed the designated smoking area was an uncovered cement area in the back of the facility. The current weather condition was heavy rain, and the area contained standing water on the pathway from the building to the cement area for smoking. An observation on 11/13/2024 at 1:12 PM, showed Resident 13's trash can in their room had an empty cigarette box with six smoked/used cigarettes in the box. An observation on 11/15/2024 at 10:50 AM, showed Resident 13 in front of the facility under the covered entrance smoking as it was raining. During an interview on 11/18/2024 at 3:04 PM, Resident 13 stated they would continue to go to the front of the facility under the covered entrance to smoke when the weather was bad, as the facility had not provided a covered area in the designated smoking area. Resident 13 stated they had continued to put their used cigarettes in their empty cigarette box and brought to their room to dispose of in their trash can. Resident 13 further stated the nurses were supposed to keep their cigarettes and lighter until they asked for them. Resident 13 stated the nurses had never stored their smoking supplies as they kept the supplies with them. During an observation on 11/19/2024 at 12:47 PM, Resident 13 was smoking in front of the facility under the covered entrance. <Resident 45> Review of the medical record showed Resident 45 with diagnoses including stoke with left sided weakness and depression. The 10/25/2024 comprehensive assessment showed Resident 45 required supervision of one staff member for ADLs, independent for use of manual wheelchair for mobility, had a moderately impaired cognition, and was able to make their needs known. Review of Resident 45's smoking evaluation, dated 11/11/2024, showed they were allowed to smoke independently. The evaluation also showed they were aware of the designated smoking area, reviewed the smoking policy, and their smoking supplies would be maintained by staff and stored at the nursing station. During an interview on 11/14/2024 at 10:04 AM, Resident 45 stated they were a current smoker, and they were able to smoke when they wanted. Resident 45 stated they smoked in the facility designated smoking area and disposed of their used cigarettes in the cigarette disposal container. Resident 45 stated they kept their cigarettes and lighter with them in their room. An observation on 11/17/2024 at 10:04 AM, showed Resident 45 outside the exit door on the west hall smoking a cigarette. Resident 45 was not smoking in the designated smoking area. An observation on 11/18/2024 at 2:51 PM, showed Resident 45 smoking outside the exit door on the west hall and not in the designated smoking area. During an observation on 11/19/2024 at 11:02 AM, showed Resident 45 and Resident 13 in the front of the facility under the covered entrance smoking. The current weather condition was cool, dry and windy. <Resident 27> Review of the resident's medical record showed they were admitted to the facility with diagnoses including End Stage Renal Disease (the kidneys no longer function properly) with dialysis (a treatment that removes waste and excess fluid from the blood) and a history of a cerebral vascular accident (damage to the brain from interruption in blood flow) with right arm hemiplegia (a condition that causes paralysis or weakness to one side of the body). Review of the most recent comprehensive assessment dated [DATE] showed the resident had mild cognitive impairment and limited use of their right arm. During an interview on 11/13/2024 at 10:59 AM, Resident 27 stated they had smoked since they were [AGE] years old and were not interested in quitting. The resident patted their upper right pocket and stated they had a pack of cigarettes and a lighter under their jacket so they could smoke out front when they wanted to. Resident 27 was asked if they were aware there was a designated smoking area in the back of the building, and they stated yes but only smoked out front and further stated they kept their cigarettes and lighter in their room. I don't turn them in because I like to keep them close. Review of a document in the resident's record titled Smoking Policy showed Resident 27 had signed it on 05/24/2024. The document outlined the conditions for remaining an independent smoker as follows: Smoking materials must be stored at the nurse's station. Residents cannot keep materials in their room or on their person. The resident smoking area is located off campus (out back), there are no other designated smoking areas on the campus. Residents who fail to comply with this policy will lose their independent smoking privileges and may be subject to discharge. During a concurrent observation and interview on 11/17/2024 at 1:40 PM, Resident 27 stated they had a new carton of cigarettes and showed the surveyor where they kept them along with their lighter in the top right drawer of their nightstand. I can keep them safe here; I do not need to give them to the nurse. During an interview on 11/17/2024 at 2:00 PM, Staff FF, Licensed Practical Nurse, stated they were aware that Resident 27 had cigarettes and a lighter in their room. Staff FF further stated they never turned in their cigarettes and lighter for safe storage at the nurse's station and preferred to keep them in their room. During an interview on 11/18/2024 at 11:12 AM, Staff A, Administrator, stated they were aware of the residents who kept their smoking equipment in their rooms and were not smoking in the designated area. Staff A stated their preference was for the residents to comply with the smoking policy however they just do not. Reference: WAC 388-97-1060(3)(g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement pressure offloading interventions timely to prevent the development and/or worsening of pressure injuries for 2 of 3 residents (Residents 1 and 3) reviewed for pressure injuries. Resident 1 experienced harm when they developed a facility acquired pressure injury with infection to their coccyx (tailbone) and placed other residents at risk of new or worsening skin impairments. Findings included . Review of the National Pressure Injury Advisory Panel (leading expert in pressure injuries/wounds), September 2016 defines pressure injury stages as follows: Stage 1 Pressure Injury has intact skin with a localized area of non-blanchable erythema (redness). Stage 2 Pressure Injury is a partial thickness skin loss with exposed dermis (the top inner layers of skin) . Stage 3 Pressure Injury is a full thickness loss of skin, in which adipose (fat) tissue is visible in the ulcer. Slough (dead tissue) and or eschar (dried blood and tissue) may be visible, granulation tissue and epibole (rolled or curled under edges) may include with undermining (a pocket of dead space under the visible wound edges) and tunneling (a passage way under the wounds surface which may be shallow or deep and impairs wound closure). Stage 4 Pressure Injury is a full thickness loss of skin and tissue with exposed or directly palpable fascia (a layer of connective tissue), muscle, tendon, ligament, cartilage, or bone in the ulcer. Epibole undermining and tunneling often occur. Unstageable Pressure Injury is a full thickness skin and tissue loss to which the extent of the tissue damage cannot be seen. Review of the facility policy, Skin Integrity and Wound Management, revised on 02/01/2023, showed the facility would review pre-admission information to prepare of resident's skin and wound needs, complete a comprehensive evaluation of the resident on admission, implement pressure injury prevention for identified, modifiable risk factors, and determine the appropriate support surface for the bed and chair. <Resident 1> Review of the medical record showed Resident 1 admitted to the facility on [DATE] with diagnoses of lumbar spinal stenosis (the narrowing of the open spaces in the lower spine), lumbar spondylolisthesis (the misalignment of the bones in the lower spine often pinching the nerves), and lumbago with sciatica (back pain caused by pressure on the sciatic nerve located in the lower back, buttocks, and hip area). Review of the comprehensive assessment, dated 01/30/2024, showed Resident 1 had moderate cognitive impairment, required the assistance of one person with dressing, grooming, repositioning, and the assistance of two people for transfers with the use of a mechanical lift. Furthermore, the assessment showed Resident 1 had no skin impairments and was at risk for pressure injuries. Review of the nursing admission assessment, dated 01/24/2024, showed Resident 1 had chronic pain that was made worse by activity such as getting up or turning. The assessment