**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to consistently implement care plan interventions related to bed height and mattress type to prevent accidents/falls for 1 of 1 sample resident (Resident 7) reviewed for falls and accident hazards. Resident 7 experienced harm when they fell out of bed and sustained a left hip fracture (broken bone), pain, and required hospitalization. These failures placed residents at risk for potential falls, injuries, and a decreased quality of life. Findings included . Review of the facility's policy titled, Fall Response & Management, revised on 05/17/2021, showed for a fall with injury, staff should avoid moving the resident their status is fully evaluated to prevent further injury if an injury occurred as a result of the fall. Staff were to evaluate the resident's limb strength and motion. Don't perform range of motion (ROM) exercises if a fracture is suspected or if the resident complains of any odd sensations or limited movement. Review of the facility policy titled, Accidents and Supervision to prevent accidents, revised on 10/15/2022, showed the facility provides an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. The facility monitors to verify interventions are in place and effective and is to ensure that interventions are implemented correctly and consistently. Resident 7 was admitted to the facility on [DATE] with diagnoses to include vascular dementia (a general term for problems with reasoning, planning, memory, and other thought processes cause by brain damage from impaired blood flow to the brain) with behavioral disturbance, history of stroke, atrial fibrillation (a fast irregular heart rate) with long term use of blood thinners and history of falls. The resident was readmitted to the facility on [DATE] with a diagnosis of a left femur fracture. A review of Resident 7's activity of daily living (ADL - includes activities such as dressing, transfers, bed mobility, walking/locomotion, bathing personal hygiene, toileting and eating) care plan, dated 06/20/2022, showed Resident 7 was a two-person extensive assist for bed mobility, transfers, dressing, and toileting. Review of Resident 7's care plan, printed on 04/10/2024, showed a focus of impaired mobility with risk for falls, and actual fall with fracture on 03/17/2024. Interventions included to keep the bed in a position (care plan did not specify the position) for safe transfers and lock bed brakes, initiated on 06/20/2022. A perimeter mattress (a type of mattress to create a raised edge and defines the perimeter for enhanced fall prevention without using restraints) to assist resident in clearly identifying the edge of their bed, initiated on 11/18/2023. The care plan did not show updates/changes being done after Resident 7 sustained a fall with fracture on 03/17/2024. Review of the facility incident reporting log, dated 03/17/2024 at 12:05 AM, showed Resident 7 sustained an unwitnessed fall in their room. The facility documented in the reporting log the fall resulted in a fracture. Review of the facility's investigation for Resident 7's fall on 03/17/2024, showed Staff D, Registered Nurse (RN), documented the resident was found lying on the floor on their left side and the bed was in the high position. Staff D documented Resident 7 stated I fell out of bed. Staff D documented Resident 7 was unable to move their left leg, complained of left groin pain, and had a skin tear to their left elbow. Staff D documented Resident 7 was assisted into bed with a Hoyer (a type of mechanical lift device) lift, the provider was contacted, and gave orders to send the resident to the emergency room to rule out a possible fracture. Staff D documented that 911 was called and Resident 7 was sent to the hospital. Review of Resident 7's clinical record showed a form titled Acknowledgement of Physical Restraint Use, a consent for the use of a scoop (perimeter) mattress dated 11/21/2023. Review of a nursing progress note, dated 03/18/2024 at 10:04 AM, showed the Interdisciplinary Team (IDT)) met to review Resident 7's recent fall with injury that occurred on 03/17/2024. The progress note showed Resident 7 reported they were self-transferring when they fell. Observation on 4/10/2024 at 11:40 AM, Resident 7 was observed sitting in their wheelchair next to the bed. A standard mattress was observed on the bed. There was a blue fall mat (a safety feature that is placed on the floor along the side of the bed) on the floor next to the left side of the resident's bed. In a joint observation/interview on 04/10/2024 at 1:56 PM, Staff F, Certified Nursing Assistant (CNA), stated they found specific resident information on the [NAME] (care plan for nursing assistants). Staff F entered Resident 7's room and observed the mattress in place stating, This is the mattress that has always been on their bed. Staff F stated the mattress in place was a standard mattress not a perimeter mattress. Staff F stated they thought Resident 7's fall interventions in place included a fall mat at the bedside and low bed (a bed that was able to go to the floor) because that's what was in their room currently. Review of Resident 7's [NAME], dated 03/22/2024, showed under the section Safety/Falls to keep the adjustable bed in position for safe transfers, and lock the brakes. The [NAME] did not indicate that a perimeter mattress was on the bed, the bed should be kept in the low position, or fall mat was in use. In an interview on 04/10/2024 at 2:25 PM, Staff E, RN, stated they were aware that Resident 7 had fell and sustained a left hip fracture. Staff E stated they were unsure where to find resident's fall intervention information but I would just use common sense. Staff E observed the resident's mattress and stated, That is a regular mattress, not a perimeter mattress. In an observation on 04/22/2024 at 7:35 AM and on 04/24/2024 at 9:39 AM, Resident 7 was observed lying in bed, with a standard mattress in place, a blue fall mat on the left side of the bed and the bed was in the low position. In an observation on 04/30/2024 at 1:26 PM, Resident 7 was observed in lying in bed with no perimeter mattress in place. A blue fall mat was folded up by the door, the bed was positioned approximately three to four feet off the ground, and not in a low position. In an interview on 04/30/2024 at 1:35 PM, Staff H, Maintenance Director, stated the facility owns their own perimeter mattresses, but they do not maintain a log for them. Staff H was unable to state if Resident 7 had a perimeter mattress in place but did not think they did. Staff H stated the maintenance department was notified verbally by nursing when a perimeter mattress needed to be placed for a resident. In an interview on 05/01/2024 at 11:57 AM, Staff E stated if a resident had a fall, complained of pain, and unable to move during assessment, they would not move the resident, and would call 911. Staff E stated that Resident 7 was physically unable to operate their bed controller, staff assist them with raising and lowering their bed. In an interview on 05/01/2024 at 12:11 PM, Staff G, CNA, stated the resident was not physically able to independently adjust their bed using the bed controller, stating I do it for them. Staff G stated resident specific fall interventions would be listed on the [NAME]. In an interview on 05/01/2024 at 1:30 PM, Staff C, RN/Regional Nurse Consultant, stated if a