**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to 1) recognize a change in condition for 3 of 6 residents (Residents 39, 9 and 35) reviewed for quality of care, and 2) ensure residents received treatment and care in accordance with professional standards of practice and physician orders for 2 of 5 residents (Resident 8 and 71) reviewed for unnecessary medications. This failure placed residents at risk for a delay in treatment, unmet care needs, and negative health outcomes. Resident 39 experienced harm when the facility failed to recognize the immediacy of a change of condition and did not notify the physician with a resident who exhibited signs and symptoms of change in orientation, oxygen level, blood pressure and pulse which resulted in hospitalization. Resident 9 experienced harm when their nephrostomy tube (a flexible tube inserted through the skin into the kidney to drain urine externally when normal drainage is blocked) became obstructed, resulting in hospitalization intervention. Findings included . Review of a policy titled Changes in Resident's Condition or Status, dated 09/05/2024, showed the facility would notify the resident's Primary Care Provider and the resident or Resident's Representative (RR), the resident would be thoroughly assessed, and the facility would monitor the resident for changes. The policy showed the Licensed Nurses (LNs) would communicate with other team members for continuity of care and were to document their assessments and monitoring.<Resident 39> Review of the medical record showed Resident 39 initially admitted to the facility on [DATE] then readmitted to the facility from the hospital on [DATE] with diagnoses including a Urinary Tract Infection (UTI) with Septic Shock (life threatening infection which arises when the body responds to infection causes injury to the body), respiratory issues with use of continuous oxygen, and heart disease. Resident 39 previously sustained a fracture of the upper back and sternum (breastbone or flat T-shaped bone in the middle of the chest), and wore a hard plastic neck collar for stability. The 06/30/2025 comprehensive assessment showed the resident was alert and oriented and able to make their needs known and required substantial assistance with toileting and hygiene and was dependent on staff with dressing. During an interview on 07/15/2025 at 10:15 AM, Resident 39 was seated on their recliner in their room. The resident had a house coat on with a large plastic neck collar around their neck. The resident stated they had an episode of confusion and severe pain at the facility on 07/03/2025 when they had not been feeling well for a few days and ended up in the hospital with an infection and stayed in the hospital for 12 days. Resident 39 stated they were admitted back to the facility for physical therapy before they could discharge home. Review of the 07/02/2025 nurses progress notes showed that the physician had ordered laboratory testing for Resident 39 which showed an elevation in the resident’s white blood cell count (which is used to measure the amount of these cells in the blood which may determine infection) and other laboratory results. Additionally, the physician ordered a chest x-ray and increased Resident 39’s pain medication. Review of the 07/03/2025 progress notes showed the following changes were charted for Resident 39 which showed at 8:58 AM the resident who was on continuous oxygen, had an oxygen level of 79% (normal is 90% to 100%), at 9:53 AM the resident had an increase of severe pain, at 12:38 PM the resident’s pulse was 117 (normal is 60-100 beats per minute). Review of the 07/03/2025 at 2:55 PM nurses progress notes showed Resident 39 was sent to the emergency room (ER) due to abnormal vital signs (blood pressure and pulse), increased lethargy (lack of energy), and oxygen level drop despite increases of oxygen administered. Resident 39's blood pressure was 62/48 (120/80 normal range). The resident was clammy and speech was slurred/difficult to understand. The paramedics (emergency medical service) were called, while the resident was on the phone with Resident Representative (RR) at that time. RR asked Staff H and then the paramedics to take Resident 39 to the ER as the resident was not themselves for the last three days. There was no change of condition assessment completed by the licensed nurse. During an interview on 07/16/2025 at 11:20 AM, Resident 39 stated they had not experienced that type of infection before and had no recollection about being asked to go to the hospital or any memory about that day. Resident 39 stated they did not recall speaking with their RR at that time. The resident stated they woke up in the hospital in the Intensive Care Unit (ICU) and were there for two weeks. Review of the hospital 07/03/2025 emergency room intake encounter notes stated the resident was not able to answer questions and resident’s representative stated the resident had not been eating and had changes over the last two to three days at the facility. The resident was admitted to ICU for management. Review of the 07/13/2025 hospital discharge summary showed the resident was admitted to the hospital on [DATE] through 07/13/2025 and readmitted to the facility on [DATE]. Admitting diagnoses to the hospital were Septic shock due to bacterial urinary tract infection, heart failure, lung issues and diabetes (chronic condition where the body cannot regulate blood sugar levels). The summary showed that resident was admitted to ICU with significant low blood pressure that required medication with intravenous (IV) fluids. Additionally, the resident received four different antibiotics IV for their bladder infection. During an interview on 07/17/2025 at 10:30 AM, Staff H, Registered Nurse, (RN) stated Resident 39 started having issues around 9:00 AM on 07/03/2025 where they had so much pain that it would not respond to the pain medication given to them. Staff H stated that Resident 39’s oxygen level dropped to 79%. Staff H stated turned the oxygen up and the oxygen level was okay then dropped down again. Staff H stated the resident did not want to go to the hospital. Staff H stated the resident was in and out of falling asleep and Staff H did not want to disturb the resident. Staff H stated this change of condition continued and the resident who was a full code did not want to go to the hospital. Staff H stated Resident 39 called their RR and decided to go to the hospital around 2:45 PM. Staff H stated they felt they could not make the resident go to the hospital even though they had significant changes. Resident 39 was on the phone with their RR and the RR asked Staff H that Resident 39 be sent to the hospital due to the resident’s decrease in orientation and increased pain. Staff H called the paramedics around 2:55 PM and documented they notified the nurse practitioner. During an interview on 07/17/2025 at 1:08 PM, Resident 39’s RR stated they had concerns with the resident on 07/01/2025 when people visited the resident, they noticed a change in the resident’s memory and felt they were confused. Resident 39 complained of not feeling well. On Tuesday 07/01/2025 the resident had a change in condition the resident was pale and looked bad.” On Wednesday 07/02/2025 the resident was not coherent, and the nurse did not think anything was wrong. Resident 39 did not know what time of day it was and was confused. While the RR was talking to Resident 39 on the phone and Staff M, Medical Director (MD), who was in the resident’s room ordered a chest X-ray and blood work on 07/02/2025 and increased the residents pain medication. The RR stated they had spoken to on 07/02/2025 that afternoon to Staff F, RN, who was informed of Resident 39’s change in their ability to think clearly and not being themself when expressing our concerns. Staff F stated they attributed Resident 39’s complaints to participation in physical therapy and medication. During an interview on 07/17/2025 at 1:55 PM, Staff M stated if they had known about those changes in vital signs on 07/03/2025 and Resident 39’s change in condition they would immediately have had the resident transferred to the hospital. During an interview on 07/18/2025 at 11:44 AM, Staff N, Advanced Registered Nurse Practitioner (ARNP) stated they did not receive a call from the facility concerning Resident 39’s change of condition or decreased on oxygen level. If that information was communicated to them, they would immediately have admitted the resident to the hospital. During an interview on 07/21/2025 at10:18 AM, Staff I, RN, stated after the morning meeting on 07/03/2025 at 10:00 AM they saw that Resident 39 had a 79% oxygen level on their computer. Staff I went to Resident 39’s room with a pulse oximeter to check the resident’s oxygen level. Staff H stated to Staff I that they increased the resident’s oxygen from 1 liters (unit of measure) to 4 liters and the oxygen level improved to 90% at that time. Staff I asked Staff H to notify the physician about the change made by increased oxygen from 1 liter to 4 liters of oxygen to Resident 39. <Resident 9> Review of Resident 9’s medical record showed they were admitted to the facility on [DATE] with diagnoses to include epilepsy (a brain disease where nerves cells do not signal properly, which causes seizures), neuromuscular dysfunction of the bladder (condition where the bladder cannot properly store or release urine due to nerve damage) and pyelonephritis (a bacterial infection causing inflammation of the kidneys). Review of the resident’s comprehensive assessment dated [DATE] showed Resident 9’s cognition was intact and able to make their needs known. Resident 9 required assistance from two staff members for mobility and activities