**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure residents were free from accident hazards when staff provided a one-person transfer with toileting assistance instead of the care planned two-person transfer with toileting assistance for 1 of 3 sampled residents (Resident 1) reviewed for accident hazards. This failure placed residents at risk for injury and a diminished quality of life. Resident 1 experienced harm when he was assisted with one staff rather than two and sustained three rib fractures and subsequent pleural effusion (a build-up of excess fluid between the layers of the pleura outside the lungs), pain, and bruising. Findings included Resident 1 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). The Quarterly Minimum Data Set (MDS), an assessment tool, dated 07/26/2023, documented Resident 1 had severe cognitive impairment and required two-person extensive assistance with transfers and toileting. Resident 1's Activities of Daily Living (ADL) care plan, initiated on 03/02/2021, included interventions for toilet use and documented the resident required extensive assistance of two staff. Interventions for transfers were documented as requiring a two-person stand-pivot when the resident was alert and able to follow cues. Resident 1's urinary and bowel incontinence care plan, initiated on 03/02/2021, documented the resident required assistance of two persons for toileting needs. An event note, dated 09/06/2023 at 7:55 PM, by Staff D, Licensed Practical Nurse (LPN), documented Resident 1 was assisted to the floor while tranferring to the toilet and slid off the seat and on to the floor. The note documented staff called for assistance, the resident was assessed and assisted back to their wheelchair. Resident 1 reported pain of 2 out of 10 to their right flank (side) and had denied hospital transport for evaluation. A facility investigation report, initiated 09/06/2023 by Staff D, documented they (the nurse) had been notified Resident 1 was assisted to the floor after slipping on feces on the toilet seat. The report documented the event happened during transfer/while transferring to the toilet in the shower room and resident was assisted to the floor. A staff witness statement, completed by Staff F, Nursing Assistant (NAC), reported they were the only staff providing care and documented the type of incident was an assist to the floor and resident had slid from the toilet seat. An event note, dated 09/07/2023 at 12:22 PM, documented Resident 1 was not able to take deep breaths and recommended staff listen to lung sounds especially on the right side. An event note, dated 09/08/2023 at 5:40 AM, documented Resident 1 reported soreness on his right side, rating his pain a 3 out of 10. An event note, dated 09/09/2023 at 5:40 AM, documented Resident 1 had appeared to have difficulty with bed repositioning and cares and slept very little. An event note, dated 09/11/2023 at 3:24 PM, documented Resident 1's restorative program (program to improve or maintain level of function) was discontinued due to bruising and pain to his side. An event note, dated 09/13/2023 at 1:21 PM, documented Resident 1 was transferred to the ER for increased pain related to the fall and was admitted for evaluation. A hospital chest Computed Tomography (CT) scan (shows detailed images of inside the body) report, dated 09/13/2023 at 5:14 PM, documented Resident 1 had acute (sudden injury) and displaced (out of normal position) right posterior (back) rib fractures 9, 10, 11 (3 different ribs affected) and adjacent reactive pleural effusion (a build-up of excess fluid between the layers of the pleura outside the lungs). Resident 1 was readmitted to the facility on [DATE]. An alert note, dated 09/17/2023 at 12:25 AM, documented resident rated his knife like pain laying still an 8 out of 10 and he had difficulty sleeping and movement increased his pain. On 10/02/2023 at 4:41 PM Staff D said Resident 1 was care planned for two-persons to assist the resident with toileting and transfers stating, [Resident 1] is a heavy load. When asked about Resident 1's fall on 09/06/2023, Staff D said the resident was being transferred from their wheelchair to the toilet and normally the resident would stand up and staff would assist resident to pull their paints down and assist onto the toilet and in this instance there was feces on the toilet seat and the resident slid off the toilet on to the floor. Staff D said Resident 1 