resident complained of pain in the left lower extremity and groin during an assessment after a fall, the resident should not have been moved and 911 should have been called. This is a repeat citation from survey dated 05/24/2023. Refer to WAC 388-97-1060 (3)(g) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to comprehensively assess the increased risk for skin breakdown, follow written policy and procedures, develop, and implement timely interventions necessary to prevent the development of avoidable pressure ulcers (PUs)for 4 of 6 sampled residents (Resident 1, 2, 3 and 4), reviewed for PUs. These failures caused harm to Resident 1 who admitted to the facility with a Stage 2 PU which deteriorated into an unstageable PU with osteomyelitis (bone infection), debridement (removal of dead [necrotic] or infected skin tissue to try to help wound heal), and a hospital treatment. developed a facility acquired unstageable PU with osteomyelitis (bone infection) and Residents 2, 3, and 4 experienced harm when they developed facility acquired PU's with partial and full thickness skin loss, and pain. This failed practice placed other residents at risk for the development of PUs, serious harm, and diminished quality of life. Findings included . The National Pressure Ulcer Advisory Panel (NPUAP) Pressure Injury (PI- also known as a PU) definition and stages of PU's include: -A PI (PU) is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as the result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate (the skin temperature, humidity, and airflow next to the skin's surface), nutrition, perfusion (measures how well the circulatory system is working), co-morbidities, and condition of the soft tissue. -Stage 2 PI (PU) is a partial-thickness skin loss with exposed dermis (the middle layer of the skin). The wound bed is viable, pink, or red, moist, and may also present as an intact or ruptured serum-filled blister. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. Stage 3 PI (PU) is a Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining (occurs when significant erosion occurs underneath the outwardly visible wound margins resulting in more extensive damage beneath the skin surface) and tunneling (when a wound progresses to form passageways underneath the surface) may occur. Stage 4 PI (PU) is a full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough (dead tissue that may appear yellow, tan, gray, green or brown in the wound bed) and/or eschar (dead tissue may be visible. Epibole (rolled edges), undermining occurs when significant erosion occurs underneath the outwardly visible wound margins resulting in more extensive damage beneath the skin surface), and/or tunneling (when a wound progresses to form passageways underneath the surface) often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable PI. Unstageable PI is an obscured full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 PI's will be revealed. Stable eschar (i.e. dry, adherent, and intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. Unstageable PI (PU) is an obscured full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, and intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury (DTPI) is a persistent non-blanchable deep red, maroon, or purple discoloration. Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration, or epidermal separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin color changes. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures are visible, this indicates a full thickness PI. Review of the facility policy titled, Prevention and Treatment of Pressure Ulcer & Other Skin alterations, revision date of 07/13/2018, stated the facility has a system in place to promote skin integrity, prevent PU development/other skin alterations, promote healing of existing wounds consistent with professional standards of practice and prevent further development of additional skin alterations unless the individual's clinical condition demonstrates they were unavoidable to ensure that a resident who has a PU receives necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing. The policy stated with each dressing change or at least weekly (and more often when indicated by wound complications or changes in wound characteristics), an evaluation of the PU/PI or non-pressure skin alteration should be documented. At a minimum, documentation should include the date observed and location, staging if applicable; size; drainage description if present; pain if present; and wound bed description including evidence of healing or necrosis (tissue death). The interdisciplinary team, resident/family collaborate to establish goals and interventions to address resident specific risk factors for the prevention of skin alteration, promote the healing of wounds, and/or prevent further breakdown. <RESIDENT 1> Resident 1 admitted to the facility on [DATE] with diagnoses that included left femur fracture, anemia, and failure to thrive (when a resident has a loss of appetite, eats and drinks less than usual, loses weight, and is less active than normal). Review of the admission skin inspection form, completed by nursing dated 12/20/2023, showed Resident 1 has a PI on (did not state location) buttock measuring 2 centimeters (cm) by 1 cm. Will continue to monitor pressure injury [PU], have the wound nurse follow and attempt to alleviate pressure as resident allows. The body diagram on this form (Section B: Skin Impairments) that allowed for further description/location/measurements of the wound/s was left blank. Review of Resident 1's care plan, dated/created 12/22/2023, showed the resident has an actual Stage 2 PU to their coccyx (tailbone), was present on admission, and measured 1.08 cm x 0.48 cm. Interventions included to assess, record, and monitor the status of the wound, and to notify the physician for any improvements or decline of the PU. Review of form titled, Wound Evaluation, dated 12/25/2023, Staff I, Licensed Practical Nurse (LPN)/Wound Nurse, documented Resident 1 had a Stage 2 PU on the sacrococcygeal (a joint form between the oval surface at the lower part of the spine and the tailbone) area measured 1.08 centimeter (cm) long by 0.48 cm wide 1.08 cm long by 0.48 cm wide. A review of Resident 1's admission Minimum Data Set (MDS- an assessment tool) assessment, dated 12/26/2023, showed Resident 1 was cognitively intact and they required maximum assistance with toileting and bed mobility. The MDS assessment identified the resident admitted with a Stage 2 PU and was at a high risk for developing a PU. Review of Resident 1's wound evaluation form, dated 01/02/2024, Staff I documented Resident 1 had a Stage 2 PU on the sacrococcygeal area measured 8.96 cm long by 0.87 cm wide, a deterioration in their PU. Review of Resident 1's weekly skin inspection, dated 01/10/2024 completed by nursing, documented Right buttock PI [PU] measuring 2 cm by 1 cm. The body diagram on this form (Section B: Skin Impairments) was blank. The comment section documented to continue to monitor, continue with current treatment, and wound nurse following PU to the resident's coccyx and right buttocks. The skin inspection stated the resident now had two PU's (the coccyx PU was not measured). Review of Resident 1's wound evaluation form, dated 01/15/2024, Staff I documented the resident had a Stage 2 PU on the sacrococcygeal area measured 1.97 cm