of daily living. During an observation and concurrent interview on 07/15/2025 at 3:07 PM, Resident 9 stated they had a nephrostomy tube (a flexible tube inserted through the skin into the kidney to drain urine externally when normal drainage is blocked) to help with their kidneys. The nephrostomy drainage bag had a yellow-colored liquid within the bag. Review of Resident 9’s physician orders showed the resident had a nephrostomy tube that required monitoring for signs infection and the monitoring of the resident’s output into the bag twice a day. During an observation and a concurrent interview on 07/18/2025 at 9:27 AM, Resident 9 was lying in bed, the nephrostomy tube laid to their left side empty on the bed. The resident stated their bag was emptied during the night shift and was unsure how often the staff emptied the bag and that the tube hurt when it was moved too much. During an observation and concurrent interview on 07/22/2025 at 10:05 AM, Resident 9 was fully dressed, with a blanket on their lap, sitting in their wheelchair at the front desk stated they were going for a scheduled appointment and would be back that afternoon. During an observation and concurrent interview on 07/22/2025 at 3:26 PM, Resident 9 was lying in their bed speaking to paramedics in their room. The resident’s representative (RR) also in the room, stated “I'm making this happen. The RR stated the resident had texted them the night before, about their pain. The RR stated the pain was in their abdomen and were also complaining of some burning with their urine. The RR stated the last time Resident 9 went through that type of pain and burning, was a few months ago and the resident had to stay in the hospital intensive care for three days, as they had sepsis (a serious condition in which the body responds improperly to an infection) which cause them to have grand-mal seizures (a type of seizure that causes a sudden loss of consciousness, stiffening of the body, and jerking movements). Review of the nursing treatment administration record (TAR) dated July 2025 showed the licensed nurses were to document nephrostomy tube output twice a day. On 07/13/2025 there had been no output documented for the evening shift. Further review of the documentation showed on 07/18/2025 with zero output documented for the day shift. On 07/19/2025 zero output was documented for the evening shift. On 07/20/2025 through 07/22/2025, zero output had been documented for both shifts. During an interview on 07/23/2025 at 8:40 AM, Staff O, Licensed Practical Nurse (LPN), stated Resident 9 had been admitted to the local hospital with sepsis. Staff O stated they had received that in a report from the prior shift nurse but had not followed up with the hospital. During an interview on 07/23/2025 at 9:02 AM, Staff C, LPN, stated Resident 9 had refused to go to their appointment. Staff C stated the resident became nauseated and vomited, so they gave the resident an antinausea medication and went back to their med cart. Staff C stated the next thing they saw were Paramedics, RR, and the Resident Care Manager (RCM) in Resident 9’s room, and the resident being sent out to the local hospital to be evaluated. During an interview on 07/23/2025 at 9:10 AM, Staff E, LPN/RCM, stated Resident 9 had pain to the abdomen that radiated to their back, and that they had talked with their primary physician who told Resident 9 to get to the hospital. Staff E then stated the RR was also in the room and verified the information from the resident. Staff E stated Resident 9 had been admitted to the local hospital but unsure why they had been admitted , and they would need to call for an update. Staff E stated they did not document the conversation they had with the resident or RR. In an interview on 07/23/2025 at 10:42 AM, Resident 9’s RR stated that the resident was admitted to the local hospital on [DATE], due to their nephrostomy tube being blocked, a UTI and abnormal labs. The RR stated the resident had requested pain medication but, the nurse stated could only administer a small dose due to the blood pressure being low, The RR stated, “I kept watching the blood pressure waiting for it to drop, I was scared”. The RR stated, it was the third time that the resident had to be seen by the local hospital. The RR stated on 07/20/2025 the resident had contacted them about significant pain; staff did not seem to listen to Resident 9’s concerns. Review of the local hospital admission note dated 07/22/2025, showed Resident 9 was admitted to the hospital with the diagnoses of a complicated urinary tract infection and sepsis. In an interview on 07/23/2025 at 11:21AM, Staff O, LPN, stated the nurses documented in the TAR for Resident 9’s nephrostomy drain output. Staff O stated if the drain did not put anything out, they would call the doctor. Staff O stated the prior shift report would let them know how much output the resident had from the nephrostomy drain. Staff O stated they had not informed the physician for the resident’s zero output. In an interview on 07/23/2025 at 11:32 AM, Staff E, LPN/RCM, stated the expectation of the nurses on the floor was for the nurse to call the doctor for any signs of infection and when there was zero output from Resident 9’s nephrostomy drainage bag. Staff E stated that the nurses did not follow the orders to monitor the output and did not contact the doctor about the lack of output. During an interview on 07/23/2025 at 1:17 PM, Staff B, DNS stated the expectation was for nursing to document and follow doctor orders. Staff B stated they had reviewed the documentation of Resident 9’s nephrostomy tube output and acknowledged that the doctor had not been notified of the zero output from the resident’s nephrostomy. <Resident 35> Review of the resident’s medical records showed they were admitted to the facility with diagnoses to include a stroke (blood flow to the brain is blocked or a blood vessel bursts) with right side deficits and brain aneurysms (a bulge in a blood vessel). The 06/20/2025 comprehensive assessment showed Resident 35 was cognitively intact and their vision was not impaired. During an interview and concurrent observation on 07/15/2025 at 4:18 PM, Resident 35 stated they had trouble seeing, their vision was blurry, and they experienced dizziness. Resident 35 stated they informed the staff and asked to speak to the provider. Resident 35 stated the provider, a Contracted Nurse Practitioner (CNP), had seen them on 07/14/2025 and the resident informed the CNP of their vision issues. Resident 35 stated they informed the CNP that they had a history of having three brain aneurysms, and these were some of the symptoms they had experienced and requested imaging to ensure that was not the issue. Resident 35 stated they were told by the CNP that they did not feel that was the issue and would have to discuss with the facility whether imaging was appropriate or not and asked them if they “really wanted to put your body through that…are you even going to be here next year.” Resident 35 stated they had not heard anymore about it. Resident 35 was observed squinting at the television, with the left eye smaller than the right (this was normal per the resident), and complained of head pain over the left eye and some dizziness. During an interview on 07/16/2025 at 12:08 PM, Resident 35 was lying in bed and stated they felt like their vision was “better today but not much.” Resident 35 stated they had not talked to the nurse regarding their vision changes, only the CNP and had not heard anything about the imaging being ordered. During an interview on 07/18/2025 at 3:42 PM, Resident 35 stated they had not heard anything regarding the imaging. Resident 35 stated they felt like their vision symptoms were coming and going and had “nauseous waves going over me [feelings of being sick to your stomach that come and go].” Resident 35 stated when they would lay flat, they would feel pressure in their head but if they elevated the head of their bed, the pressure seemed to relieve. Resident 35 stated they informed Staff F, RCM, about the pressure when lying flat and vision changes. Resident 35 stated Staff F informed them they had received an order from the CNP for a Computed Tomography (CT, a type of imaging that can visualize details inside the body) scan and they would get that scheduled. Review of the July 2025 Physician orders showed an order on 07/14/2025 for Resident 35 to be scheduled for a CT scan. The order showed a reason for the CT scan was for “visual changes and dizziness.” The order showed it was discontinued on 07/17/2025. Review of Resident 35’s progress notes showed no documentation from the CNP for the 07/14/2025 visit, no LN documentation as to who ordered the CT scan or why it was ordered, and no documentation that showed Resident 35’s current vision changes, dizziness, nausea, or increased pressure to their head had been monitored or assessed. The review also showed no notification to the provider regarding the increased pressure to Resident 35’s head when lying flat. During an interview on 07/22/2025 at 3:28 PM, Staff E, RCM, stated they knew about Resident 35’s concerns with their vision changes and dizziness and knew the CNP had ordered a CT scan for the resident. Staff E stated they were unaware Resident 35 had experienced feeling pressure to their head while lying flat and had not seen any nursing documentation regarding those concerns. Staff E stated Resident 35 should have been put on alert charting so they could monitor the symptoms they were having but they did not do that. Staff E stated they did not see the CNP’s progress note from their visit on 07/14/2025 in Resident 35’s medical record and would call to request them. Staff E