was being assisted by Staff F, and he was a large guy and must have thought he could do it himself. Staff D said she assessed the resident for injuries, and the resident declined to go to the ER, but the resident later developed a huge bruise and the pain had worsened and Resident 1 eventually agreed to go to the ER. On 10/03/2023 at 5:15 PM, Staff E, NAC, said staff knew what level of assistance to provide for toileting and transfers by what was on the care plan. Staff E said Resident 1 was a two-person assist. When asked about Resident 1's fall on 09/06/2023, Staff E said Staff F had been transferring Resident 1 in the bathroom and the resident was already on the floor when she arrived but it was her understanding that when Staff F tried to transfer Resident 1, the resident slid and hit a bucket that was on the floor. On 10/04/2023 at 12:59 PM, Staff F, NAC (agency), said staff knew what level of assistance residents required by what was on the care plan. Staff F said Resident 1 was a one to two-person assist depending on how the resident was doing. Staff F said he was familiar with the resident and he felt the resident was good to transfer with one person that day. When asked about Resident 1's fall, on 09/06/2023, Staff F said Resident 1 was taken to the bathroom, the resident stood up, and Staff F pulled the resident's pants down and the resident sat on the toilet. Staff F said as the resident was trying to get up, the resident slid. Staff F said he tried to support Resident 1, but it exceeded his strength. When asked if the resident was done using the bathroom or if the resident had stood up unexpectedly, Staff F said Resident 1 was done and Staff F was assisting the resident to stand up and resident was weaker at that time and slid/landed on right side of their body where there was a bucket on the floor. Staff F said he was unable to hold the resident up and the resident came down on the bucket. At 1:22 PM, Staff C, LPN, Resident Care Manager, said staff knew what level of assistance a resident needed by the care plan. Staff C said Resident 1 could be a one or two-person assist for toileting and transfers depending on his Parkinson's that day and Resident 1 could sometimes tell staff, or staff could tell if the resident was going to be able to stand or if they would need a second person. On 10/04/2023 at 1:52 PM, Staff B, Registered Nurse and Director of Nursing, said staff knew what level of assistance was required by accessing the chart and clicking on the task. Staff B said Resident 1 was a two-person assist for transfers. When asked if two staff had provided toileting assistance, Staff B said she did not know if one or two staff provided assistance for the toileting and transferring at the time of Resident 1's fall. Staff B said she did not interview Staff F, as the nurse on the floor at the time of the fall (Staff D) did that. Staff B said Staff F would definitely need to be in-serviced if he was transferring Resident 1 with only one staff. Staff B said Resident 1 was a big guy and sometimes able to tell staff when resident had to have a bowel movement and sometimes staff would use a shower chair but at the time of the fall he was transferred to the toilet. Staff B said she updated the care plan to include the use of the shower chair for toileting and no other changes were made. Review of care plan revision history showed the toilet use intervention changed on 09/14/2023 to; The resident needs extensive assist of two to be changed. Use shower chair in corner with grab bars when needing to have a BM [bowel movement]. At 2:04 PM, Staff A, Administrator, said staff knew what level of assistance a resident required by the care plan. Staff A said Resident 1 had slid off of the toilet. Staff A said they were not sure what Resident 1's care plan indicated but the resident was able to pull himself up with the bar but could become shaky after toileting due to his Parkinson's. Reference WAC 388-97-1060(3)(g) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident 30 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], documented the resident was cognitively intact and required extensive assistance with activities of daily living. A Nutritional Assessment, dated 10/12/2022, documented, Met with resident in her room during lunch meal. Reports feeling poor to fair. Intake appears to be fair to good with complaints of constipation. Weight appears to be relatively stable. Resident 30's