showed Resident 1 had weakness in both legs, and impaired mobility to the right leg from sciatica. The assessment showed skin integrity issues to include a bruise to Resident 1's right antecubital (crook of the elbow) and several small, scattered scabs to the tops of their toes. Review of the baseline care plan, dated 01/25/2024, showed Resident 1 was at risk for skin breakdown due to decreased mobility and advanced age and preventative interventions were daily observations of skin by nursing assistants (NAs), weekly skin assessments by Licensed Nurses (LNs), reposition assistance every two to three hours, and application of moisture barrier cream to skin with every cleansing. Review of the medical record showed a skin assessment, dated 01/29/2024, documented no new skin issues. Review of the nursing progress note (PN), dated 02/03/2024 at 6:06 AM, showed a discolored area to right buttocks was noted with a plan to follow up with the treatment nurse. Review of the medical record showed no further description of the discolored area or update to the care plan. Review of the nursing PN, dated 02/03/2024 at 1:24 PM, showed a skin assessment was completed with documentation of an abrasion/blister to the right buttock and sacrum area (the upside-down triangle shaped area at the bottom of the spine). Review of the medical record showed no further description of the skin impairment was documented. Review of the nursing PN, dated 02/04/2024 at 8:01 AM, showed Resident 1 continues with discolored area on (their) bottom. Dressing placed. Review of the medical record showed no order for wound care or wound dressings were in place as of 02/04/2024. Review of the Wound Consultant PN, dated 02/05/2024 at 9:52 AM, showed Resident 1 had two wounds: Wound 1 was a Stage 3 pressure injury to the coccyx measuring 1.6 centimeters [(cm) a measurement of length] by 0.9 cm by 0.2 cm and Wound 2 was an abrasion to the right buttock measuring eight cm by 3.2 cm by 0.1 cm. The PN showed the wound care plan included recommendations for more aggressive offloading including air mattress. Maintenance request submitted today for mattress placement. Recommend wheelchair cushion evaluation for optimal offloading support. Review of Resident 1's Care Plan (CP), updated 02/15/2024, showed a Low Air Loss (LAL) mattress was implemented as an intervention for pressure reduction on 02/08/2024 (five days after pressure injury was identified). Review of the Wound Consultant PN, dated 02/12/2024 at 6:10 AM, showed Wound 1 had deteriorated severely, showed signs of infection with purulent (pus) drainage, a foul odor, and had increased in size measuring 4.2 cm by 4.6 cm (more than three times the previously documented size). The PN showed the actual depth of the wound was not measurable due to the presence of dead cells and necrotic (dead) tissue, and a culture (laboratory test that identifies the presence of germs such as bacteria, virus, or fungus) of the wound was obtained. Furthermore, the PN showed recommendations to obtain a Computed Tomography [(CT) computerized x-ray imaging that takes detailed pictures of areas inside the body] scan to rule out osteomyelitis (infection in the bone) of the coccyx. Review of the nursing PN, dated 02/15/2024 at 4:22 PM, showed Resident 1 discharged from the facility to a local hospital for a planned surgery to their lumbar spine. During an interview, on 03/18/2024 at 10:30 AM, Staff D, RN-Wound Nurse, stated it was the facility process to implement air mattresses for pressure reduction once a resident's skin impairment opened, and they did not use air mattresses as a preventative intervention. Staff D stated Resident 1 had a higher risk for skin breakdown due to their diagnoses of pain and immobility. When asked if different interventions were used for pressure injury prevention for Resident 1 due to their identified high risk for skin breakdown, Staff D stated the facility's standard interventions for pressure injury prevention were implemented and utilized an air mattress once Resident 1's pressure injury was identified. During an interview, on 03/18/2024 at 2:03 PM, Staff E, Licensed Practical Nurse (LPN), stated they completed the skin assessment on 02/03/2024 documenting a blister to the coccyx area. Staff E stated Resident 1 frequently refused to be repositioned while in bed due to pain in their lower back and right hip. When asked if Resident 1's refusals for repositioning made them an increased risk for skin breakdown, Staff E stated, Yea, I guess. Staff E stated they were not able to determine if Resident 1's skin impairments were pressure-related as it was the facility's process to have the wound management nurse and/or a Wound Consultant classify it. Staff E stated they applied a protective dressing, but was not able to put pressure relieving equipment, such as an air mattress, in place. Staff E stated this type of equipment could only be accessed during the week by management nurses. < Resident 3> Review of Resident 3's medical record showed they admitted to the facility on [DATE], with diagnoses of heart failure, immunodeficiency (a failure of the immune system to protect the body from infection), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). Review of the comprehensive assessment, dated 03/10/2024, showed Resident 3 required supervision or touching assistance for transfers, utilized a walker and wheelchair for mobility, and was cognitively intact. Review of the admission PN, dated 03/07/2024, showed Resident 3 had a pressure injury to their sacrum. No other description of the pressure injury was documented. Review of the nursing PN, dated 03/14/2024 at 10:40 AM, showed a skin assessment was completed and a Stage 4 pressure injury, measuring 2.5 cm by 1.8 cm by 0.3 cm, was observed to Resident 3's sacrum. During an interview, on 03/18/2024 at 11:45 AM, the Resident 3 stated they were aware they had a pressure injury to their sacral area and had acquired it while in the hospital prior to admitting to the facility. Additionally, Resident 3 stated they had just received a new air mattress today (11 days after admission) to help heal their backside. During an interview, on 03/18/2024 at 12:10 PM, Staff F, Maintenance Director, stated they placed air mattresses for residents when staff members placed work orders in the computer system. Staff F stated once they received the order for the mattress, they retrieved it from the facility supply, air it up to ensure there were no leaks to the mattress, and then placed it on the bed for the resident. Additionally, they stated the nurses were responsible for the settings of the mattress. During the same interview, Staff F stated they had an on-call phone number posted at the front office and the nurse's station for maintenance needs after hours and on weekends. Staff F stated they were on call for the weekends but had not received any calls. During an interview, on 03/18/2024 at 11:15 AM, Staff C, stated it was the facility process to use air mattresses for residents who have skin breakdown. Staff C stated the facility was aware of Resident 3's pressure injury prior to admission, and they should have had an air mattress on their first day. Staff C further stated that there was no way to determine if Resident 3's pressure injury had worsened or improved since there were no wound measurements available from admission for comparison. During an interview, on 03/18/2024 at 3:05 PM, Staff A, Administrator, stated the expectation regarding pressure injury prevention and treatment was to follow the facility's policy. During an interview, on 03/28/2024 at 11:10 AM, Staff C, RN-Resident Care Manager, stated Resident 1's wound culture results returned on 02/14/2024 showing a current infection, and an order was received to start antibiotic (medication that fights bacterial infections) treatment. Reference: WAC 388-97-1060 (3)(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with standards of practice regarding thorough/accurate assessments, obtaining a medical evaluation, and implementing preventative measures to prevent the development or worsening of pressure injuries for 3 of 6 sampled residents (Residents 42, 45, and 15), reviewed for pressure injuries. This deficient practice resulted in actual harm to Resident 42 when avoidable, facility acquired pressure ulcers developed, and placed other residents at risk for worsening of pressure injuries, medical complications, and unmet care needs. Findings included . The National Pressure Ulcer Advisory Panel (NPUAP), dated 2016, Pressure Ulcer (Injury) Stages included: • Stage I: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. May