stated they “assumed” the order was discontinued because “maybe it had been scheduled.” Review of the CNP’s progress note provided by Staff E, dated for 07/21/2025 at 4:16 PM, showed Resident 35 reported they had “vague vision/dizziness” complaints and had experienced “waves” of lightheadedness and dizziness that would last seconds before resolving. The note showed the television appeared “more blurry” and was concerned their symptoms were related to their history of brain aneurysms. The note further showed the CNP educated and reassured Resident 35 that their symptoms were “unlikely related” to the aneurysms because of the intermittent dizziness. The note showed a CT scan had been ordered and the RCM had been notified. The note was signed and dated 07/22/2025 at 4:16 PM. During an interview on 07/23/2025 at 12:48 PM, Staff F stated they had received an order from the CNP through an electronic mail (email) on 07/14/2025. Staff F stated they had processed the order on 07/14/2025 and faxed the order over but the order was not completed correctly so needed to amend the order and resend it. Staff F stated they had been “busy” and had not done that yet “I will probably get to that today.” Staff F further stated when they received the email they should have placed Resident 35 on alert charting to monitor for any worsening of their symptoms, and they did not do that. Staff F stated they did speak to the resident regarding their symptoms but were unaware they had pressure in their head when lying flat. Staff F stated the order they received was not an emergent order. Review of a note that was emailed on 07/14/2025 at 4:33 PM, sent to Staff F by the CNP, showed they had seen Resident 35 and would be ordering a CT scan. The note showed Resident 35 had complained of on and off dizziness and “brain zaps [brief electric shock-like sensations in the head],” and worsening vision symptoms that were related to their brain aneurysms. The note showed since symptoms were improving the CNP assured Resident 35 that it was unlikely related to the brain aneurysms, and even if it was, they would most likely not be a candidate for surgery, “so what’s the point of doing imaging,” but Resident 35 insisted. During an interview on 07/23/2025 at 1:54 PM, Staff B, DNS, stated when a resident experienced a change in their health condition, the LNs should assess the resident, notify the provider, notify the family, update the care plan as needed, and put the resident on alert charting. Staff B stated the alert charting would have remained in place until the resolve of symptoms or as ordered. Staff B stated Staff E and Staff F should have placed the resident on alert charting when they became knowledgeable Resident 35 had vision changes, dizziness, or increased pressure to their head. <Resident 8> Review of the resident’s medical records showed they were admitted to the facility with diagnoses to include lumbar spondylopathy (wear and tear to the lower back region) and nerve pain. The 07/01/2025 comprehensive assessment showed the resident’s cognition was intact and they received routine and as needed pain medication. Review of the 05/19/2025 through 05/31/2025 Medication Administration Records (MAR), showed an order dated 05/19/2025 for Oxycodone (a brand of medication used for pain) five milligrams (mg, a unit of measure), give one tablet every four hours as needed (PRN) for a pain level of six or seven (a pain scale of 0-10 with zero meaning no pain at all and 10 meaning the most excruciating pain ever felt). The record showed an order dated 05/19/2025 for Oxycodone five mg, give two tablets for a pain level of eight, nine, or ten. Both orders showed pain location and non-pharmacological (does not involve medication) interventions were to be documented in a progress note. The order for one tablet was administered three times with one administration given outside of the parameters ordered (pain level of ten). The order for two tablets was administered 12 times with one administration given outside of the parameters ordered (pain level of seven). Review of the June 2025 MARs showed the same Oxycodone orders (05/19/2025) as the May 2025 MAR did. The records showed the order for one tablet of Oxycodone was administered seven times, with five of those administrations given outside of the ordered parameters (greater than a pain level of seven). The record showed the order for the two tablets of Oxycodone was administered 38 times, with 22 of those administrations given outside of the ordered parameters (for pain levels of five to seven). Review of the 07/01/2025 through 07/21/2025 MAR showed the same Oxycodone orders (05/19/2025) as the May 2025 MAR. The record showed the order for one tablet was administered three times with one of those administrations given outside of the ordered parameters (pain level of eight). The record showed the order for two tablets was administered 23 times and 15 of those administrations were given outside of the ordered parameters (pain levels of four to seven). Review of the nursing progress notes from 05/19/2025 through 07/21/2025 showed no non-pharmacological interventions had been documented prior to administering the PRN Oxycodone and two notes on 05/25/2025 and 05/26/2025 that showed the location of Resident 8’s pain. During an interview on 07/23/2025 at 10:03 AM, Staff K, LPN, stated their process for administering PRN medication was to assess the resident’s pain level and location, attempt to see if a non-pharmacological intervention would help, and then administer the pain medication if that was not effective. Staff K stated they then would document in a progress note. During an interview on 07/23/2025 at 10:14 AM, Staff O, LPN, stated they would ask the resident what their pain level was and give them their pain medication. Staff O stated the residents “know what they want and just tell me what to give them.” Staff O stated they would document where their pain location was in the progress notes. During an interview on 07/23/2025 at 1:54 PM, Staff B stated they would expect the LNs to follow physician orders as they were written. Staff B stated if the pain medications were not effective, they would expect the LNs to notify the provider for additional directions or to lower or increase the pain levels ordered or change the medication. Staff B stated the LNs should have documented their location assessment and the non-pharmacological interventions they attempted prior to administering the PRN pain medication. <Resident 71> Review of the resident medical record showed they were admitted to the facility on [DATE] with diagnosis including heart complications, dementia (a progressive disease that destroys the memory and other important mental functions) pancreatic (an organ inside the body that aid in digestion and introducing hormones need for the body’s daily function) cancer and placed on comfort measures (provider orders to assist with a resident’s suffering during their end of life). The 07/09/2025 comprehensive assessment showed the resident had cognitive impairments but was awake/alert to themselves, was talking with staff and understood where they were at. Review of Resident 71’s provider orders showed Lorazepam (a specific antianxiety medication belonging to a group of drugs that affect brain activities associated with mental processes, emotions and behavior. The common side effects include drowsiness, confusion, loss of balance and memory problems) could be administered every two hours as needed for anxiety and terminal agitation (a set of behaviors characterized by sudden agitation, anxiety, anger or confusion). Review of Resident 71’s care plan dated 07/02/2025 showed the resident was at risk for rehospitalization that timely communication to the provider was needed regarding any change in the resident’s condition. Additionally, Resident 71 was at risk for falls, and the goal was for the resident to not have an injury that would require them to be hospitalized . Review of a progress note on 07/09/2025 showed that on 07/08/2025 at 8:30 PM Resident 71 was found after a fall on the floor of their room with blood where the resident’s head was resting. Staff L, LPN, noted Resident 71 was weak, unable to sit up on their own and their range of motion was “ .limited due to weakness.” Staff L documented that neurological checks (a comprehensive evaluation of a person’s nervous system, to assess brain/nerve function to help diagnose potential neurological disorders that may require emergency treatment and would be needed following a head injury, increased confusion or change in behavior) were started and that the facility’s provider was notified. No documentation showed that the Resident 71’s representative was notified after the fall. Review of the facility’s investigation into Resident 71’s 07/08/2025 unwitnessed fall, showed the resident was bleeding from a head injury after being found on the floor of their room. The neurological checks showed no evaluation was conducted until 07/09/2025 at 8:00 AM (11 and a half hours after Resident 71’s fall) and Lorazepam was administered due to Resident 71 becoming “ .very restless and was trying to get out of bed .” The investigation showed the cognitive assessment of the resident on 07/09/2025 was “ .nonverbal and very hard to arouse (to wake up) .” Additionally, Resident 71’s resident representative was notified of the unwitnessed fall on 07/11/2025 (three days after the residents fall). Review of Resident 71’s MAR for July 2025, showed Lorazepam was administered on 07/08/2025 at 9:40 PM and 07/09/2025 at 12:00 AM, 5:00 AM, 7:20 AM, 3:33 PM and 8:30 PM. Observation on 07/16/2025 at 10:08 AM showed Resident 71 in their bed, unable to wake or open eyes. During