long by 0.68 cm wide. There was no assessment of the right buttock PU. Review of weekly skin inspection form, dated 01/17/2024 completed by nursing, documented Has pressure injury on buttock, measuring 2 cm by 1 cm. The body diagram on this form (Section B: Skin Impairments) was blank. The comment section documented to continue to monitor, continue with current treatment, and wound nurse following PU to the resident's coccyx and right buttocks, no new skin issues. Review of a progress note, dated 01/22/2024 at 8:43 PM (five days after the licensed nurse assessed the PU), Collateral Contact (CC) 1, contracted wound company's Physician Assistant Certified (PAC), documented Initial Visit, Resident 1 admitted to facility with a possible Stage 2 on sacrum, staff were concerned because the wound had deteriorated. Physical exam of wound showed DTPI on the sacrum measured 8.98 cm x 4.67 cm x 0.1. CC1 recommended a new treatment orders and air mattress for the resident's bed. Review of a progress note, dated 02/05/2024 at 7:47 PM, CC1 documented follow up assessment of a new wound that is deteriorating. CC1 documented Resident 1 had dementia, morbid obesity with impaired bed ability. Resident 1's wound was unstageable due to slough in lower left sacrum and coccyx that measured 8.98 cm by 4.67 cm by 0.02 cm. Treatment changes recommended included a low air loss mattress (the second time this was recommended by CC1) for pressure reduction. Review of Resident 1's wound evaluation form, dated 02/12/2024, Staff I documented the resident had an unstageable PU, present on admission, on the sacrococcygeal -middle measured 6.96 cm long by 3.06 cm wide (review of the picture taken there appears to be two separate PU's located on the resident's left buttock and coccyx). The PU was documented as a Stage 2 on admission and in fact had deteriorated to an unstageable PU. Review of the care plan, revised on 02/13/2024, to indicate the resident now has an actual unstageable PI (PU) to the coccyx that was present on admission and measured 1.08 cm by .48 cm (on 12/22/2023 the resident had a Stage 2 with the same exact measurements. The interventions were not updated, and the air mattress was not implemented on the care plan per CC1's recommendations on 01/22/2024 and 02/25/2024 (the resident was admitted with a Stage 2 PU on their coccyx not an unstageable PU). Review of the Significant Change in Status MDS Assessment 02/24/2024, showed Resident 1 had moderate cognitive impairment (a decline from their admission MDS), and they required maximum assistance with toileting and bed mobility. Review of the Care Area Assessment (CAA, a systematic process to interpret the triggered information from the MDS assessment to assess the potential problem and determine if the area should be care planned) 02/24/2024, showed Pressure Ulcer/Injury CAA was triggered related to Resident 1 needing increased assistance with activities of daily living including bed mobility, transfers, toileting, hygiene and having current skin issue and noted incontinence episodes- all increase the risk for pressure injury or exacerbation of current injury. CAA documented that Resident 1 needed a special mattress or seat cushion to reduce or relieve pressure and required regular schedule of turning, neither intervention was documented as implemented on the care plan. Review of a progress note dated 03/04/2024 at 4:36 PM, CC1 documented Resident 1 was seen for sacrum/coccyx PU. CC1 documented the resident had impaired bed mobility and was totally dependent for repositioning and offloading. Resident 1's wound was unstageable with most of the wound be covered in slough, measuring 6.67 cm by 2.44 cm by 0.0 cm. Further documentation showed that the resident needs a low air loss pressure reducing mattress (the third time the air mattress was recommended), as they were immobile and had poor bed mobility. In a late entry progress noted, dated 03/04/2024 at 2:36 PM, Staff I documented that Resident 1 was seen by CC1 today for an unstageable PU to their sacrum. Staff I documented the resident would be turned/repositioned while in bed with assistance from nursing staff and a low air loss mattress was started due to wound treatment. Review of Resident 1's wound evaluation form, dated 03/18/2024, Staff I documented the resident had an unstageable PU, present on admission, on the sacrococcygeal -middle measured 6.96 cm long by 3.06 cm wide (review of the picture taken by the facility show that the wound is one large wound now, with muscle and possible bone exposed). Review of a progress note dated 03/18/2024 at 8:21 PM, CC1 documented Resident 1 was seen for sacrum PU. Resident 1's wound was unstageable with most of the wound be covered in slough and eschar, measuring 8.4 cm by 4.7 cm by 5.4 cm. Further documentation showed that the resident required clinical debridement. Following debridement, the wound was staged as a Stage 4 on the sacrum with bone exposed. Review of a nursing progress note, dated 03/20/2024, showed Resident 1 was sent to the emergency room by facility after wound x-ray results indicated possible osteomyelitis. The resident did not return to the facility. Resident 1's diagnosis list was updated, dated 03/20/2024, to include a Stage 4 PU and osteomyelitis (infection of the bone) of the sacral region. In an interview on 04/30/2024 at 1:30 PM, Staff H, Maintenance Director, stated if residents need specialty equipment such as a lipped mattress (perimeter mattress), transfer pole, low air loss mattress etc., the maintenance department would be responsible to install those devices. Staff H stated they would not install anything unless directed by the proper person, such as an air mattress, nursing would need to assess the resident first and ensure that it was appropriate then maintenance would install it. Staff H stated there was a log maintained that tracked which residents have air mattresses. Staff H provided a copy of the log titled Equipment Rental, that showed an air mattress was placed for Resident 1 on 03/05/2024, 43 days after it was recommended by CC1. In an interview on 05/01/2024 at 1:30 PM, Staff C, Registered Nurse (RN)/Regional Nurse, stated they were familiar with Resident 1 and had reviewed their record recently. Staff C reviewed the progress notes of CC1 where they recommended an air mattress be placed on multiple occasions and stated they had recently spoke to the owner of the contracted wound company and were told by the owner that a low air loss mattress should not have been recommended for this resident but that the facility doctor should have been notified of the recommendation and given the opportunity to make a decision. Staff C then reviewed the log provided by maintenance showing that the air mattress for Resident 1 was not placed until 03/05/2024 and Staff C stated they had been asking for this log for a few days now and no one was able to give it to them. Resident 1 no longer resided in the facility and was not able to be interviewed. <RESIDENT 2> Resident 2 admitted to the facility on [DATE] with diagnoses including anemia, right femur fracture, dysphagia (difficulty swallowing), protein- calorie malnutrition (the body lacks enough protein and energy to function properly), and cognitive impairment. A review of Resident 2's admission MDS assessment, dated 02/18/2024, showed Resident 2 had severe cognitive impairment, required extensive