weight record showed he weighed 228 pounds on 10/12/2022, and when weighed again on 11/07/2022, resident weighed 194 pounds. This demonstrated an actual weight loss of 34 pounds, 14.91%, in 26 days. Resident 30's EHR (electronic health records) did not show an adjustment to the resident's meal plan, further investigation, or documented evidence the resident 30's weight loss was triggered or addressed at a weight meeting. On 03/05/2023 at 2:19 PM, Resident 30 stated, They bring me lunch and set it here, and I sleep through it. I don't eat it. I am okay with that, I guess. On 03/07/2023 at 9:47 AM, Staff E, Director of Rehabilitation, stated, If there is weight loss, the resident is going to be discussed at our Friday's meeting to see how to address it. Staff E said Resident 30 had swelling and went to the hospital. Staff E said she would provide additional information, including meeting notes on Resident 30's weight loss. No additional information was provided. At 10:43 AM, Staff B stated, When there is a weight loss, it triggers, and we discuss it at a meeting. Staff B said Resident 30 was hospitalized numerous times with hip and sepsis, and that is probably why the weight loss. Staff B stated, We should have put a note in. On 03/08/2023 at 1:50 PM, Staff G said Resident 30 was not weighed after returning to the facility after hospitalization. Staff G stated, There was no base line. If these weights are not accurate, then we need to get in there to provide some sort of intervention. Reference WAC 388-97-1060 (3)(h) Based on observation, interview and record review, the facility failed to accurately monitor meal intake and resident weights and failed to implement and evaluate the effectiveness of weight loss interventions to determine if additional interventions were needed for 2 of 2 sampled residents (22 & 30) reviewed for nutrition. This caused harm to Resident 22 when the resident felt fatigued and weak after a 11.78 % weight loss in 98 days, just over three months. This failure placed residents at risk for weight loss, inadequate nutrition and diminished quality of life. Findings included . Review of the facility policy, undated, entitled Resident at Risk (RAR) Policy showed the facility conducted weekly resident at risk meetings to review residents who were identified or had the potential for developing nutritional issues. A list of actions or reviews were listed for different members of the team to complete prior to the meeting. For the nurse designee, one task included reviewing current snack/supplement intake and considering the cause to review pain management, psychosocial needs, and/or mood/depression. During the meeting, the care plan was to be updated with interventions that were resident specific and individualized. 1) Resident 22 was admitted on [DATE] with diagnoses including rehabilitation, pain management from a sacrum fracture, multiple myeloma in remission (a cancer that forms in plasma cells then accumulates in the bone marrow), Gastro-Esophageal Reflux Disease (a condition in which acid from the stomach comes up into the esophagus causing irritation), dysphagia- pharyngoesophageal phase (difficulty swallowing food), nausea with vomiting, anxiety and depression. The significant change Minimum Data Set (MDS), an assessment tool, dated 02/09/2023, showed Resident 22 was cognitively intact, able to make needs known, had a swallowing disorder, and had a weight loss of more than 5% or more in a month or 10% or more in six months that was not physician prescribed. Review of hospital discharge documents, dated 11/02/2022, showed Resident 22's multiple myeloma was considered to still be in remission and she was to follow up after discharged from the skilled nursing facility. The hospital discharge documented Resident 22 did not have edema and appeared distressed and remained tearful. Review of Resident 22's weights showed a 5.9 pound increase after admission over the month of November 2022. Starting in December 2022 to March 2023, Resident 22's weights started a decrease from 203 pounds on 11/24/2022 to 173 pounds on 03/02/2023. This was a 30 pound decrease in 98 days. The nutritional care plan, dated 11/15/2022, showed Resident 22 was at nutritional risk with a goal to not have significant weight loss. A revision, dated 02/16/2023, after Resident 22 had significant weight loss, did not include additional goals and interventions. A Nutrition Assessment, dated 11/30/2022, showed