an interview on 07/18/2025 at 12:40 PM, Staff F, RCM, stated the process for a resident having an unwitnessed fall and hitting their head would be to start neurological checks to assess for complications that may require emergency treatment and to notify the provider and Resident 71’s representative. Staff F stated that neurological checks were to be started right after a resident had been found and performed every 15 minutes (min) for one hour, then every 30 min for two hours, then every hour for four hours, and then every four hours for the next 24 hours. Staff F stated that Resident 71 was unable to make care decisions due to their cognitive ability and the resident’s representative would need to be notified after Resident 71s fall. Staff F stated they would be unable to assess changes in the Resident 71’s mentation nor accurately evaluate neurological checks since the resident was being administered their Lorazepam medication. Staff F stated that neurological checks should have been completed per the facility process, and they were not per Resident 71’s neurological assessment documentation and the provider/resident representative would have needed to be involved in a discussion on continued care interventions with the residents unwitnessed fall, head injury, and Lorazepam administration. During an interview on 07/18/2025 at 3:21 PM, Staff L, LPN, stated they had notified the on-call provider about Resident 71’s fall, but did not communicate that it was an unwitnessed fall, that the resident had hit their head, or clarify orders with completion of neurological checks versus Lorazepam medication administration. Staff L stated they did not notify Resident 71’s representative of the fal

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to identify and take timely action when a change of condition after a fall occurred for 1 of 3 residents (Resident 1) reviewed for changes in condition. Resident 1 experienced harm due to right hip pain and a delay in medical treatment for a fractured right hip. Findings included . <Resident 1> Review of the medical record showed Resident 1 was admitted to the facility on [DATE] with diagnoses which included heart problems. Review of the resident's comprehensive assessment, dated 09/10/2024, showed they had moderately impaired cognition. Review of the resident's plan of care, dated 09/04/2024, showed they required two staff to turn and reposition in bed, toileting and transfers; and one staff to assist with dressing and personal hygiene. Review of a facility investigation form, dated 09/11/2024 at 9:30 PM, showed Resident 1 was found by staff lying on the floor. Resident 1 stated they were trying to go to the bathroom and lost their balance upon standing. The resident was transferred by three staff using a mechanical lift from the floor to their bed. No injuries were observed and the resident denied pain. Review of a facility investigation form, dated 09/13/2024 at 9:45 PM, documented by Staff A, Registered Nurse (RN), three days later on 09/16/2024 at 6:02 PM, showed Staff A heard Resident 1 yelling out. Staff A found the resident with both feet on the floor trying to walk. The resident's back was leaning on the bed so Staff A assisted them to sit on the floor. Staff B, Nursing Assistant (NA), assisted Staff A to lift the resident back to bed. There were no identified injuries, range of motion was within normal limits and the resident denied pain. Resident 1 stated they were trying to walk. Review of a written statement by Staff B showed that sometime after dinner on 09/13/2024 Staff A came to find them to report Resident 1 was on the floor and had slid out of bed. Staff A requested assistance to place the resident back in bed. An hour later, Staff B wrote that Staff A told them not to tell anyone as the other nurses and aides would give Staff A a hard time if they knew Resident 1 was on the floor. Staff A stated they did not want to call the family or document the fall and to keep it a secret. Staff B stated they were not comfortable in not reporting the fall so they informed Staff C, RN. Review of a written statement by Staff D, NA, showed the incident occurred after dinner on 09/13/2024. Staff D passed by Resident 1's room and observed Staff A and B in the room. Staff B told Resident 1 that they could not be transferring on their own and needed to use the call light. Staff A asked Resident 1 if anything hurt and they needed to stay in bed. Staff D stated Staff B informed them on 09/13/2024 that the resident fell. Review of Resident 1's Progress Notes (PNs), dated 09/13/2024 at 3:06 PM, showed swelling and pain were observed to the left hip area (documented following the resident's fall on 09/11/2024 at 9:30 PM). The physician was notified and orders received for an x-ray of the resident's left hip. The order was placed with the portable x-ray company, who stated they would be at the facility on 09/14/2024 to take the x-ray. Review of Resident 1's PNs, dated 09/13/2024 at 10:00 PM, but not documented by Staff A until 09/16/2024 at 6:02 PM (approximately three days following the fall), showed Resident 1 sustained no injuries following the fall on 09/13/2024. Staff A documented Resident 1 already had an order for an x-ray to be obtained due to swelling from a previous fall on 09/11/2024. Review of PNs, dated 09/13/2024 at 11:15 PM, documented by Staff C, RN, showed ongoing follow up for fall showed no signs or symptoms of a latent injury. Resident 1 continued with impulsive behaviors and was a significant fall risk. There were no further assessments documented by Staff C of the resident. Review of PNs, dated 09/14/2024 at 7:00 AM, documented by Staff E, Licensed Practical Nurse, showed they received report from Staff C that Resident 1 did not sleep at all that night. The resident was alert and oriented to self only. Swelling was observed to the right and left thighs with skin tight and hard to the right thigh. The resident complained of pain to their right thigh at times and stated they were unable to move their right leg as it was too painful. The physician was notified and orders received to transport the resident to the emergency room for possible blood clots. Review of the resident's Medication Administration Record for September 2024, showed Tylenol was administered by Staff A at bedtime on 09/13/2024. There was no further pain medication administered to the resident, and no documentation of the resident refusing Tylenol. Review of hospital records, dated 09/14/2024, showed Resident 1 had a fractured right hip and surgery was planned for 09/15/2024. The resident was readmitted to the facility on [DATE]. During an interview on 09/26/2024 at 3:20 PM, Staff E, stated when they received shift report from Staff C the morning of 09/14/2024, they reported Resident 1 did not sleep well, but there was no report of the resident having a fall the evening of 09/13/2024. Staff E stated they did not find out the resident had fallen the evening of 09/13/2024 until 5:00 PM on 09/14/2024. Staff E stated they wondered why the resident was complaining of their right leg hurting. Staff E stated their assessment of the resident the morning of 09/14/2024 was that they could not turn as they were in so much pain. The resident yelled out they had not slept all night. It was very different from the day before as Staff E had assisted the resident off the toilet without difficulty. During an interview on 09/26/2024 at 12:50 PM, Staff F, Physical Therapist/Director of Rehab, stated during the day on 09/13/2024 Resident 1 had physical and occupational therapy. In addition to a group exercise program they walked 75 feet with one person assist and a walker. During an interview on 09/26/2024 at 3:40 PM, Staff C, stated they were aware of Resident 1's left hip problem on 09/11/2024 but did not know they had fallen the evening of 09/13/2024 (despite being informed of the fall by Staff B on 09/13/2024). Staff C stated they took over the care of Resident 1 at 10:00 PM on 09/13/2024 from Staff A and continued until 6:00 AM on 09/14/2024. The resident was restless and moving around in bed. Staff C stated they offered the resident Tylenol but they refused it. They did not find out Resident 1 fell on [DATE] until the next day. During an interview on 09/26/2024 at 4:05 PM, Staff B, stated that Staff A asked them for assistance in getting Resident 1 off the floor. In observing the resident they could definitely tell [Resident 1] was in pain and [Staff A] wasn't doing anything, heavy to get into bed, [Staff A] only grabbed [Resident 1's] feet. The resident's face was really red and they were grimacing in pain. An hour later, Staff B stated that Staff A told them not to tell anyone Resident 1 had fallen as they did not want to do the paperwork. Staff A stated they had witnessed the fall so they did not need to fill out paperwork. Staff B then reported to Staff C regarding Resident 1's fall and that Staff A did not want to tell anyone about it. Staff C responded the resident was already on the fall list so there wasn't much they could do. Staff B stated they wrote their statement regarding the resident's fall on 09/13/2024, three days later on 09/16/2024. During an interview on 09/30/2024 at 9:48 AM, Staff G, NA, stated they received shift report at 10:00 PM from Staff B that Resident 1 fell earlier that evening on 09/13/2024. Not too long after that, the resident told Staff G they were aware they had a fall and complained of pain in their right leg. The resident was not able to move their right leg. Staff G stated usually they could turn the resident without assistance but they had to get help that night due to the resident's pain and inability to move their right leg. Staff G obtained