indicate at risk persons. • Stage II: Partial thickness loss of dermis (the middle layer of skin in your body) presenting as a shallow open ulcer with a red, pink wound bed. • Stage III pressure injury full-thickness loss in which fatty tissue is exposed. • Stage IV pressure injury full-thickness loss of skin and tissue with exposed bone and tendon. • Unstageable: Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown material in the wound bed) and/or eschar (tan, brown or black dead tissue that sheds or falls off from the skin) in the wound bed. Review of the facility's policy titled, Skin Integrity and Wound Management, dated 02/01/2023, showed nursing staff: • Will continually observe and monitor patients for changes and implement revisions to the plan of care as needed. • Complete risk evaluation on admission/readmission, weekly for the first month, quarterly, and with significant change in condition. • Perform and document skin inspections an all newly admitted /readmitted patients weekly thereafter and with any significant change of condition. • Perform daily monitoring of wounds or dressings for presence of complications or declines. • Implement pressure injury prevention for identified modifiable risk factors. • Notify Physician to obtain orders. • Review care plan and revise as indicated. <Resident 42> Review of the medical record showed Resident 42 was admitted to the facility on [DATE] with diagnoses including fractured right hip and, kidney disease (damage to the kidneys that impairs the filtering of blood). The admission comprehensive assessment, dated 03/13/2023, showed the resident required extensive assistance of two people with repositioning, transferring, and activities of daily living (ADLs). Further review of the assessment showed the resident had two facility acquired unstageable pressure injuries to the right and left buttocks and was at risk for potential pressure injuries. Record review of a wound progress note by the Contracted Wound Consultant (CWC), dated 03/13/2023, showed a right buttock deep tissue injury measuring 6.0 by 7.8 by 0.1 centimeters (cm, a unit of measure) and a left buttock deep tissue injury measuring 10.8 by 12.3 cm. Additionally, the CWC documented the buttock wounds were likely due to prolonged bed pan use, and recommended to discontinue the use of the bed pan. Further review of the resident's medical record showed no documentation between admission on [DATE] and the CWC's visit on 03/13/2023 regarding the right and left buttocks wounds. During an interview on 10/13/2023 at 10:58 AM, a Resident Representative (RR) stated Resident 42 was admitted to facility for physical and occupational therapy, and the only skin issue was a surgical incision to their right hip. The RR further stated in the first few days, Resident 42 was bed bound and used a bed pan which resulted in two pressure injuries, to their right and left buttocks. The RR stated CWC had informed them the pressure injuries were acquired due to prolonged sitting on the bed pan. The RR further stated staff told them that they (RR) would have to turn Resident 42 every two hours because the staff did not have time to do so. On 10/13/2023, the State Surveyor attempted to observe wound and personal cares for Resident 42, however, the resident refused stating they did not feel comfortable. Record review of the care plan focus for incontinent care, dated 03/07/2023, showed staff was to provide a bed pan per the resident's choice. An intervention, dated 03/14/2023, staff were to line the bed pan with briefs to reduce pressure to buttocks. Record review of the care plan focus for actual skin impairment, dated 04/11/2023 (29 days after pressure injuries were found) showed the intervention of no bed pan use due to skin breakdown. Both care plans and their interventions were in place and active at time of review, showing different directives to staff for Resident 42's bed pan use. During an interview on 10/16/2023 at 7:24 PM, the CWC stated they had assessed the pressure areas on Resident 42 and noted that the wounds were the shape of the bed pan. The CWC further stated anything can cause a pressure injury if a person laid on it long enough. During an interview on 10/17/2023 at 12:29 PM, Staff O, Nursing Assistant (NA), stated they could not recall specific orders for the use of the bed pan for skin issues. During an interview on 10/18/2023 at 9:27 AM, Staff D, Treatment Nurse (TN), stated the prolonged use of the bed pan was the cause of the left and right buttock pressure injuries. Staff D further stated the minute the CWC observed and evaluated the wounds, they immediately knew it was caused from the bed pan because it was the exact shape of the bedpan. During an interview on 10/18/2023 at 8:34 AM, Staff B, Director of Nursing Services (DNS), stated that Resident 42's wounds to their right and left buttocks was from sitting on the bed pan for an extended period. Staff B further stated it was their expectation that residents should not sit on the bed pan longer than 15 minutes and that the correct process was not followed. <Resident 45> Review of the medical record showed the Resident 45 was admitted to the facility on [DATE] with diagnoses including right humerus (the largest bone of the arm) fracture, stroke, and dementia. The 08/28/2023 admission comprehensive assessment showed the resident required the extensive assistance of two people with repositioning, transferring, ADLs and had moderately impaired cognition. The assessment showed the resident had no skin issues and was at risk for pressure ulcers. Record review of the admission skin assessment progress note, dated 08/24/2023, showed Resident 45 was admitted with redness to their coccyx (tailbone). Record review of the physician's encounters dated 08/24/2023, 08/30/2023, and 09/01/2023, showed skin to be warm, dry, and intact. Record review of the August 2023 Treatment Administration Record (TAR) showed no orders to monitor the redness to the coccyx. Review of the September 2023 TAR showed an order, dated 09/01/2023, for barrier cream to coccyx every shift for skin breakdown prevention related to their incontinence and decreased mobility. Record review of the progress note, dated 09/07/2023, showed sheering (occurs when forces moving in opposite directions are applied to tissues in the body) to left buttock near the upper coccyx that was dime-sized and skin around the area was intact. The September 2023 TAR showed no orders related to sheering. Record review of the skin care plan, dated 09/07/2023, showed interventions initiated on 09/25/2023 for Resident 45 to be turned and repositioned every two hours and to apply barrier cream to the buttocks with each cleansing. Review of the CWC's progress note, dated 09/11/2023, showed a coccyx (tailbone) unstageable pressure injury measuring 5.0 by 8.0 by 0.1 cm at the wound base with eschar (dead tissue that forms over healthy skin) no slough (dead tissue that needs to be removed from the wound for healing to take place.) Further review of the progress note showed a recommendation for a Low Air Loss (LAL) mattress for more aggressive offloading due to wounds. Review of physician's orders, dated 10/03/2023, showed a LAL mattress was ordered (22 days after the CWC's recommendation). Record review of a skin assessment, dated 09/14/2023, showed nursing was still documenting only sheering to the left buttocks, near the upper coccyx that was dime-sized and the skin around the area was intact after the CWC assessed Resident 45 to have the coccyx unstageable pressure injury three days prior. Review of the change in condition evaluation form, dated 09/20/2023, showed notification to the physician of the skin issue, nine days after Resident 45 was assessed by the CWC . During an interview on 10/18/2023 at 8:41 AM, Contracted Physician Assistant-Certified (CPA-C) stated the change in condition evaluation form was how the providers get notified of any changes in condition, and that the CPA-C reviewed the forms daily. The CPA-C stated they were not sure when they were notified of Resident 45's change in condition and their expectation was to be notified within 24 hours, and for interventions to be placed immediately to prevent worsening of skin issues. During an interview on 10/18/2023 at 11:08 AM, Staff D stated their expectation was for the admitting nurse to place an order for any skin issues on the TAR. Staff D further stated that the correct process was not followed by the admitting nurse for Resident 45. During an interview on 10/18/2023 at 10:05 AM, Staff LL, Registered Nurse (RN), stated on admission, there was