assistance from two staff with transfers, toileting, and bed mobility. The MDS assessment showed the resident admitted to the facility without PU/PI's. Review of the admission skin inspection form dated 02/12/2024, Staff J, LPN/Nurse Manager documented Resident 2 had a surgical incision on the right hip with a bruise from above the knee to the hip. The section with the body diagram was left blank. The form did not indicate that Resident 2 had any PU's present on admission. Review of Resident 2's care plan printed on 04/10/2024, showed a potential for alteration in skin/tissue integrity related to incontinence, created/initiated on 02/12/2024. On 03/14/2024 the care plan was revised to show Resident 2 had an actual skin alteration DTPI to the right heel. Interventions included to offload their heels or use Prevalon boots (a boot that provided continuous pressure relief) when in bed, created/initiated on 02/12/2024. Skin inspection done during CNA care opportunities, and to report changes to the Licensed Nurse (LN) created/initiated on 02/12/2024. The LN to perform weekly skin inspections to include review/check for footwear and report alterations as needed to the resident's provider, created/initiated on 02/12/2024. Right heel wound treatment orders (not specified), created/initiated on 03/14/2024 and Med pass (wound management/weight loss liquid supplement, created/initiated on 04/05/20204. Review of Resident 2's Skin Inspection Eval form, dated 03/11/2024, Staff J, LPN/Nurse Manager documented no new skin issues this week. The section with the body diagram was left blank. The form did not show that Resident 2 had any current PU's. Review Resident 2's Skin Inspection Eval form, dated 03/14/2024, Staff J, LPN/Nurse Manager documented Right heel worsening now deep purple in color. Family notified. Treatment in place. Off load heels while in bed. The section with the body diagram was left blank. The were no measurements of the PU on the form. During an observation on 04/08/2024 at 10:00 AM, Resident 2 was observed lying in bed on their back. The resident was noted to be on a standard mattress, heels resting directly on the mattress. The resident was not wearing foam boots. Attempted to interview this resident but they were unarousable at this time. Observation on 04/08/2024 at 1:40 PM, Resident 2 was in the same position as early in the day. There were no pressure relieving devices in place. Review of a Skin/Wound Eval form, dated 04/08/2024, documented Resident 2 had a DTPI on the right heel and was documented present on admission. The PU measured 4.2 cm long by 3.6 cm wide. The form had a section where the resident's physician and family were to be notified of the new skin alteration, this section was left blank. During an observation on 04/10/2024 at 9:40 AM, Resident 2 was observed lying in bed in the supine (on back) position, asleep unable to arouse. There were no pressure relieving devices in place at the time of this interview. At 11:45 AM, Resident 2 remained lying in bed, with the head of bed slightly elevated. The residents' feet/legs were positioned directly on the mattress with no pressure relieving devices in place. At 3:10 PM, returned to room for follow up observation and the resident remained in bed, asleep and was observed to be wearing light blue heel protector boots on bilateral feet. Review of Resident 2's clinical record on 04/11/2024, showed that on 04/10/2024 at 12:48 PM, during the facility skin sweep of all residents, Resident 2 was found to have additional wounds not identified during the skin inspection completed on 04/08/2024. Staff I identified a DTPI on the lateral (to the side of, or away from, the middle of the body) right foot, measuring 7.64 cm x 2.18 cm (in-house acquired) and a DTPI on the left heel, measuring 3.16 cm x 2.32 cm (in-house acquired). <RESIDENT 3> Resident 3 admitted to the facility on [DATE] with diagnoses including bipolar disorder, diabetes mellitus, polyneuropathy (the simultaneous malfunction of many peripheral nerves throughout the body), and anemia. A review of Resident 3's' Quarterly MDS assessment, dated 02/27/2024, showed Resident 3 was cognitively intact, required partial/moderate assistance from staff for bed mobility and had no PU/PI's present. Review of Resident 3's weekly skin inspection form, dated 03/25/2024, Staff K, RN, documented the resident had no skin issues/injuries noted on their arms/legs or feet. Review of the Skin & Wound evaluation, dated 04/01/2024, Staff I, documented Resident 3 had a DTPI on the right heel, was present on admission, and measured 2.4 cm x 1.3 cm, with 100% black eschar covering the wound. The evaluation form did not indicate if the resident physician and family had been notified. Review of weekly skin inspection form, dated 04/02/2024, showed Resident 3 had no skin issues present, arms/legs/feet were clear (this form was completed a day after the DTPI was noted on the resident's right heel). In an interview on 04/08/2024 at 8:32 AM, CC2, Resident 3's family member, stated they were at the facility on 03/31/2024 to visit with the resident for Easter. CC2 stated they went a little early to the facility to help the resident get ready before other family members showed up. CC2 stated when they were helping Resident 3 put their socks on and asked for Neosporin (an ointment). CC2 asked what they needed that for, and the resident stated, For my foot and showed CC2 their right heel. CC2 stated there was a huge black sore on their heel that they had never seen before, stating What the h*ll is that? CC2 went out to the nurse on duty and told the nurse they needed a bandage on Resident 3's foot, and the nurse tried to hand them a Band-Aid. CC2 stated that they laughed and asked, What is that going to cover, [Resident 3] has a huge wound on her foot, you need to come look at it. CC2 was very upset at finding the sore stating These people get paid a lot of money to care for people, they get one shower a week and then they don't even know she has this huge sore on her foot, it's just not right. I don't want them to just sit in this place, keep getting sores because they aren't getting care, then die there, I am trying to get her moved out of there to an adult family home. During an interview/observation on 04/08/2024 at 9:35 AM, Resident 3 was lying in bed in a supine position. The resident was not observed to have any pressure relieving devices in place. The resident's feet were noted to be bare, with a gauze type dressing wrapped around the right foot. The resident stated they have a sore on their right foot and was unsure for how long they had the sore, stating it really hurts sometimes and thought the nurse changed the dressing three times a week. Resident 3 stated they do not have any kind of boots they wear on their feet, usually they wore just socks. Observation on 04/09/2024 at 1:50 PM, Resident 3 was observed self-propelling their wheelchair and wearing socks. The resident returned to their room, got into their bed, and there no pressure relieving devices present on their bed or in the room. Review of the current care plan, printed on 04/10/2024, showed a focus area of potential for alteration in skin/tissue integrity related to a scabbed area right knee, and history of moisture associated dermatitis. Interventions in place as of 11/21/2023 included: - Needs assistance to apply protective garments (specify: geri-sleeves, a protects sensitive thin skin on the resident's arms, Tubigrip (fabric that provides continuous support) legs, Prevalon boots, etc.). - Offload heels or use Prevalon boots when in bed. - Skin inspection during NAC care opportunities, report changes to LN. - Weekly LN skin inspections to include review/check footwear. Report alterations as indicated. On 04/10/2024, Resident 3's alteration in skin/tissue care plan was updated to include an actual alteration in skin integrity regarding a PU to the right heel. Interventions included to off load the resident's heels when in bed, Registered Dietitian would monitor and evaluate the resident's nutritional intake and condition of their wound and make recommendations as indicated. On 4/11/2024, an intervention was added to encourage Resident 3 to float their heels when in bed, assist the resident when they need help, and the resident required consistent reminding to continue to float their heels. Observation on 04/10/2024 at 9:15 AM, Resident 3 was observed lying in bed, sleeping in the fetal position. The resident was observed with a dressing in place on the right foot, and there was no pressure reliving devices observed on their feet or in their room. During an interview and observation on 04/10/2024 at 9:30 AM, Staff K, RN, stated they were the nurse for Resident 3 today. Staff K stated the resident currently had a PU on their right heel and the interventions in place included dressing changes and offloading their heels. Staff K stated they thought they had tried to have the resident wear pressure relieving boots at one point but stated Theres no way they would wear those. Staff K stated the resident did not have Prevalon boots in the room and doesn't remember ever seeing those type of boots in this facility. At 9:40 AM, Staff K was observed to change the resident's dressing to their right heel. Resident 3 complained of pain in the right foot during the dressing change, that went unaddressed by Staff K. Staff K stated the facility had a wound nurse and that was how wounds were assessed to determine progression or deterioration of the wound, stating we just change the dressings, do the treatments, and were not responsible to measure anything. The wound appeared to be the approximate size of a golf ball and was solid black/brown in color. The edges around the wound were noted to be red in color and appeared irritated. Staff K stated that the wound looked the same the last time they saw it. In an interview on 04/10/2024 at 12:25 PM, Staff B, RN/Director of Nursing (DNS), stated that the expectation for staff who find new skin alterations is to complete a Skin alteration incident investigation (Risk Management). Staff B was asked to provide the investigations for Resident's 2, and 3's in house skin issues and they stated that they had not been completed. Staff B stated that they would be completing investigations now for both residents and would get them to me tomorrow. Staff B was asked if a resident admitted with a skin issue that deteriorated while in the facility would they expect an investigation and they stated Yes. Staff B reviewed the completed skin inspections from 04/01/2024 and 04/02/2024 and was unable to provide any information regarding the skin check on 04/02/2024, completed by Staff L, documented the resident did not have any skin issues/PI on their feet, stating, They [Staff L] are going to be upset that they missed that, referring to Staff L completing a skin check and not documenting that Resident 3 had a PU on the right heel. Review of the facility's skin investigation dated 04/10/2024 at 12:39 PM, Staff B documented the report was completed due to worsening of Resident 3's right heel wound, initially not completed on 04/01/2024 when staff noted a deterioration in wound status. < RESIDENT 4> Resident 4 admitted to the facility on [DATE] with diagnoses including protein-calorie malnutrition, dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems) without behaviors, Alzheimer's disease, and dysphagia. Review of the admission MDS assessment, dated 02/23/2024, showed Resident 4 had severe cognitive impairment and had no PU/PIs on admission. Review of Resident 4's weekly skin inspection forms showed the following: -On 02/18/2024 (admission to the facility), both of the resident's feet were purple, blanchable, and were that the resident's baseline. - On 03/21/2024 and 03/28/2024, there were no skin issues noted. - On 04/05/2024 and 04/11/2024, showed a right heel wound was identified, there was a treatment in place, and there were no measurements of the wound (the section with the body diagram was left blank). Review of Skin & Wound Evaluation, dated 04/08/2024, showed Resident 4 had a Stage 3 right heel PU. The evaluation showed the PU was present on admission (per the weekly skin inspections the PU developed on 04/05/2024 after the resident admitted to the facility) to facility and measured 2.3 cm x 2.3 cm x 1.3 cm. Observation on 04/16/2024 at 12:50 PM, Resident 4 was observed sitting up in their wheelchair, wearing only non-skid socks on their feet. Observation on 04/16/2024 at 3:10 PM, Resident 4 was noted to be lying in bed with their heels lying directly on the mattress. There was a blue boot and two pillows on the chair in their room, but no pressure relieving devices were observed in place. Observation on 04/19/2024 at 2:14 PM, Resident 4 was lying in bed watching TV. The resident's heels were lying directly on the mattress, and no pressure relieving devices were in place. Observation on 04/22/2024 at 7:44 AM, Resident 4 sitting in their bed, with their legs extended out directly on the mattress, wearing non-skid socks on both feet, no pressure relieving devices were observed in place. Observation on 04/22/20204 at 9:30 AM, Resident 4 was sitting up in their wheelchair in their room, there were no protective heel boots observed on the resident feet or in the room. During an observation/interview on 04/22/2024 at 11:25 AM, CC1 stated Resident 4 currently had a PU on their right heel but was unsure if they admitted with it or if it was acquired in the facility. CC1 removed an undated dressing on the right heel. The wound appeared as red tissue, no yellow tissue noted. At the time of the observation the measurements were 2.4 cm long by 1.7 cm wide and 0.2 cm deep. CC1 stated interventions in place currently for Resident 4 included heel prep to the right heel and foam boots on both of their feet when up in a chair or in bed. CC1 asked Staff M, RN/Nurse Manager, if the resident had protective boots available and Staff M opened the residents closet and stated, there are some in the closet and closed the door. Staff M was asked if Resident 4 refused to wear the boots and they stated, not that I have seen. After CC1 and Staff M completed the residents wound treatment, they exited the room and did not attempt to place the protective boots on the resident. During a joint record review/interview on 04/22/2024 at 12:43 PM, Staff B reviewed the current care plan for Resident 4 and stated interventions in place currently included to check the resident's footwear and complete weekly skin inspections. Staff B reviewed the physician orders and stated an intervention in place included to elevate the resident's heels when in bed, started on 03/17/2024. Staff B stated their expectation for Resident 4's protective boots were that Staff M should have removed them from the closet and placed them on the resident before leaving the room. Refer to WAC 388-97-1060 (3)(b) .