assistance from Staff H, NA, to change the resident as they were incontinent. After changing the resident Staff G reported to Staff C at approximately 11:30 PM on 09/13/2024 that the resident was in a lot of pain. Staff C stated they would give the resident something for pain. The resident was not sleeping much and stated they were in pain. Staff G turned the resident with assistance every two hours. Staff G stated they informed the day shift NA on 09/14/2024 that the resident fell the previous evening and was getting an x-ray that morning. During an interview on 09/30/2024 at 12:19 PM, Staff H, stated they and Staff G tried to change Resident 1's brief and noticed they were in a lot of pain in their right hip. Staff H stated they had informed Staff C the resident was having pain in their right hip. The resident was restless but different that night as they were not trying to get out of bed due to not being able to move their right leg. During an interview on 09/30/2024 at 12:26 PM, Staff D, stated they were walking by Resident 1's room after dinner and could hear Staff A and B in the room. Staff B was telling the resident to stay in bed and Staff A was asking the resident if anything hurt. The resident was in bed at the time of the observation. Later, Staff B came to the nursing station and stated the resident fell again. Either on on 09/14/2024 or 09/15/2024 Staff D stated they were asked to write a statement as nothing had been reported regarding the resident's fall. Staff D stated they did not report it to the night shift NAs as they thought it would be reported in shift report by the Licensed Nurses. Staff E did not know the resident fell until later in the day. Reference (WAC) 388-97-1060(1) This is a repeat deficiency from the Statement of Deficiencies dated 07/17/2024, 04/16/2024, 01/09/2024, and 09/13/2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to consistently assess, perform dressing changes as ordered, and implement wound provider recommendations timely for application of a wound treatment device for 1 of 3 residents (Resident 2), reviewed for pressure injuries (PIs - injury to the skin and underlying tissue due to prolonged pressure). The facility failed to timely monitor, assess, implement wound provider recommendations, and perform dressing changes as ordered. This failed practice resulted in harm to Resident 2, when they experienced worsening/deterioration of the PI to the sacrum (the triangular bone at the base of the spine that connects the lower back to the pelvis). Findings included . Review of the National PI Advisory Panel's (NPIAP, the leading expert in PIs/wounds) guidelines and definitions, dated September 2016, defined PI stages as follows: Stage 1 PI had intact skin with a localized area of non-blanchable erythema (redness). Stage 2 PI was a partial thickness skin loss with exposed dermis (the top inner layers of skin). Stage 3 PI was a full thickness loss of skin, in which adipose (fat) tissue was visible in the ulcer. Slough (dead tissue) and or eschar (dried blood and tissue) might be visible, granulation tissue and epibole (rolled or curled under edges) might include with undermining (a pocket of dead space under the visible wound edges) and tunneling (a passageway under the wounds surface which might be shallow or deep and impaired wound closure). Stage 4 PI was a full-thickness skin and tissue loss with exposed or directly palpable fascia (connective tissue), muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar might be visible. If slough or eschar hides the extent of tissue loss that was an unstageable PI. <Resident 2> Review of the medical record showed Resident 2 was admitted to the facility on [DATE] with diagnoses which included PIs, cellulitis of right lower leg (infection that could cause pain, swelling, redness and tenderness), heart problems and Parkinsons (chronic, progressive and degenerative brain condition that affected the central nervous system). Review of the resident's comprehensive assessment, dated 08/15/2024, showed severely impaired cognitive function and was dependent on staff for activities of daily living. Review of the resident's plan of care, dated 08/27/2024, showed they had an unstageable PI to the right and left buttocks due to immobility. Interventions included weekly treatment documentation to include measurements of skin breakdown's width, length, depth, type of tissue and exudate (fluid that leaked out of blood vessels into nearby tissues). Review of Resident 2's Wound Observation Tool, dated 08/15/2024 (day of admission), showed an unstageable PI to the sacrum which measured 5.0 by 8.0 centimeters (cm), eschar to areas, moisture-associated skin damage (MASD - inflammation caused by prolonged exposure to moisture such as urine, stool, wound drainage), and epithelial tissue (type of body tissue that covered the inside and outside of the body, including the skin) present with necrosis (death of body tissue). Review of Resident 2's Wound Observation Tool, dated 08/24/2024, showed an unstageable PI to the sacrum that had worsened with measurements of 4.5 by 6.0 with 0.7 cm of depth. There was a moderate amount of serosanguinous drainage (thin, watery fluid that leaked from the wound) present with necrotic tissue. The consulting wound provider (Nurse Practitioner - NP) performed debridement to the wound (procedure that removed unhealthy or dead tissue from a wound to help it heal). New treatments orders were obtained. Review of a wound assessment of Resident 2, dated 08/24/2024, by the consulting wound provider (NP), showed a Stage IV PI measuring 4.5 by 6.0 by 0.7 cm. The wound bed was covered in slough and eschar with minimal granulation tissue (new connective tissue that formed during the healing process) in the wound bed. Wound edges were rolled and there was a large amount of serous exudate (the drainage that seeps out of wounds). There was no redness or thickening/hardness of the skin surrounding the wound. Review of Resident 2's Wound Observation Tool, dated 08/30/2024, showed an unstageable PI to the sacrum that had not changed since the previous assessment dated [DATE]. Review of a wound assessment of Resident 2, dated 08/30/2024, by the consulting wound provider, Nurse Practitioner (NP), showed a Stage 4 PI to the sacrum measuring 4.5 by 6.0 by 0.7 cm. There was a large amount of foul smelling purulent drainage (pus that indicated an infection). There was no redness or thickening/hardness of the skin surrounding the wound. The area was debrided by the NP. A wound culture was recommended due to the increased drainage. The assessment stated the necrotic tissue was likely the source of the drainage rather than an infection. The NP recommended a wound vac (treatment that used suction to help wound healing) to be placed after the wound culture results were received and treated if needed. Review of physician's orders showed a wound vac was ordered for Resident 2 on 09/04/2024 with dressing change to be performed three times weekly and as needed. Review of the facility delivery receipt showed the wound vac for Resident 2 was delivered on 09/05/2024. Review of Resident 2's Progress Notes, dated 09/09/2024 at 5:54 PM, showed the wound vac was applied to the sacral area (five days after it was ordered). Resident 2's plan of care, dated 08/24/2024, showed treatment assessments were to be performed weekly. Review of assessments, for the time period between 08/30/2024 through 09/18/2024 showed there was no documentation of an assessment of the sacrum by nursing or providers until 09/18/2024 (19 days later). Review of the 09/18/2024 assessment, performed by the consulting wound physician, showed the Stage 4 PI to the sacrum had worsened as shown by measurements of 4.9 by 3.5 by 2.5 cm (extended depth). The wound bed was covered with brown/gray, necrotic smelling and slough. The wound edges were rolled. The fascia was exposed across the base and the wound physician was able to probe to the bone, although it was not visualized. The physician recommended immediate evaluation and treatment at the hospital. Review of hospital records, dated 09/18/2024, showed imaging would be performed on Resident 2 to evaluate for an underlying abscess (painful, pus-filled lump that developed in the body and usually caused by an infection) and possible osteomyelitis (serious bone infection). Intravenous (via the vein) antibiotic therapy was initiated and a surgical consult was obtained. Review of Resident 2's Treatment Administration Record (TAR) for August 2024, showed daily wound care to the sacrum was not documented on 08/27/2024, 08/28/2024, and 08/29/2024. Review of Resident 2's TAR for September 2024, showed daily wound care to the sacrum was not documented on 09/03/2024 and 09/12/2024. During an interview on 09/26/2024 at 3:42 PM, Staff K, Licensed Practical Nurse (LPN)/Resident Care Manager (RCM), stated they remembered measuring Resident 2's wound when the wound vac was applied on 09/09/2024. The measurements were written on a paper towel and Staff K did not recall where that was located as it was never documented in the resident's medical record. Staff K stated the wound vac was ordered but it was not placed on the wound for an entire week. Resident 2's family was very upset due to the wound vac sitting in the resident's room that long. The resident's sacrum had 100% necrotic tissue, thus it had to be surgically debrided at the hospital. During an interview on 09/27/2024 at 9:00 AM, the consulting wound provider (NP), stated they had planned to see Resident 2 following their visit on 08/30/2024, however Staff I, Administrator, told them they could no longer see residents in the facility as they did not have all the credentialing