only redness to Resident 45's coccyx and they did not put an order to monitor the area on the TAR. Staff LL further stated that they did not follow the correct process. During an interview on 10/18/2023 at 2:25 PM, Staff B stated their expectations for the admitting nurse would be to have placed a specialty mattress right away and notified them that Resident 45 had compromised skin. Staff B further stated that an order to monitor the redness to coccyx should have been put in on the admission date. Additionally, Staff B stated that the correct process was not followed by the admitting nurse. <Resident 15> Review of Resident 15's medical record showed the resident admitted on [DATE] with diabetic neuropathy (nerve damage due to chronically high levels of glucose, or sugar, in the blood), and depression. The admission comprehensive assessment, dated 07/24/2023, showed the resident had moderately impaired cognition, required limited staff assistance with bed mobility, transfers, walking, dressing, and two person staff assistance with their toileting needs. The assessment showed Resident 15 had no wounds or skin issues on admission and was assessed to not have any risk for pressure ulcers or injuries. A concurrent observation and interview, on 10/11/2023 at 12:36 PM, showed Resident 15 was sitting in their wheelchair (w/c) with both feet wrapped with white gauze that extended from the heel to the ankle. Both feet were extended out in front with toes pointed to the ceiling and the heels resting on the floor. The resident stated they had ulcers on the back of both of their heels that they acquired while wearing crocs (a type of slip-on sandal shoe, with an open back and a strap, made of foam) shoes. The resident further stated they had worn their shoes while lying in bed, with their heels resting on the back strap of the shoe and caused the ulcers. Resident 15 further stated I have diabetic neuropathy, so I don't have any feeling in my feet. Review of nursing progress notes, dated 08/10/2023, showed the resident was noted to have DTI [Deep Tissue Injury: A pressure-related injury to subcutaneous tissues under intact skin] purplish/red to the back of Resident 15's right heel, and a DTI to the back of the left heel w/drainage and increased swelling. The note further showed the resident can't feel [Resident 15] feet too well and the straps from their current shoes were rubbing on the heels from resident self-propelling in their w/c. The note also showed the CWC would see the resident on 08/14/2023. A 08/14/2023 progress note showed the resident would wear prevalon boots (cushioned boots that keep the heel floated off the mattress, relieving pressure and reducing bedsores) while in bed to off load pressure. • Review of a wound note, dated 08/14/2023, showed the CWC diagnosed the ulcers as diabetic foot ulcers, and ordered protective dressings three times a week and as needed (PRN), appropriate footwear while in bed and ambulating, offloading [minimizing or removing weight placed on the foot to help prevent and heal ulcers] of the heels, and to wear prevalon boots while in bed or the recliner. Additional notes showed: a note on 09/11/2023 showed the CWC ordered tubigrip compression wraps (a multi-purpose support bandage that adjusts to the contours of the body and distributes pressure evenly over the surface) to be worn 23 hours a day with one hour of off time. • a note on 09/18/2023, showed the resident was to be non-weight bearing to their left heel until their ulcer resolved. Staff reported the resident had been resting their feet on the footboard and after the CWC inspected the bed, the CWC recommended footboard extenders be added to the bed. The left ulcer had increased necrotic (the death of cells or tissue through disease or injury) tissue, exudate, and wound breakdown. The CWC ordered an antibacterial honey gel to be applied to the wound bed and changed the dressing changes from three days a week to daily and as needed. • a note on 09/25/2023, showed the resident experienced unrelenting pain to their left lower extremity (LLE) and sent to the hospital for a possible blood clot. • a note on 10/09/2023, showed the resident re-admitted from the hospital on [DATE] and was treated for an LLE infection. The note further showed the resident's left heel ulcer had exposed and displaced hardware from past surgery history and was seen by an orthopedic (focuses on treating the musculoskeletal system) surgeon while in the hospital with a follow up scheduled. CWC ordered continue ortho follow up for guidance on management .protein supplements twice daily with meals until wound closure . Additionally, orders for a barrier cream to the edges of the wound bed of the left heel ulcer had been discontinued. • A note on 10/16/2023, showed an urgent referral to the orthopedic surgeon was needed and no culture was obtained because an antibiotic had already been started. Review of Resident 15's care plan, dated 08/15/2023, showed additional interventions for encouraging proper footwear and to offload/float heels with the boots or pillows while in bed. The care plan showed no documentation of the compression wraps, extended footboards, nor did the care plan reflect the changes to the ulcer. There was no documentation of changes or additional interventions that had been added or implemented and no documentation of the resident's refusals or non-compliance with current interventions. The care plan further showed no focus/interventions for the diagnosis of diabetic neuropathy or that the resident had no feeling to their feet. An observation on 10/12/2023 at 10:16 AM, showed Resident 15 sitting in their recliner, both feet resting on the floor, no offloading boots, footwear, or compression wraps were observed on either foot, or the bed extender. Staff E and Staff O, both NAs, entered the room to answer the call light. Neither NA offered to offload the resident's feet while in the recliner or offer offloading boots. A concurrent observation and interview, on 10/13/2023 at 9:28 AM, showed Resident 15 sitting up in their w/c, both heels were rested on the floor, toes pointed to the ceiling. There were no offloading boots, footwear, compression wraps, or footboard extenders observed. As this surveyor was exiting the room, the resident exited at the same time and was observed to be propelling their w/c with their heels out to the smoking area. Nursing staff observed the resident but did not encourage or educate the resident on their restrictions. A concurrent observation and interview, on 10/13/2023 at 1:02 PM, showed the resident lying in bed, both feet and heels resting on the top of a stack of two pillows, the two pillows rested on the footboard of the bed. The resident's left foot and ankle had increased swelling the size of a softball. The resident stated they informed the traveling nurse of the increased swelling. Resident 15 further stated they could not sleep the night before due to the increased pain. There were no offloading boots, compression wraps, or footboard extenders observed on the resident or in the resident's room. An observation on 10/16/2023 at 7:44 AM, showed Resident 15 sitting up in their w/c, non-skid socks on both feet, and both feet were resting on the floor. There was no footwear or compression wraps observed on the resident. Resident 15 stated they continued with increased pain and swelling to the LLE. A concurrent observation and interview, on 10/16/2023 at 9:08 AM, showed during wound rounds, the CWC observed the resident's LLE to have increased redness, pain, and swelling from their previous assessment. The resident had swelling and redness from the heel to above the ankle. The resident complained of pain from their knee down to the heel. There was an open ulcer, the size of a 50-cent piece to the back of the heel, with a dark green area where the CWC showed the hardware was protruding outward. The CWC stated the staff informed them an antibiotic had been started due to the increased swelling and redness. During the dressing change, Resident 15 was observed to have two new ulcers on the outer lateral part of the left foot, one in the middle, measuring 1.8 centimeters (cm, a unit of measure) x 1.9 cm and on the bony prominence below the small toe, a 0.9 CM x 0.9 cm blackened, crusted looking ulcer. Review of Resident 15's October 2023 Medical Administration Record (MAR), showed as of 10/18/2023 no order for antibiotics had been ordered or initiated. A follow-up interview on 10/16/2023 at 7:15 PM, the CWC stated they read notes in the hospital discharge documentation that showed the hospital had determined the left ulcer had