Based on observation, interview, and record review, the facility failed to consistently recognize and respond to complaints of pain and failed to consistently implement wound care recommendations related to pain management in accordance with professional standards for 1 of 3 sampled residents (Resident 55) reviewed for pain management. Resident 55 experienced harm when nursing staff failed to recognize and respond to complaints of pain and failed to implement wound care recommendations related to pain management. This failed practice placed residents at risk for unmanaged pain and a diminished quality of life. Findings included . Resident 55 admitted to the facility 06/30/2023 with diagnoses which included diabetes, history of bleeding in the brain, and throat cancer. The resident required extensive assistance for activities of daily living and was alert with some memory impairment but was able to communicate and respond appropriately to questions such as describing their pain level and location. Review of Resident 55's electronic medical record, dated 10/21/2023, showed the resident developed a pressure wound (pressure ulcer is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device.) to the left ankle in a previously healed area. Review of Resident 55's Quarterly Minimum Data Set (MDS - an assessment tool) assessment, dated 01/06/2024, showed the resident pain interview and assessment were not completed as required. The resident's interview was marked not assessed, and there was no update related to pain management in the resident care plan. Review of Resident 55's weekly wound consultant notes, dated 10/21/2023 to 02/05/2024, showed the resident was referred to a wound consultant group who provided onsite weekly visits for wound management. The wound consultant notes showed the resident's complaints of pain were not consistent some visits the resident had no pain observed, and other visits the resident reported mild or moderate pain during assessment and treatment. The orders for wound care for the resident's left ankle wound were three times per week and as needed. Each visit note included the recommendation to administer pain medication 30 minutes prior to wound treatment; to please administer as needed (PRN) pain medication and/or topical anesthetic. Review of the current February 2024 physician orders, showed Resident 55 had an existing order for gabapentin (used to treat nerve pain), start date 06/30/23, scheduled to be given routinely three times per day at 8:00 AM, 2:00 PM and 8:00 PM, for nerve related pain and had orders for additional pain medication for breakthrough pain. An order for Tylenol (non-narcotic medication) PRN for mild breakthrough pain, and tramadol (a narcotic pain medication), with a start date of 07/11/2023, PRN for moderate to severe breakthrough pain. Review of Resident 55's Medication Administration Record (MAR), dated 02/01/2024 to 02/07/2024, showed the resident received no doses of PRN medication. The MAR did not include the wound recommendations to premedicate the resident prior to wound care. In an interview and observation on 02/04/2024 at 10:15 AM, Resident 55 pointed to their left foot and said their ankle hurt. They said they thought they could take something for pain but didn't know what it was. The resident replied I don't know to any further questions asked. In an observation on 02/05/2024 at 3:02 PM, Resident 55 was heard from the nurse's station calling out from their room stating hey, hey, my foot hurts .bad. In an observation and interview on 02/06/2024 at 1:16 PM, Resident 55 was calling out hey, hey, Staff M, Licensed Practical Nurse, went to the resident's room with their 2:00 PM gabapentin. The resident was observed to point to their left foot with a furrowed brow and say to Staff M, this d*** foot. Staff M stated, I know it is hurting and I am waiting to see if the wound nurse can come, otherwise I will do it (the dressing change) .I have until 10:00 PM to do it. Staff M did not ask further questions or further assess the resident's statement about their foot, did not offer the resident any breakthrough pain medication and left the room. Staff M stated the resident was just given their pain medication and stated the resident had nerve pain. Observation on 02/06/2024 at 1:26 PM, Staff H, Nursing Assistant Certified (NAC), and Staff Q, NAC, responded to Resident 55 calling out Hey, Hey, I need some help now. The resident was heard to state to the staff, this damn foot hurts, and Staff H and Q both stated (while standing in the hall outside of the room), the resident called out like this when they want to be moved. When asked if the resident ever stated they were having pain, Staff H stated the resident, doesn't usually . they will just say they want to be moved and stated they would tell the nurse if the resident was complaining about pain. Review of the Treatment Administration Record (TAR) for 02/06/2024 day shift (6:00 AM through 2:00 PM), showed Staff M documented Resident 55's pain level as a zero and the resident received no PRN pain medication on 02/06/2024. In an interview on 02/07/2024 at 12:37 PM, Staff N, NAC, stated Resident 55 sometimes complained about their foot hurting, I think it hurts a lot sometimes, but they don't really ask, they don't use the call light, but they will just call out and want to be moved, they will say their foot hurts or their bum hurts. We tell the nurse, and the nurse can give them medicine but [the resident] won't ask will just say they want help. In an interview on 02/07/2024 at12:43 PM, Staff O, Registered Nurse (RN), stated Resident 55 does best with yes or no questions, and stated when they asked the resident about their pain, they usually just shook their head no. I have not given them anything, nobody reported to me that they were having pain. Staff O stated the resident called out rather than using their call light. In an observation of wound care on 02/07/2024 at 2:30 PM, with Staff P, LPN/facility wound nurse, Resident 55 stated they were having pain to their left foot. Staff P asked the resident to rate their pain on a scale of zero to 10 (zero being no pain and 10 being severe), and the resident said 10. Staff P stated, that is a lot, and stated they had checked with Staff O and Staff O had given the resident their PRN pain medication. Staff P stated sometimes the resident complained of pain and sometimes not, but they were not always aware whether the resident had been pre-medicated unless they went to ask the nurse. Staff P stated they were present when the wound consultant rounds were done weekly and reviewed the notes. Resident 55 was observed to wince during cleansing of the ankle wound which was observed to be a small open area, about the size of a pea, over the bony prominence of the ankle and the surrounding tissue was pink. The resident stated, it hurts when you touch it like that. Record review showed Resident 55 had received PRN Tramadol at 2:00 PM on 02/07/2024. In an interview and observation on 02/08/2024 at 10:22 AM, Staff E, LPN/Resident Care Manager, stated Staff P was responsible for reviewing and implementing the orders and recommendations from the wound consultant visits and was not aware there were recommendations to premedicate Resident 