information on them that they needed. Resident 2 had granulation tissue and eschar to the sacral wound so they were a candidate for the wound vac. On their visit on 08/30/2024 the resident did not need any surgical debridement. The wound was bad, but they did not need to go to the hospital at that time. During an interview on 09/30/2024 at 9:00 AM, the consulting physician, stated they assumed the NP was covering for them while they were on vacation. On 09/18/2024 observation of Resident 2's sacral wound showed it stunk, and it was soft and boggy (sign of a deep tissue injury which was damage to the soft tissue caused by pressure). In probing the sacral wound with a Q-tip it went right to the bottom (indicative of increased wound depth). The consulting wound provider stated it was unacceptable for the PI to get to that point as the smell alone was so bad. They stated that Staff J, Director of Nursing, was present during the observation and stated they had no idea. There was necrosis all over the wound and that was why the resident needed to be hospitalized . During an interview on 09/30/2024 at 10:29 AM, Resident 2's representative, stated instead of the resident's wound to the bottom getting better it got worse. Dressing changes were not done as ordered. The wound vac should have been applied to the wound on 09/05/2024, but it was not done until 09/09/2024. It took a long time for the consulting wound physician to see the resident. When the wound physician did see the resident they stated there was nothing they could do at the facility thus the resident was sent to the hospital so fast. During an interview on 10/11/2024 at 2:30 PM, Staff K, stated they had taken over performing wound assessments on all residents when the consulting wound physician made their weekly visits at 6:00 AM. The second week of September 2024, they informed Staff J that one nurse could not do all the wound assessments and it was not working. Additional help was obtained for one week from administrative nursing staff, but it still was not working. Reference (WAC) 388-97-1060(3)(b) This is a repeat deficiency from the Statement of Deficiencies dated 07/17/2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to consistently monitor and develop planned interventions for edema (swelling caused by too much fluid in the tissues), monitor weight gain and effectiveness of diuretic therapy (medications that help reduce fluid buildup in the body) for 1 of 3 residents (Resident 1) reviewed for changes in condition. Resident 1 experienced harm due to a decline in their mobility and delay in receiving medical treatment. Findings included . <Resident 1> Review of the medical record showed Resident 1 was admitted to the facility on [DATE] from the hospital with diagnoses which included congestive heart failure (CHF - a weakened heart that causes fluid buildup in feet, arms and lungs), heart and lung disease. Review of the 11/20/2023 comprehensive assessment showed Resident 1 had moderate impairment in their cognition; required supervision or touching assistance with upper body dressing, personal hygiene, walking 10 feet, chair/bed to chair transfers and sit to stand position; partial/moderate assistance with lower body dressing and toilet transfers. Review of Resident 1's hospital records, dated 11/17/2023, showed Lasix 20 milligrams (mgs) - (a diuretic medication used to treat edema and swelling) was ordered to be given daily as needed for edema or shortness of breath. The resident's weight at the hospital on [DATE] was 193.5 pounds. Review of Resident 1's complete weight history between 11/18/2023 to 12/19/2023 showed the following increase of 34.6 pounds: 11/18/2023 - 192.8 pounds 11/20/2023 - 197.8 pounds 11/21/2023 - 200.6 pounds 12/05/2023 - 220.2 pounds 12/19/2023 - 227.4 pounds Review of the 11/21/2023 assessment by the Registered Dietician showed Resident 1's weight was trending upward and might be fluid, had pitting edema (type of swelling often in the legs that causes enough fluid retention to leave an indentation when pressing on the affected area) The pitting edema scale of 1+ showed trace of edema; 2+ showed mild edema; 3+ showed moderate edema and 4+ showed severe edema. The resident's ideal body weight range was 160-196 pounds. Review of Resident 1's December Medication Administration Record (MAR) showed the resident received the as needed Lasix 20 mgs on 12/02/2023, 12/03/2023, 12/07/2023 and 12/11/2023. On 12/11/2023 the physician ordered the Lasix 20 mgs to be given daily for seven days through 12/18/2023 which was done. There was no documentation Lasix was administered to Resident 1 on 12/19/2023, even though the resident continued to experience edema. Review of Resident 1's plan of care, dated 11/20/2023, showed a problem addressing Resident 1 being at risk for weight fluctuation due to multiple diagnoses which included CHF. There were no planned interventions for edema. Review of the following Progress Notes between 12/10/2023 to 12/19/2023 showed Resident 1's change in condition and lack of a thorough assessment/monitoring for edema and a delay in obtaining medical treatment: 12/10/2023 at 11:10 PM - no assessment for edema 12/13/2023 at 11:37 AM - no SOB, no assessment for edema despite new physician's orders to administer Lasix daily for seven days 12/15/2023 at 2:41 PM - only vital signs documented, no other assessments 12/16/2023 at 5:20 PM - no SOB, no assessment for edema 12/17/2023 at 3:09 PM - no SOB, no assessment for edema 12/19/2023 at 3:31 PM - resident tested positive for COVID-19 (infectious disease by a new virus causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death), labored breathing, physician and family notified 12/19/2023 at 7:49 PM - resident continued to display increased labored respirations and lethargy (a state of weariness that involves diminished energy, mental capacity and motivation), resident continued to remove the oxygen and began to reach out in the air for things not there, slow to respond and increased sleepiness, did not eat any meals that day, urinated on the floor which was not their normal behavior; physician did see the resident late in the afternoon, resident's family member voiced concern over the resident's condition and increased edema with weeping to the lower legs, 3+ pitting edema to their knees, physician gave orders to transport the resident to the emergency room (ER). Review of the 12/19/2023 and 12/26/2023 hospital records showed Resident 1 was admitted to the hospital with increased SOB and increased lower leg edema of 3+. The hospital assessment showed they had diagnoses which included chronic respiratory failure secondary to chronic CHF, lung disease and COVID-19. Resident 1 received Lasix 80 mgs intravenously (IV-administered through a vein) in the ER and 40 mgs of Lasix IV twice daily in the hospital, daily weights, and fluid and salt restrictions. Resident 1 was hospitalized for seven days. Review of Resident 1's PT sessions between 12/12/2023 to 12/19/2023 showed the following: 12/11/2023 - resident with noticeable decreased level of alertness and required long rest breaks due to SOB and over fatigue, required increased level of assistance for functional mobility, increased noticeable edema, fatigue and difficulty staying alert unless provided with constant verbal stimulation 12/12/2023 - resident with increased fatigue, swelling in both legs and abdomen and decreased alertness - all reported to nursing 12/14/2023 - therapist communicated with nursing due to resident's most recent decline in overall alertness and functional mobility and level of assistance required for all functional performance, resident with increased edema and swelling 12/15/2023 - noticeable increased edema and overall increased respirations, increased fatigue and needed extra time for mobility and tasks, safety concerns with mobility training 12/17/2023 - recent decline in medical status including increased edema in lower legs and reduced alertness, nursing aware of the change in condition, resident had been sleeping in their chair at night which was likely contributing to their increased edema 12/18/2023 - most recent decline with overall health due to fragile medical condition and history of heart concerns with increased fluid retention, nursing will address resident's family concerns along with therapy regarding the amount of swelling in both legs and abdomen 12/19/2023 - resident required two staff to assist in turning in bed, noted increased swelling and overall increased respirations with complaints of SOB, therapist notified nursing staff immediately to assess resident's medical condition due to noted increased swelling to lower legs and abdomen In an interview on 01/09/2024 at 9:30 AM with Staff G, PT Assistant, they stated Resident 1 had been walking well when admitted . They began having a functional decline due to the swelling in their lower legs. Staff G stated on 12/19/2023 they were not appropriate for therapy due to the weeping of their lower legs so therapy was not performed. On 12/18/2023 Staff G requested a care conference with Resident 1's family due to their decline in function. They had fluid overload and were doing minimal range of motion to get the fluid moving. Their stomach was also distended (swollen due to pressure inside). Resident 1 needed a recliner chair and refused to use leg rests as they self propelled and they placed additional pressure on their stomach. In an interview on 01/09/2024 at 2:51 PM with Staff H, Registered Nurse, they had notified the physician the morning of 12/19/2023 as Resident 1 was gasping for air while lying down. The physician increased the dosage of Lasix from 20 mgs to 40 mgs at that time. Staff H was unable to accurately