hardware burrowing through their skin and the resident had been seen by the orthopedic surgeon while in the hospital with a follow-up scheduled. The CWC further stated they communicated with Staff D the need for the follow up with the orthopedic surgeon on the 10/09/2023 visit and thought it had been scheduled prior to today's visit. Review of the hospital discharge documentations, dated 10/02/2023, showed the resident had broken their left ankle years ago and hardware remains in place. The note further showed the resident was treated for a LLE infection. The notes showed no mention of an orthopedic surgeon consult, no mention of exposed hardware protruding or burrowing through the skin, and no follow-up had been scheduled. During an interview on 10/17/2023 at 12:11 PM, Staff D stated they were solely responsible for ensuring new or changed orders and recommendations from the CWC were initiated and completed after each visit. Staff D stated on days the CWC comes in, they are scheduled for 6 hours and that was not enough time to complete all the orders and recommendations and at times could take up to two days. Staff D further stated the footboard extenders and compression wraps must have been overlooked. Staff D stated they had not notified the provider of the resident's non-compliance with the offloading boots, nor had the resident been assessed for additional interventions due to that non-compliance. During an interview on 10/17/2023 at 3:00 PM, Staff F, Certified Dietician (CD), stated they reviewed the CWC's recommendation for increasing the protein supplement but decided against it because the literature didn't support the use of protein for healing diabetic foot ulcers. Staff F stated they did not document that decision, nor did they communicate it to the CWC. Review of Resident 15's September 2023 TAR showed, no new orders for the left heel ulcer had been started on 09/18/2023 for daily dressing changes and the antibacterial honey gel. The CWC's new orders were not initiated until 09/20/2023, and the first dressing change didn't get done until 09/21/2023. The resident missed two daily dressing changes and two days without the new antibacterial gel. Further review of the October 2023 TAR showed, the CWC's orders to discontinue the barrier cream to the wound bed edges was not initiated until 10/12/2023. Resident 15 received the barrier cream on 10/10/2023 and twice on 10/11/2023, once on the day shift and again on the evening shift. Review of the physician orders for September 2023, showed no new orders for the footboard bed extenders or the compression wraps and showed no new order for the twice a day protein supplement with meals. Review of the skilled nursing progress notes showed Staff G, Licensed Practical Nurse, documented on 10/11/2023 and 10/14/2023, showed the resident had redness and swelling to the left lower extremity (LLE) with no documented intervention or notification to the provider. An observation on 10/18/2023 at 9:56 AM, showed Resident 15 lying in bed, both feet are lying in the offloading boots. Boots are not closed, but they are on. During an interview, on 10/18/2023 at 10:02 AM, Staff G stated their documentation of Resident 15's LLE redness and swelling was thought to be left over from their infection from the hospital so wasn't sure if it was new or old so I didn't report it to the provider. Staff G further stated the staff don't always know Resident 15's actions and they will put themself into bed without the staff knowing and education is attempted but the resident is non-compliant. Staff G further stated they had not discussed risks and benefits of being non-compliant with their treatment nor had they notified the provider of the non-compliance. Staff G further stated Resident 15 will comply to recommendations if reminded and encouraged to do so. Staff G stated the resident had them on today and that made them happy. During an interview on 10/18/2023 at 2:22 PM, Staff EE, NA, stated Resident 15 will normally follow directions if they are encouraged and educated and will allow you to float their heels correctly. During an interview on 10/18/2023 at 8:26 AM, the CPA-C stated they were not notified the resident had surgical hardware protruding out of their heel ulcer, nor were they informed the resident had complained of increased pain, redness, or swelling to the LLE since 10/11/2023. The CPA-C stated they would have expected the nursing staff to notify them of any changes to the resident, whether it was old or new, and allowed them the ability to assess and make that determination, not just ignore it. The CPA-C further stated they had not had any visits with Resident 15 since the week prior so no antibiotics could have been started. The CPA-C further stated they did not communicate that information to the CWC and does not know where the CWC would have gotten that information. The CPA-C continued to say they were not notified Resident 15 needed a referral to the orthopedic surgeon and had not ordered one since readmission. The CPA-C further stated they had not made any further assessments or recommendations other than therapy for the resident's non-compliance with interventions. The CPA-C further stated, based off the information given of how the heel ulcers were acquired, their assessment would lean more to the ulcers being caused by pressure. Lastly, the CPA-C stated they would expect dietary recommendations made by the CWC should have been followed and did not recollect discussions with Staff F regarding the decision to not increase the protein supplement. Additional information provided by the facility on 10/20/2023, showed a provider's visit on 10/19/2023, showed Staff MM, Medical Director, assessed the resident to have ongoing left heel pressure ulcer with cellulitis .visible orthopedic hardware .left lateral foot stage II PU. Further review showed the resident had been started on an antibiotic to be taken four times a day and had been scheduled to see the orthopedic surgeon on 10/27/2023. Reference: WAC 388-97-1060(3)(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure restorative therapy services were implemented to prevent avoidable reduction of range of motion (ROM) and mobility for 2 of 3 sampled residents (Residents 39 and 4) reviewed for restorative therapy. This failure resulted in actual harm to Resident 39 who developed, right and left leg contractures (a condition of shortening and hardening of muscles, tendons, or other tissue that leads to muscle stiffening and loss of range of motion of the effected body part)and placed other residents at risk for contractures, decreased mobility, and pain. Findings included . Record review of the facility policy titled, Restorative Nursing, dated 08/07/2023, showed the facility will provide restorative nursing programs for residents who: • .have restorative needs arise during the course of a longer-term stay . • .will benefit from restorative programs • .to help the patient obtain and maintain optimal physical, mental, and psychosocial functioning . Further review of the policy showed they would develop specific measurable goals and document goals and interventions on the resident's restorative care plan and document daily on the Restorative Nursing record. <Resident 39> Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses including stroke, dysphagia (difficult swallowing), and rheumatoid arthritis. The 09/30/2023 comprehensive assessment showed the resident required extensive assistance of two persons with repositioning, transferring, and activities of daily living (ADL's). The resident was assessed to have moderately impaired cognition, with range of motion (ROM) impairment to only left side of upper extremity (UE) and lower extremities (LE). The assessment further showed that they did not have any restorative programs or skilled therapies during the assessment period. A comprehensive annual assessment, dated 07/01/2023, showed no restorative programs or skilled therapies during that assessment period. Record review from a hospital stay, showed a physical therapy note dated 08/04/2022, that documented the resident was able to perform squat/pivot transfers with two-person extensive assistance with the improvement of their neurologic status and left side mobility and strength. There were no documented contractures in the therapy evaluation. Record review of the Occupational Therapy (OT) admission evaluation, dated 08/10/2022, showed that Resident 39 was able to go from a lying to a sitting position with assistance and from a sitting to lying position with assistance. No transfers or ambulation was attempted on admit. Further