55 had not been implemented. Staff E was not aware the resident was having complaints of pain which were not being recognized or assessed by the nursing staff. Staff E stated the residents PRN used to be routine, but they were not having complaints of pain and did not want it anymore, so it was changed to as needed, maybe something is changed. Staff E walked to the Resident 55's room where Staff E asked the resident how they were doing and if they had any pain. The resident stated, not really .except for that ankle and pointed to their left foot. Staff E was observed to ask the resident further probing questions about their pain and touched the resident's lower leg, foot and around the ankle where the bandage was in place and the resident stated, it hurts under there, it throbs all the time. Staff E asked if it was better after they had received a pain pill, and the resident stated they thought so. Staff E stated they would notify the provider the resident was having increased complaints of pain and would update the resident record with the wound recommendations and to increase the frequency the staff was monitoring the resident's pain to every four hours. Review of Resident 55's current pain monitor, dated 02/01/2024 to 02/07/2024, showed the monitor was set up for twice per day in the day and evening. Each of the day shift entries for the month of February were 0, except 02/04/2024, which was documented as a 2. The evening entries showed 02/01/2024, a 1, and 02/02/2024, a 2, and the remaining entries were 0. In an interview on 02/08/2024 at 11:53 AM, Staff C, RN/Director of Nursing Services, stated there should be coordination between the floor nurses and the wound nurse if staff were to premedicate 30 minutes before a resident's treatment, so they needed to know when the wound nurse was coming. The wound notes were in the progress notes section of the medical record and there was no way to acknowledge it, but the wound care nurse would stop in, we would talk, and Staff P lets me know directly after the wound rounds if there were new orders or recommendations but stated they did not personally double check that the record was updated. Staff C was informed of the concern related to lack of recognition, further assessment, and intervention of Resident 55's complaints of pain and Staff C stated they would provide education right away. This is a repeat citation from survey dated 03/24/2023. Refer to WAC 388-97-1060 (1) .

Based on interview, and record review the facility failed to protect a cognitively impaired resident from unwanted touch for 1 of 1 resident (Resident 2) reviewed for sexual abuse. Resident 2 experienced psychosocial harm, based on a reasonable person concept, when they received a non-consensual sexual touch from Resident 1, who had been identified in the past of inappropriate behaviors and sexually suggestive statements with female staff and a history of wandering into Resident 2's room on multiple occasions. The facility failed to identify an incident of sexual abuse, report it timely to the state agency, and potentially placed cognitively impaired residents at risk for unwanted sexual touch and psychosocial harm. Findings included . Review of the facility policy titled, Abuse, revised on 08/01/2023, showed the facility respects the resident right to be free from abuse and neglect. The facility identifies residents most at risk of neglect and abuse. The policy also showed that allegations of sexual abuse are reported to the state agency within two hours if there was alleged abuse or serious bodily injury as a result of an event. Review of the online incident report submitted by the facility to the state agency, dated 10/16/2023 at 9:43 AM, showed After review of documentation from the event on 10/14/2023 the interdisciplinary team decided this even was a reportable situation. The report showed the date and time of this incident occurred on 10/16/2023 at 9:30 AM, almost 48 hours after the allegation of sexual abuse had occurred. Review of a facility incident investigation, dated 10/14/2023, showed Staff D, Nursing Assistant Certified (NAC), observed Resident 1 with their hand up Resident 2's shirt. Staff D removed Resident 1 from the room and notified the nurse. The summary of the investigation showed the interventions implemented after the incident included a room move was completed for Resident 1 (which occurred on 10/16/2023, two days after the incident), both residents were placed on alert charting (not completed until 10/18/2023). Review of each resident's medical record showed no documentation indicating these interventions were implemented timely. <RESIDENT 1> Resident 1 was a long-term care resident of the facility with diagnoses to include major depressive disorder, cognitive communication deficit, cerebral ischemia (brain injury) and mild cognitive impairment. According to the Quarterly Minimum Data Set (MDS - assessment tool) assessment, dated 09/05/2023, the resident had moderate cognitive impairment and required supervision with mobility in their wheelchair (w/c). Review of Resident 1's behavior progress notes showed: - On 09/24/2022, the resident made a statement about another female resident being their spouse. No other inappropriate behavior noted at this time. - On 12/31/2022 at 2:10 PM, the resident was redirected out of another resident's room twice this shift. Resident found sitting next to female resident and making statements that they believe the female resident was their wife. - On 01/07/2023 at 11:07 AM, the resident had increased agitation with staff when trying to redirect them from another resident's doorway (Resident 2). Resident 1 believed Resident 2 was their spouse. Resident 1 was noted sitting outside of Resident 2's room and trying to enter when staff were not around. Documentation showed, when Resident 1 seen a male staff member enter Resident 2's room they made threatening comments to the staff stating they would kill them. - On 01/27/2023 at 8:21 AM, review of a physician note, Resident 1 touched them inappropriately during their meeting and the facility had reported the resident pulled a staff member into their bed. - On 10/14/2023 at approximately 10:15 AM, Resident 1 went into Resident 2's room and the aide witnessed Resident 1 putting their hand up Resident 2's shirt. Review of Resident 1's care plan showed: - Focus problem, created on 01/27/2023, of the potential to demonstrate verbally and physically inappropriate sexualized behaviors towards staff related to poor impulse control. Interventions included analyze key times, places, circumstances, triggers and what de-escalates Resident 1's behavior and document; if the resident becomes agitated and begins inappropriate conversation, intervene before agitation escalates, if response was aggressive, staff should walk calmly away and approach later. - Focus problem impaired cognitive function or impaired thought processes, created 10/18/2023 (four days after the inappropriate touching incident on 10/14/2023), related to difficulty making decisions, impaired decision making, long and short-term memory loss. Interventions included room move completed to assist in deterring Resident 1 from entering the female resident's room they mistake as their wife; Resident 1 has history of mistaking another female resident for a member of their family, during these events redirect resident away from the