the assessment was based off of a weight of 199 pounds, taken one day prior on 11/29/2022. Resident 22 was deemed at risk for nutritional issues based on age, past medical history, wight status and status post fracture. The goal was to monitor intake and weights, meals to be consumed greater than 65 percent and maintain the current weight of 199, +/- three pounds. A Nutrition Assessment, dated 02/14/2023, showed the assessment was based off a weight of 183 pounds, taken one month prior on 01/17/2023. The risk factors were unchanged. The interventions provided by Staff G, Registered Dietitian, included offering a nutritional supplement to aid in healing and add a multivitamin to aid in micronutrient profile. The goal was to monitor intake and weights, meals to be consumed greater than 65 percent and maintain current weight of 183 pounds, +/- three pounds. Weights showed Resident 22 weighted 173.5 pounds on 02/09/2023. Resident 22's medical record showed on 03/04/2023, 23 days after the dietitian's recommendation, an order for the nutritional supplement (ProSource) was obtained. Nutritional meeting notes, dated 01/06/2023, showed the team recommendations: diabetic snack, re-weigh, Ensure (a dietary supplement) one can daily and monitor. The Ensure was not listed as a meal replacement. Nutritional note, dated 01/13/2023, showed a team recommendation included the previous items, from 01/06/2023, except the Ensure needed to be increased to twice daily. Nutritional notes, dated 01/20/2023 and 01/27/2023, showed the recommendations were the same as on 01/06/2023. Nutritional meeting note, dated 02/24/2023, showed the same recommendations as 01/06/2023 with the addition that the Ensure could be changed to four ounces three times a day. Nutritional meeting notes, dated 01/20/2023, 01/27/2023 and 02/24/2023, referenced the same 01/17/2023 weight of 183 pounds, five weeks old. No other nutritional meeting notes were found in the resident's medical record. The January 2023 and February 2023 Medication Administration Record showed nutritional meeting recommendations were not implemented or updated. A dietitian note, dated 01/13/2023, showed the current interventions included one can of Ensure a day and a diabetic snack. New recommendations by Registered Dietitian were to monitor weight and could increase frequency of Ensure if weight was still down after reweight next week. Review of the dietitian notes, dated 01/13/2023 and 03/03/2023, showed recommendation to increase the Ensure frequency, if weight was still down, was not implemented while weight loss continued. A dietitian note, dated 03/03/2023, documented Resident 22's current weight was 173 pounds, showing a 30 pound weight loss from the 90 day weight of 203 pounds. The current physician orders continued to say one can of Ensure per day and a diabetic snack. A nutritional order, dated 03/03/2023, was for ProSource Oral Liquid, Give 30 ml by mouth one time a day for Weight loss for 14 Days. Laboratory work was ordered for weight loss that same day. Meal monitoring, dated 02/09/2023 to 03/08/2023, showed 69 entries out of 81 meal opportunities. Only 5 of the 27 days had three meal entries consistent with the facility's meal times. On 03/05/2023 at 11:49 AM, Resident 22 said she had lost weight and was surprised she had not lost more. Resident 22 was observed to be sitting on her bed, leaning over a trash can which was between her feet. The resident said she had just thrown up. Resident 22 said the food was terrible and they did not give her alternatives to eat when nauseated. Resident 22 said the staff did not give her easy items to eat when the food smell made her sick. At 12:00 PM, Staff I, Certified Nursing Assistant (CNA), was observed bringing Resident 22 her lunch tray. Resident 22 told Staff I she had just thrown up. Staff I offered water as an alternative to the lunch tray. No food alternatives were offered or provided. At 12:40 PM, Resident 22 was observed sitting on her bed and pushed away the lunch tray. The food was not eaten but a few small bites in total. Resident 22 said she could ask for Ensure but she had forgotten. Resident 22 said she wished they could do something about her appetite. Review of meal monitoring on 03/05/2023 showed the second entry/lunch meal was recorded as 25-50 percent when the resident ate less than 25 percent. On 03/06/2023 at 10:51 AM, Resident 22 said she was nauseated again, and her appetite was gone. Resident 