review of the record showed no contractures. Record review of the Physical Therapy (PT) admission evaluation, dated 08/10/2022, showed that Resident 39's right and left lower leg, hip and knee were able to contract and provide resistance and no documented contractures. Record review of the PT recertification, dated 09/09/2022 to 10/08/2022, showed that Resident 39 was able to lower their legs off of the edge of the bed with cueing and no documented contractures. Record review of the PT recertification, dated 10/6/2022 to 11/04/2022, showed that Resident 39 was able to lower their legs off the edge of the bed independently and was able to stand in the standing frame (an assistive device that supports the resident in a standing position). Further review showed no documented contractures. Record review of the PT recertification, dated 11/05/2022 to 12/04/2022, showed that resident 39 was able to ambulate with a front wheeled walker (FWW) with assistance up to 45 feet and no documented contractures. Record review of the PT recertification, dated 11/17/2022 to 01/16/2023, showed that resident 39 had a decrease in physical function after prolonged sitting in their wheel chair for an out of town appointment but progressed and was able to ambulate with a FWW up to 10 feet and no documented contractures. Record review of the PT recertification, dated 01/16/2023 to 3/18/2023, showed that resident 39 had a decline in function during this time period going from stand and pivot transfers to a hoyer lift (a device that allow a person to be lifted and transferred with a minimum of physical effort) and no documented contractures. Record review of the PT recertification dated 02/24/2023 to 03/25/2023, showed that resident had bi lateral (both sides) hip and knee contractures with a change in plan of care to focus on contracture management. Record review of the Functional Maintenance Transition Plan (FMP, a program to help resident's maintain the functionality, strength and independence they gained during their skilled therapy) dated 03/10/2023, showed a program was written for active range of motion and positioning with a goal to reduce the risk of bilateral lower extremity contractures. Further record review showed no FMP for the nursing assistants to perform restorative therapy services was active in the resident's medical record. Record review of the PT Discharge summary, dated [DATE], showed a discharge diagnosis of bilateral knee/hip contractures. Record review of Resident 39's care directives to staff in their medical record on 10/13/2023 showed no active FMP in place. Observations on 10/10/2023 at 11:53 AM, and 12:49 PM and on 10/11/2023 at 10:32 AM and 11:43 AM showed Resident 39 in bed, lying on their back rolled over on their left shoulder, and their neck contracted to the left . Resident 39's right leg was bent at the knee upward and externally rotated outward with their ankle touching outer thigh. Resident 39's left leg was bent at the knee upward with their ankle touching their outer thigh. Resident 39 was in the same position during each observation. During an interview on 10/12/2023 at 12:24 PM, Staff E, Staffing Coordinator/Nursing Assistant (SC/NA), stated that they did not have active restorative services only the FMP program. Staff E further stated that Resident 39 did not have an FMP program and they were not sure why. During an interview on 10/17/2023 at 11:20 AM, Staff, PP, Occupational Therapist, stated that Resident 39 should have been on an upper extremity FMP and the resident's neck contracture caused limitations that limited movement of their head and neck from left to right prohibiting full ROM. Staff PP stated this was new since they had last seen them. Staff PP further stated that unless someone reported to them there was a decline in functioning, they would not do an evaluation, and no one had reported anything about the neck limitations. Additionally, Staff PP stated that if Resident 39 had been on an FMP, their neck would not of had a decline in function and their expectations would be for Resident 39 to be on a ROM program daily to maintain their functioning. During an interview on 10/17/2023 at 2:53 PM, Staff L, Physical Therapist Assistant (PTA), stated that they called the original PT who completed Resident 39's assessment and they clarified there were no contractures documented on admission. Staff L further stated they noticed a higher increase in tone (tension in a relaxed muscle) to Resident 39's right and left leg in December 2023. Staff L stated, When the resident stood up, [they were] not able to put [their] right foot all the way down. Staff L stated that they increased Resident 39's exercises specifically for the contractures that were forming in the right knee. Additionally, Staff L stated that the last FMP program was initiated on 05/19/2023 and that they did not cancel it and was unsure as to why it was cancelled. Staff L stated it was their expectation that staff would go through therapy to cancel any FMP. During an interview on 10/17/2023 at 4:38 PM, Staff B, Director of Nursing Services (DNS), stated that their expectation was that any resident who would benefit from restorative therapy services, or who was showing any sort of decline, be evaluated by the DNS or the minimum data set nurse (MDS, a standardized assessment tool that measures health status in nursing home residents ) and have an FMP implemented. Staff B further stated that they had to maintain the resident's highest level of functioning and that was not done for Resident 39. Additionally, Staff B stated that Resident 39 should have had an FMP in place for their contractures and that they did not have a proper process in place. During an interview on 10/17/2023 at 5:23 PM, Staff C, Resident Care Manger/MDS Coordinator stated that they usually kept a good eye out for functional decline but during this time (February 2023 and March 2023) they had to work the floor due to short staffing. Staff C further stated that the correct process would have been to monitor Resident 39 for a significant change and have an FMP in place and that they did not follow the correct process. <Resident 4> Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses including parkinsons (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) peripheral neuropathy (when the nerves that are located outside of the brain and spinal cord (peripheral nerves) are damaged causing weakness, numbness and pain.)The 06/27/2023 comprehensive assessment showed the resident required extensive assistance of two persons with repositioning, transferring, and activities of daily living (ADL's). The resident was assessed to have intact cognition. Observation on 10/10/2023 at 12:05 PM, showed Resident 4's fingers curled inward towards the palm of their hand at the second knuckles. Record review of Resident 4's medical record, dated 06/21/2023, showed Resident 4 was diagnosed with left and right hand contractures. Record review of OT consultation, dated 07/18/2023, showed Resident 4 had contractures to both hands and that they made consistent progress towards goals. Resident 4 received those therapy services three times a day between 07/18/2023 and 08/16/2023. During an interview on 10/13/2023 at 9:02 AM, Resident 4 said they used to get therapy for their hands and then therapy showed the NA's how to do it. Resident 4 said they can't remember the last time a NA did the hand exercises with them. Resident 4 stated that their fingers were getting worse since therapy stopped. Record review of Resident 4's FMP dated 08/02/2023, showed staff to perform ROM exercises. The bottom of this document showed three NAs signed and dated that they were trained to perform these duties. Record review of NA Charting for Resident 4's ROM exercises, dated 09/18/2023 through 10/17/2023, showed to perform ROM exercises one time a day and as needed. There was no charting for 22 days over this 30 day look back period. During an interview on 10/13/23 at 9:08 AM and at 12:06 PM Staff M, NA, stated that Resident 4 was unable to do things with their fingers. Staff M stated that Resident 4 had a splint and needed to have finger exercises done for their contractures. Staff M stated that the PTA trained them on how to do the exercises and put the brace on. Staff M stated that these things were not being done because they did not have enough time on their shift to do it. During an interview on 10/17/2023 11:11 AM, Staff N, Licensed Practical Nurse (LPN), stated that Resident 4 had some ROM decline. Staff N stated that Resident 4's FMP was not being done because the NAs did not have time on their shifts