recall if any Lasix had been administered to Resident 1 that day as there was no documentation on the MAR of the medication being given on 12/19/2023. Staff H stated staff should have been doing daily weights on residents with CHF and checking their legs for edema. Staff I, LPN, stated on 01/08/2024 at 11:45 AM, Resident 1's family member had come to them on 12/19/2023 asking them to observe the resident's legs. Upon observation of the resident's legs Staff I replied the resident's Lasix needed to be increased thus they instructed Staff H to notify the physician. The family member also wanted the resident's legs elevated so a recliner was found and placed in the resident's room. Staff E, Director of Nursing, stated on 01/08/2024 at 8:40 AM, the physician did not see Resident 1 until late evening on 12/19/2023. The physician also did not recall ever seeing the electronic fax sent to them by Staff F on 12/17/2023 regarding Resident 1's leg edema and family concerns. Staff E also stated there was no facility policy on monitoring of edema but per corporate staff they were to use best practice which was checking for pitting edema every shift or doing daily weights. Collateral Contact 1 (Resident 1's representative) stated on 01/05/2024 at 12:11 PM, that all the resident did all day was sit in their wheelchair with their legs down until they got the recliner. Their edema had not been a consistent problem since their admission to the facility, but had worsened when they visited on 12/15/2023. Collateral Contact 2 (family member of Resident 1) stated on 01/05/2024 at 11:45 AM, that staff was aware of their edema on 12/14/2023 but nothing was being done. On 12/18/2023 Resident 1's legs had ballooned, and the excuse staff gave was that they were waiting for the physician to give orders for medications. Reference (WAC) 388-97-1060(1) This is a repeat deficiency from the Statement of Deficiencies dated 09/13/2023 and 04/24/2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe transfer utilizing the sit-to-stand lift (a mechanical lift used to assist residents that have difficulty standing up on their own) for 2 of 2 residents (Residents 1 and 2), reviewed for resident's that used a sit-to-stand transfer device. Resident 1 experienced a left arm fracture when they slipped out of the mechanical lift device during the transfer from their bed to the wheelchair when the waist support strap was not tightly secured. This failure placed other residents at risk for injury, falls, and a diminished quality of life. Findings included . The facility policy titled Transfer using a Sit to Stand Mechanical Lift, last reviewed on 09/15/2023, showed the facility will ensure two staff members are present during the transfer of residents that required a mechanical lift. The policy also showed when staff utilized the support slings, they must be snug, and comfortable or the resident could slide out of the sling. Additionally, staff were to ensure the resident's knees were secured against the knee pads and their feet were positioned on the foot plate. Review of the [NAME] II Sit-to-Stand (the mechanical lift utilized in the transfers involving Residents 1 and 2) lift instructions for use, showed the calf support straps may be used for residents that needed to have their weakened legs secured or as a reminder not to step off the footrest. <Resident 1> Review of the Resident 1's medical record showed they were admitted to the facility on [DATE] with diagnoses which included stroke with left sided weakness and arthritis. The 07/19/2023 comprehensive assessment showed Resident 1 had severe cognitive impairment (trouble remembering, learning new things, concentrating, or making decisions that affect everyday life) and required extensive assistance of two staff to assist with transfers. Review of the post fall nursing documentation, dated 09/21/2023 at 3:53 PM, showed Resident 1 was lowered to the floor when staff attempted to transfer them from the bed to the wheelchair. At 3:54 PM documentation showed the fall happened at 8:15 AM on 09/21/2023 and the physician was notified at 12:00 PM, when the resident complained of left arm pain and refused to move it. On 09/21/2023 at 5:54 PM, the resident had an x-ray of their left shoulder, elbow and wrist which showed an acute left humeral neck fracture (a broken bone in the upper part of the arm near the shoulder). The resident was then transferred to the local emergency room (ER) for an evaluation. Review of hospital records, dated 09/21/2023, showed Resident 1 was discharged from the ER with their left arm in a sling and they were to follow up with an orthopedic physician (specializes in conditions involving the musculoskeletal system). During an interview on 09/27/2023 at 9:11 AM, Resident 1 stated they had injured their left arm during a transfer when staff had gotten them out of bed using a sit-to-stand lift device, which caused them to fall to the floor. Resident 1 stated their left arm began to hurt immediately. During an interview on 09/28/2023 at 2:08 PM, Staff D, Nursing Assistant (NA), stated they were assisting Resident 1 with Staff E, NA, from their bed to the wheelchair using a sit-to-stand lift. During the transfer Staff D stated Resident 1 would not keep their right foot on the foot plate. Staff D stated they placed the support strap around the resident's waist when the resident was sitting on the bed. When they stood the resident up the support strap became loose and they were unable to tighten or adjust it during the transfer. Staff D stated when the resident raised their arms above their head they became dead weight during the transfer and slipped out of the mechanical lift. Staff D and Staff E assisted the resident to the floor. Staff D and Staff E stated there were no calf support straps on any of the sit-to-stand lift devices in the facility, and they had not been trained on how to use them. Staff D stated the sit-to-stand lift device was required to be performed with two staff members. During an interview on 09/27/2023 at 3:43 PM, Staff A, Licensed Practical Nurse/Resident Care Manager, stated the sit-to-stand was not used correctly, and calf support straps should have been used. <Resident 2> Review of Resident 2's medical record showed they were admitted to the facility on [DATE] with diagnoses which included stroke with paralysis on the right side of their body and history of falls. The 08/23/2023 comprehensive assessment showed the resident had severly impaired cognition and required limited assistance with two staff with transfers. Review of the Resident 2's plan of care, dated 08/18/2023, showed they required a sit-to-stand lift by two staff to transfer between surfaces and they were at risk for falls. An observation on 09/27/2023 at 4:09 PM showed Resident 2 was being transferred from their bed to the wheelchair by one staff member. The resident had their left hand resting on the sit-to-stand sling support bar and their right arm was hanging down. The upper body support strap was around their upper chest which raised the resident's shoulders upwards, suspending them by the upper body chest support. The calf support straps were not utilized during the transfer despite the resident's paralysis/weakness to their right side. During an interview on 09/27/2023 at 4:14 PM, Staff F, NA, stated they had multiple trainings on the usage of the sit-to-stand lift. Staff F stated they had never used the calf support straps, and had not seen them in the facility. Staff F stated Resident 2 had no strength on their right side. Reference WAC: 388-97-1060(3)(g) This is a repeat deficiency from the Statement of Deficiencies dated 06/14/2023 and 12/06/2022.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to respond timely to a visibly swollen and painful ankle for one of three residents (Resident 1) reviewed for quality of care. This deficient practice of delay in treatment and services, and lack of pain control caused actual harm to Resident 1, when the facility took over 48 hours to identify that their change in condition required a transfer to a higher level of care facility for evaluation and treatment, and during that time failed to adequately assess and treat pain. Findings included . Review of the facility policy titled Changes in Resident's Condition or Status, updated on 08/18/2022, stated .any change from baseline in a resident's status must be identified and addressed ., and .notable changes include decline in functional status, new or increasing confusion, (new) onset of pain, falls, deteriorating mobility . Further review of the policy showed the procedure to include .identify a suspected change .complete a physical assessment focusing on identified change .communicate the change to the appropriate practitioner, notify the resident's family .document the procedure . Resident 1. Review of the medical record showed the resident admitted to the facility on [DATE] with diagnoses of generalized muscle weakness, history of falling, and alcoholic cirrhosis of the liver (a condition in which the liver is scarred and permanently damaged from drinking excessive alcohol). Review of the comprehensive assessment completed on 03/31/2023 showed the resident had moderately impaired cognition, required extensive assistance of one person for transfers, bed mobility, dressing, toileting, personal hygiene and used a wheelchair for mobility. During an interview on 04/21/2023 at 11:00 AM, Staff L, Nursing Assistant (NA), stated they were able to get the resident out of bed to the bathroom the morning of 04/10/2023 but they were not able to put weight on the left leg due to pain. Staff L explained they observed the left ankle to be swollen and notified Staff P, Registered Nurse (RN), and Staff N, Physical Therapist (PT) of the change on 04/10/2023 at 10:00 AM. Staff L stated the resident was always confused. During an interview on 04/24/2023 at 11:34 AM, Staff N confirmed they were notified by Staff L the morning of 04/10/2023 that the resident complained of left ankle pain. Staff N explained they assessed the left ankle to be red, swollen, and tender to touch. Due to the significant changes in the resident's ankle Staff N stated therapy was held on that day and confirmed the presentation of the left ankle was new compared to their last therapy session on 04/05/2023. Staff N stated that Staff L had informed them they had already notified the nurse in charge, Staff P of the changes in the resident's ankle. The following day (04/11/2023) Staff N stated they went to Staff O, Agency Licensed Practical Nurse (LPN), (Licensed Nurse in charge of the resident's care that day), to check on the status of the resident's left ankle. Despite significant changes in the resident's ankle on 04/10/2023 Staff O was unaware of those changes and did not have an update. Staff N further explained they requested Staff Q, Medical Director (MD), to evaluate the resident's left ankle as they were in the facility that day (04/11/2023). Despite Staff L stating they had notified Staff P on 04/10/2023 of the changes to the resident's left ankle, Staff P stated on 04/21/2023 at 12:54 PM they were unable to recall the notification. They stated they did not observe or assess the resident's feet or ankles on that day (04/10/2023). Review of Staff Q's Progress Note (PN), dated 04/11/2023 at 9:00 AM, showed the resident had a painful left ankle and complained they could not walk, which had developed in the last few days and had not occurred before. The MD assessment showed the left ankle was firm with swelling, thus questionable dislocation or lesion. The stated plan was to obtain an x-ray Stat (immediately). During an interview on 04/24/2023 at 10:37 AM, Staff Q stated they were notified of a concern with the resident's left ankle by Staff N on the morning of 04/11/2023. Staff Q explained their evaluation of the left ankle showed redness and a bony prominence to the lateral (outer) side of the (left) ankle indicating the bones were not aligned. Staff Q explained they gave a verbal order to the nursing staff for an x-ray of the left ankle to be done right away. Review of the above physician's orders in the Electronic Health Record (EHR) showed Staff O placed an order for x-ray two views of left ankle for tenderness/swollen ankle on 04/11/2023 at 9:26 AM to a mobile x-ray company. When staff processed/transcribed the physician's verbal order, it showed no indication it needed to be completed urgently as originally requested by the physician. During an interview on 04/24/2023 at 9:40 AM, Staff O, Agency Licensed Practical Nurse, stated they could not recall details from the xray order they verbally received for Resident 1. During an interview on 04/24/2023 at 12:01 PM, Staff R, Collateral Contact, confirmed the mobile x-ray company electronically received an order for a left ankle x-ray for the resident on 04/11/2023 at 11:42 AM. Staff R explained the order was placed as routine which allowed the x-ray technician to determine the x-ray's priority based on their current workload. Staff R further explained the technician was dispatched at 11:48 AM, arrived at the facility at 6:46 PM, and completed the x-ray at 7:00 PM (9.5 hours after Staff Q gave verbal orders for the x-ray to be done right away). Staff R confirmed the mobile x-ray company made the maximum number of attempts to fax the completed x-ray report to the facility but was not successful. Staff S, NA, (caregiver for the resident on the evening shifts of 04/10/2023 and 04/11/2023) stated on 04/21/2023 at 2:30 PM that they were aware the resident's foot was sore but did not notice that the resident was in pain. The resident was restless in bed and frequently throwing their blankets on the floor. The resident was different in that they were not trying to get up on their own like they usually did. Review of the PN, dated 04/12/2023 at 7:15 AM, showed the resident had an unwitnessed fall at 4:10 AM on 04/12/2023 and was found lying on their back between the bed and window of their room. Staff M, LPN, assessed the resident's range of motion to all limbs and noted .diminished flexibility with swollen ankle . to the left lower extremity, and the results from the x-ray performed earlier were still pending. Despite noted changes in the resident's left ankle (pain, redness, swelling and difficulty walking) the morning of 04/10/2023 an interview with Staff M on 04/24/2023 at 3:16 PM, showed no information was given to them during shift report on 04/10/2023 at 6:00 PM regarding the resident's left ankle. On 04/11/2023 they were informed by the previous shift that an x-ray had been ordered by the physician, which was performed by a mobile x-ray company between 7:00 to 8:00 PM on 04/11/2023. Following the x-ray the technician left a CD (compact disc) with the images of the x-ray at the nursing station. When Staff M observed the resident's ankle during medication administration on 04/11/2023 it was twisted outward and not straight. Tylenol was administered for resident complaints of pain in their neck and lower back following their fall the morning of 04/12/2023. Staff M stated they did not attempt to locate the x-ray results when there was a delay in receiving the results, or notify the physician that a CD was made available following the x-ray. Review of the resident's Medication Administration Record showed Tylenol was administered on 04/12/2023 at 5:08 AM and the medication was ineffective. During an interview on 04/24/2023 at 1:10 PM, Staff H, RN/Minimum Data Set Coordinator, stated the facility never received a faxed copy of the resident's x-ray report. Staff H explained they were looking up x-ray reports for another resident and observed the resident's x-ray report was available. They printed the report from the mobile x-ray company's EHR system on 04/12/2023 at 9:50 AM (over 24 hours after the x-ray was first ordered and over 14 hours after the x-ray was completed) and documented the results of an .unstable ankle fracture . in a PN. Review of the PN dated 04/12/2023 at 11:16 AM, showed the MD was notified of the x-ray results and gave orders to send the resident to the emergency department for evaluation and treatment (one and a half hours after receiving the x-ray report and 26 hours after the x-ray was completed). Review of the ambulance report, dated 04/12/2023 showed the emergency call for transport to the hospital was received on 04/12/2023 at 11:50 AM and the resident arrived at the hospital at 12:28 PM. Review of the hospital records, dated 04/12/2023, showed the resident arrived at the hospital with main complaints of left ankle closed displaced fracture (broken bones with a gap between the pieces) and increased confusion. Further review showed the resident was admitted to the hospital for a surgical fusion (connecting bones together using hardware such as pins and screws) procedure of the left ankle. The resident had swelling and pain to the left ankle and increased confusion secondary to their liver disease. During an interview on 04/21/2023 at 12:00 PM, Staff K, Director of Nursing Services (DNS), stated the resident's ankle should have been assessed on 04/10/2023 when the change was initially identified by staff. Staff K stated they understood STAT meant be done right away and the time it took to complete the x-ray and receive the report seemed slow. Further interview with Staff Q on 04/24/2023 at 10:37 AM, showed that Staff Q stated the amount of time it took from ordering the x-ray to being notified of the x-ray results (25 hours and 50 minutes) was not acceptable. Staff Q explained pain could have been the cause of the resident's confusion. Staff T, Emergency Medical Technician (EMT), stated during a telephone interview on 04/19/2023 at 11:02 AM, that the resident's foot was very swollen, damaged, with a possible dislocation upon arrival to the facility on [DATE]. Staff T stated, they did not attempt to stablize it, ice it or elevate the foot, nothing was being done. The resident had an altered level of consciousness and was not registering pain. Staff U, EMT, stated during a telephone interview on 04/18/2023 at 6:57 PM, that the resident complained of pain when a splint was applied to the left ankle prior to transport to the hospital on [DATE]. They stated staff had only given one dose of Tylenol to the resident despite the left ankle being an obvious fracture. Despite the observations of pain, and/or swelling and tenderness to the resident's left ankle between the morning of 04/10/2023 to 04/12/2023 at 12:00 PM, review of their medical record during that time showed there were no nursing assessments regarding the change of condition (with the exception of the resident's fall on 04/12/2023). Despite the resident's complaints of ankle pain and changes in behavior, the only pain medication administered to the resident during that time was Tylenol (given for mild pain) which was administered for complaints of neck and back pain following the fall on 04/12/2023. Staff did not reach out to the physician when pain measures were ineffective. There were no other pain medications ordered by the physician for the resident. In addition, despite Resident 1's known fracture on 04/12/2023 at 9:50 AM, staff failed to provide non-pharmacological interventions to decrease swelling and pain regarding a fracture such as ice, elevation, and splinting. Reference (WAC) 388-97-1060(1) This is a repeat deficiency from the statement of deficiencies dated 02/25/2022.