22 gave the example of how she used to love scrambled eggs but now when she ate them, they got down about halfway, then came up. There was a high calorie nutritional supplement on the table and Resident 22 said she had not drunk it yet but would. At 2:12 PM, the pasta lunch meal was observed and appeared to have only bites taken out, less than 25 percent. Resident 22 said she didn't eat much lunch, she tried but it wouldn't go down. Resident 22 said she drank the [nutritional supplement] that was given to her this AM instead of eating lunch. Review of meal monitoring on 03/06/2023, the second entry/lunch meal was recorded as 51-75 percent when the resident ate less than 25 percent. On 03/07/2023 at 2:51 PM, Staff K, CNA, said Resident 22 ate cereal in morning and drank the Ensure. Staff K said Resident 22's meal consumption depended on how much she liked it, and she documented 51-100 percent of meals in the computer. On 03/08/2023 at 10:49 AM, Staff L, CNA, said if Resident 22 did not eat a meal, they offered Ensure. At 11:08 AM, Staff E, Director of Rehab, said the facility had been monitoring Resident 22 during weekly meetings. When asked if Staff E had concerns with weight loss for Resident 22, Staff E declined to answer. Staff E said the resident did not eat much for meals, she snacked throughout the day. Staff E said yesterday Resident 22 was eating popcorn instead of her lunch. Review of the meal monitoring for 03/07/2023 showed 51-75 percent of the meal was consumed. At 11:18 AM, Collateral Contact 1 (CC1), Family, said Resident 22's appetite was really off and she had a lot of fatigue and weakness. From day one, Resident 22 complained of the food, they could not get her to eat. Resident 22 had strong food preferences. She could not or would not make herself eat. CC1 said recently Resident 22 had not been eating the desserts which was not her normal. CC1 said she brought a few meals from home and Resident 22 ate those. When asked what the staff did about the resident not eating meals, CC1 said they did not do a whole lot. They bring it in and come back to remove the tray. CC1 said it looked like Resident 22 had lost weight. At 12:38 PM, Resident 22 said the lunch was terrible; greens were not salted and the mashed potatoes were too salty. The resident said she would not touch the meatloaf. Resident 22 was observed to have eaten about 1/3 of the dessert and a few bites from each side dish. The amount eaten was less than 25 percent. At 12:50 PM, Staff J, CNA, was observed with Resident 22's meal tray and said Resident 22 ate about zero to 25 percent of her meal, then removed the tray. The amount eaten was similar to the amounts eaten on the previously observed trays. Review of meal monitoring on 03/08/2023, the second entry/lunch meal was recorded as 76-100 percent when the resident ate zero to 25 percent. At 1:25 PM, Staff B, Registered Nurse and Director of Nursing Services, said for a resident with significant weight loss, it was not appropriate to be on monthly weights. She expected them to be weighed weekly. Staff B said the CNAs inaccurately documented higher percent consumption and only offered an Ensure (ordered daily) instead for a meal alternative. Staff B said she spoke to Resident 22 on 03/05/2023 and found out the resident thought she could only get the alternative (Ensure) three times a week. Staff B said the CNAs had received training on how to accurately document the percent of meals eaten. At 1:45 PM, Staff G, Registered Dietitian, said this was not an expected weight loss. We did not expect this on admit. Staff G said Resident 22's weight of 170 pounds was concerning to him. Staff G said when a resident triggered for weight loss, he recommended more frequent weight checks than monthly to prevent a big loss in between checks. Resident 22's appetite was fair, some days were better than others. When asked if the CNAs marked greater than 51 percent eaten per meal when the resident ate less than 25 percent, would it change his plan of care, Staff G stated, Yes. That absolutely would change the plan of care. Staff G said he was dependent on accurate meal monitoring to create an effective care plan. Staff G said Resident 22 would require extra protein and oral supplements. Ensure was not an adequate replacement for a meal. Staff G said he had identified the issue of inaccurate meal monitoring last March 2022 and had talked to the facility staff regarding its importance.