to implement the program. During an interview on 10/12/2023 at 2:28 PM, Staff L, PTA, stated that residents received skilled therapy services and when their program was completed, they received a FMP. Staff L stated that NAs were trained to implement resident FMP'S during their work shift and chart it in their system. Staff L stated that they started this program this year and that it was an alternative to the true restorative therapy program they used to have. During an interview on 10/17/2023 at 12:55 PM, Staff B, DNS, stated that their expectation was NA's completed and charted residents FMP. Staff B stated that staffing could be a barrier and that NA's had a lot of work to do and may not have time to do the FMP's. Staff B stated that the post therapy system might need to be looked at to ensure those programs were being implemented. During an interview on 10/18/2023 at 1:35 PM, Staff A, Administrator, stated that they did not have a Restorative Therapy Aide and moved to the FMP. Staff A stated that they have not conducted an audit to see if the system was working. Staff A stated that not having enough staff on the floor would impact residents with high acuity needs leading towards a decline in some residents. Reference: WAC 338-97-1060 (3)(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to ensure the prevention and the development of facility-acquired pressure ulcers for two of five residents (1 and 2) reviewed for pressure ulcers. This failure placed residents at risk for a decreased quality of life and caused actual harm to resident 1 who developed an avoidable pressure ulcer that was not present upon admission. Findings included . Review of the National Pressure Ulcer Advisory Panel's (NPUAP) definitions showed: Unstageable Pressure Ulcer: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar .If the slough or eschar is removed, a Stage 3 or Stage 4 pressure ulcer will be revealed. If the anatomical depth of the tissue damage involved can be determined, then the reclassified stage should be assigned. The pressure ulcer does not have to be completely debrided or free of all slough or eschar for reclassification of stage to occur. Stage 2 Pressure Ulcer: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister . Stage 3 Pressure Ulcer: Full-thickness skin loss Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss. The depth of tissue damage varies by anatomical location . Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the wound bed, it is an Unstageable PU/PI. Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure ulcer. Once a deep tissue injury opens to an ulcer, reclassify the ulcer into the appropriate stage. Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. Review of the facility's 09/01/2022 policy, Skin Integrity and Wound Management, showed the practice standards were to complete a risk evaluation on admission/re-admission, weekly for the first month, quarterly, and with significant change in condition .the licensed nurse will perform and document skin inspection on all newly admitted /re-admitted patients weekly thereafter .implement pressure injury prevention for identified, modifiable risk factors .Notify Dietitian. Resident 1. Review of the resident's admission record showed the resident admitted to the facility on [DATE] with diagnoses to include Parkinson's Disease (a progressive disorder that affects the parts of the body controlled by the nerves), failure to thrive (failure to grow or develop well or vigorously), severe protein malnutrition (an imbalance between the nutrients your body needs to function and the nutrients it gets), and diabetes (a disorder in which the body has high sugar levels for prolonged periods of time). Further review showed the resident had no redness, maceration, or skin breakdown, had dry and scaly skin, had the lack of ability to feel pain in one or both extremities, and was six feet tall. Review of the resident's comprehensive assessment, dated 08/05/2022, showed the resident's cognition was intact, required extensive one person assistance with bed mobility, toilet use, and personal hygiene. The resident was incontinent of bowel and bladder, and had no skin issues. The assessment further showed the resident was not at risk for pressure ulcers. Review of a 08/10/2022 Braden Scale (a tool used to predict pressure ulcer risk) assessment, showed the resident was at mild risk for pressure ulcers. Braden scale assessments on 08/17/2022 and 08/24/2022 also showed the resident was at mild risk for pressure ulcers. The record showed no assessment had been completed on 08/31/2022. Review of the Podiatrist notes on 08/30/2022, showed the resident had been seen for foot care due to increased risk status, and determined there were findings for decreased vascularization (the formation of blood cells). Review of Physician orders for November 2022, showed a 09/06/2022 order for Prevalon boots [a boot with a cushioned bottom that floats the heel off the surface of the mattress] on at all times in bed, and an 08/24/2022 order for a Low Loss Air mattress (LAL, a mattress designed to help treat and prevent pressure ulcers). An observation on 11/04/2022 at 11:45 AM, showed the resident lying in bed, head elevated, and both feet resting, flat footed, against the foot board of the bed. The resident's heels were not floated (heels are suspended in the air) and there were no Prevalon boots on the resident's feet. The resident stated, I am too tall for this bed, and my feet are always touching the bottom of the bed. The resident was observed to have a gauze dressing around their left foot. The resident stated they had a sore to their foot and had been in the same position since breakfast. Review of the facility's September 2022 Incident Reporting log showed the resident developed a facility-acquired pressure ulcer to their left heel on 09/06/2022. An observation of wound care on 11/04/2022 at 3:49 PM, showed Staff I, Licensed Practical Nurse (LPN), removed the resident's left boot, then the gauze dressing from their left foot, the gauze was not covering the wound itself, leaving the wound exposed while it was in the boot. There was an opened area the size of a fifty-cent piece, with a nickel sized area of black eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like), and maceration (soften or become softened by soaking in a liquid). The peri-wound had brown drainage to the top of the wound, and yellow slough (non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed) to the lateral part of the outer wound. There was another dime sized pressure ulcer to the lateral aspect of the foot that appeared macerated, and the resident's skin was extremely dry, and flaked off when the Nursing Assistant (NA) elevated the foot in the air. When applying the absorbent pad to the wound, the corner folded over in a triangle shape over the wound. Staff I did not straighten out the dressing before applying the gauze dressing. The resident's foot was then floated on a pillow and a new Prevalon boot obtained due to the drainage from the wound prior to the dressing change. An observation and concurrent interview on 11/09/2022 at 12:56 PM, showed Resident 1 lying in bed, feet resting flat against the footboard of the bed, head slightly elevated, and there were no Prevalon boots on or heels floated. Resident was observed grimacing and low sounding moans. The resident stated they had pain to their left foot and had just been given pain medication. The resident further stated the facility extended the foot of their bed to give them a little more room, but it didn't really help because they slid down all the time. An observation and concurrent interview on 11/09/2022 at 5:08 PM, showed the resident was in the same position as they previously were at 12:56 PM and stated they had not moved off of their back all day. An observation on 11/10/2022 at 9:29 AM, showed Resident 1 was lying in their bed, head at 30 degrees with the resident's body a quarter of the way down the bed from the head being elevated. The resident's heels were not floated, and their booted feet were touching the footboard of the bed. Follow-up at 10:26 AM showed the resident in the same position as they were at 9:29 AM. During an interview on 11/10/2022 at 11:38 AM, Staff F, Maintenance Supervisor (MS), stated they extended Resident 1's bed out as far as it could, go, but there were longer beds available, bariatric (treatment in the area of obesity) beds that can be used to give more length. Review of the resident's 08/03/2022 care plan showed an intervention added on 08/03/2022 to conduct a comprehensive skin inspection weekly due to diabetes diagnosis, on 09/06/2022 a low loss air mattress, and Prevalon boots while in bed. Review of the resident's weekly skin assessments showed no skin assessments had been completed during the first four weeks after admission. On the fifth week after admission, after the pressure ulcer had been discovered, showed a skin assessment, dated 09/07/2022. The assessment showed the resident had dermatitis (a skin condition characterized by a red, itchy, dry rash) to their buttocks, a DTPI to the left heel (acquired 09/05/2022), and a DTPI to the tailbone (acquired on 08/22/2022.) Review of the NA tasks showed the resident had tasks in the Electronic Health Record (EHR) for preventative skin care every shift as follows: 1. Heel protectors applied? 2. Lotion or cream applied? 3. pressure relieving device in place for bed and chair? 4. Did you turn the resident according to plan of care? Review of the August 2022 tasks showed staff failed to document care was provided for 50-51 out of 87-88 shifts. Review of the September 2022 tasks showed staff failed to document care was provided for 62-64 out of 90 shifts. Review of the October 2022 tasks showed staff failed to document care was provided for 73-74 out of 93 shifts. During an interview on 11/10/2022 at 9:35 AM, Staff D, Nursing Assistant Registered (NAR), stated they try to turn [resident 1] every two hours, but the ones [residents] that are 'heavier care' don't get moved as often because we get too busy and don't have enough time. Staff D further stated they were a newer NA and new to Resident 1's care and wasn't sure how often they should be turned, specifically, with a wound. During an interview on 11/10/2022 at 9:47 AM, Staff H, NA, stated they turned and repositioned Resident 1 every two hours, and floated their heels on pillows. Staff H stated they documented what they completed in the EHR and if there isn't documentation, it's because they [the resident] refused, or we [NA's] didn't do it. Staff H further stated there was an area in their charting for refusals and they would document a refusal there. Staff H further stated they were assigned to Resident 1 but had not repositioned them because they had been in a meeting. Review of the resident's 09/06/2022 nutrition assessment, showed no wounds had been identified and no interventions had been implemented. Review of the wound note on 09/12/2022, Staff E, Wound Consultant (WC), documented Resident 1 was treated for an unstageable pressure ulcer to left heel 4 cm by 3 cm by 0 cm. Review of the wound note on 10/17/2022, showed Staff E debrided (a procedure to remove debris or infected/dead tissue from a wound) the left heel, and the heel was now classified as a Stage 3 pressure ulcer. The note further showed the resident had decreased perfusion (the passage of blood, a blood substitute, or other fluid through the blood vessels or other natural channels in an organ or tissue) to the left lower extremity and ordered the resident to have an urgent vascular referral to rule out a blockage or peripheral artery disease (PAD, the narrowing or blockage of the vessels that carry blood from the heart to the legs). Review of the 10/25/2022 and 11/07/2022 wound notes showed the urgent vascular referral had still been pending. During an interview on 11/10/2022 at 4:09 PM, Staff E stated it was extremely important to follow the interventions put into place (eg. Prevalon boots) and to turn and reposition residents with wounds even if they were utilizing a LAL mattress, or any other kind of alternating air mattress. Staff E further stated they did not know what was holding up the referral for Resident 1, and just assumed it was difficult to get an appointment. During an interview on 11/14/2022 at 3:39 PM, Staff C, Resident Care Manager (RCM), stated they could not recall an urgent vascular referral had been ordered for Resident 1. Staff C stated their understanding was skin assessments were to be completed weekly and are also dependent on the wound, which could be more often and Braden scale assessments were to be completed on admission, quarterly, and with a change of condition. Staff C further stated they were aware there were gaps in the task documentation but they are slowly getting tighter. During a follow-up interview on 11/17/2022 at 2:26 PM, Staff C stated they had faxed the referral to the provider on 11/16/2022, the vascular provider then requested another study be completed prior to them seeing the resident. When the surveyor asked about the referral being sent prior to 11/16/2022, Staff C stated that the referral had been initially faxed on 10/25/2022 (8 days after the urgent request) through their computer system but did not have a confirmation or documentation that the fax had been sent or was received. Resident 2. Review of the resident's medical record showed the resident admitted to the facility on [DATE] with diagnoses to include dementia (a group of symptoms that affects memory, thinking, and interferes with daily life) and heart failure. The comprehensive assessment, dated 08/28/2022 showed the resident's cognition was severely impaired, required extensive two person assistance with bed mobility and toilet use. The resident was incontinent of bowel and bladder, and had no skin issues. Review of the 06/13/2022 care plan showed the resident had a history of two DTPI's to their right heel, with prevention interventions of Prevalon boots while in bed, provide turning and repositioning assistance every two to three hours, off-load/float heels while in bed, and weekly skin checks by a licensed nurse. Review of Physician orders for November 2022, showed an order on 04/12/2022 for Prevalon boots on when up in WC [wheelchair] to protect footrests, and a 08/16/2022 order for a Promat mattress (alternating pressure therapy). Review of the facility's September 2022 Incident Reporting log showed the resident developed two facility-acquired pressure ulcers on 08/30/2022. One to the left heel and one to the right medial mid foot. Review of the facility's 09/01/2022 Incident Investigation Summary showed on 08/30/2022, during shift change, the resident did not have their Prevalon boots on and the resident had their feet crossed over one another. The LN assessed the resident's heel and observed two fluid filled blisters (Stage 2 pressure ulcers). One to the left inner heel that measured 3.5 centimeters (cm) by 5.5 cm, and one to the right medial mid foot that measured 3.5 cm by 3.5 cm. Review of the resident's Braden Scale assessments showed on 08/31/2022, the resident was at moderate risk for pressure ulcers, the only assessment since 02/01/2022 (seven months since previous assessment). Review of the resident's weekly skin assessment, dated 08/26/2022, showed the resident's skin was intact. The assessment further showed interventions to assist the resident turn and reposition every two to three hours, and to off-load/float their heels while in bed. Review of the NA tasks showed the resident had tasks to be completed every shift as follows: 1. Monitor the Prevalon boots were always on? 2. turn and reposition the resident every two hours? Review of the August 2022 tasks showed the staff failed to document care was provided for 62-63 out of 93 shifts. Review of the 09/01/2022 through 09/09/2022 tasks showed staff failed to document care was provided for 23 out of 26 shifts. During an interview on 11/09/2022 at 1:13 PM, Staff J, NA, stated they cannot recall when they last had education on pressure ulcer prevention. Staff J further stated when asked about missing documentation that they were taught if you don't write it down then it wasn't done. During an interview on 11/09/2022 at 5:17 PM, Staff K, NA, stated if they had missing documentation,it would be because we didn't do it, or that issue [task] wasn't addressed. During an interview on 11/10/2022 at 11:00 AM, Staff B, Director of Nursing (DON), stated they recognized there was an issue with facility-acquired pressure ulcers and they addressed those concerns during an all staff meeting the month prior but could not produce documentation to support that. Staff B stated their expectation was that LN's completed weekly skin assessments and recognized that was not being done. Staff B further stated the nursing staff had understood that when the resident was being followed by the wound consultant, the weekly skin assessments did not need to be completed, that was not the case. The wound consultant only focused on the wound assessment itself, and not the entire body. No education had been given to the nursing staff, maybe a little verbal reminder. WAC Reference: 388-97-1060 (3)(b)