female resident, ensure both residents are safe and attempt to re-orient to current situation. - Focus problem elopement risk/wanderer, created on 11/03/2023 (20 days after the wandering and sexual abuse incident on 10/14/2023), as evidenced by decreased cognition, decreased safety awareness, and history of wandering. Interventions included address wandering behavior by walking with or attempt to redirect from inappropriate area; engage in diversional activity; distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, or a book. Observation on 12/12/2023 at 12:30 PM, Resident 1 was sitting in their w/c in their room. Resident 1 was not able to answer questions that were asked. <RESIDENT 2> Resident 2 was a long-term resident of the facility with diagnoses to include cerebral palsy (disorder resulting in impaired muscle coordination), quadriplegia (paralysis affecting all limbs of the body), and cognitive communication deficit. According to the Quarterly MDS assessment, dated 11/02/2023, Resident 2 had severe cognitive impairment and required extensive assistance from staff for all activities of daily living. Review of Resident 2's progress notes, dated 10/14/2023 through 10/18/2023, showed no psychosocial monitoring had been documented by facility staff for the resident following the allegation of sexual abuse on 10/14/2023. On 10/18/2023 at 12:16 PM, four days after the incident, Staff B, Registered Nurse (RN)/Chief Nursing Officer (CNO), documented they completed a visual observation of Resident 2 related to the incident with a male resident on 10/14/2023, no signs or symptoms of psychosocial distress noted. Observation on 11/28/2023 at 11:10 AM, Resident 2 was observed in their room in their w/c and was unable to be interviewed. During an interview on 12/12/2023 at 1:30 PM, Staff C, RN, stated they were the nurse on duty at the time of the incident between Resident 1 and Resident 2 on 10/14/2023. Staff C stated Staff D had notified them Resident 1 was in Resident 2's room and had their hand up Resident 2's shirt. Staff C stated they separated the two residents immediately and kept Resident 1 near the nurse's station for the remainder of their shift but was unsure as to when Resident 1's room was changed but that they did not handle the room change at the time of the incident. Staff C stated they notified facility management and the families but did not report it to the state hotline and had not realized at the time it needed to be reported. Staff C stated they thought they had put both Resident 1 and Resident 2 on alert charting and was unable to state why neither resident had been placed on psychosocial monitoring following the incident of non-consensual touching on 10/14/2023. On 12/12/2023 at 2:00 PM, Resident 2 was observed in bed making loud noises and unable to be interviewed. During a joint interview/record review on 12/12/2023 at 3:00 PM, Staff B stated when there was an incident that involved non-consensual touch between two residents their expectation was to protect the residents first and then the incident should be reported to the state immediately. Staff B stated Staff C was a fairly new nurse and was unsure about the reporting process of this specific incident. Staff B stated after this incident they had became aware there was a history of inappropriate behaviors with Resident 1 and that this was not the first time they had been found in Resident 2's room, but it was before they worked at the facility. After review of both Resident 1 and Resident 2's clinical records, Staff B was unable to show documentation that either resident had been monitored by facility staff after this incident, stating I had the Nurse Practitioner (non-employee of facility) see both residents on 10/16/2023. Staff B was unable to provide additional information about the delay in reporting to the state agency, the delay in moving Resident 1's room until 10/16/2023, or the delay in updating/revising the care plans of either resident until 10/18/2023. Refer to WAC 388-97-0640(1)(5)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to permit a resident to return (re-admit) to the facility for 1 of 1 sampled resident (Resident 2), reviewed for transfer to the hospital when the resident was ready to return to the facility after a hospital stay. Resident 2 experienced harm and a decreased quality of life when they expressed unnecessary psychosocial distress when the resident was not permitted to return to the facility where she had lived since June 2023, and felt they had nowhere to safely discharge. Findings included . Review of the facility's policy, Transfer and Discharge, revision date 10/15/2022, showed residents who are sent emergently to the hospital are considered facility-initiated transfers because the residents return is generally expected. The facility allows residents whose hospitalization exceeds the bed-hold period under the State plan to return to the facility immediately upon first availability of a bed in a semi-private room even if the resident has an outstanding Medicaid balance, if the resident requires the services provided by the facility, and is eligible for Medicaid nursing facility services. Resident 2 was admitted to the facility on [DATE] with diagnoses including colon cancer, chronic pain syndrome, anxiety disorder, major depressive disorder, and sepsis (infection in the bloodstream). Review of a facility form titled, Brief Interview of mental status, dated 09/20/2023, showed Resident 2 was cognitively intact. Review of Resident 2's progress note, dated 09/23/2023, showed the resident was sent to the emergency room (ER) for complaints of uncontrolled pain. The resident stated they wanted to go and make sure everything was ok as they were supposed to start chemotherapy (chems - a drug treatment that uses powerful chemicals to kill fast-growing cells in the body) the following day. Review of a progress note, dated 09/24/2023, Staff C, admission Coordinator, documented Received a call from resident they will remain in the hospital for several days, offered a bed hold and Resident 2 stated they could not afford to pay the bed hold fee but would like to return to the same bed. Review of the hospital discharge planner communication documentation between the hospital and the facility, dated 09/25/2023 at 9:39 AM, showed the hospital declined Resident 2 to return to the facility. The facility's reason was Per nursing we cannot accept patients on Chemotherapy. Review of a progress note, dated 09/26/2023, showed Staff D, the prior Social Services Director (SSD), documented they had spoken with Resident 2 and the resident reported being told they could not return to the facility if they were receiving chemo (chemo) due to infection control and safety issues. Staff D stated they informed Resident 2 they would not be able to receive chemo while a resident in any skilled nursing facility (SNF) and suggested the resident look for placement at an adult family home (AFH). Staff D documented the resident verbalized understanding of this and felt they would be returning to the facility in a few days. Review of hospital progress note, dated 10/11/2023, showed Collateral Contact 1 (CC1), hospital discharge planner, documented speaking with Staff C about Resident 2 returning to the facility. Staff C reported they were unable to accept the resident back due to neutropenic (a condition that lowers white blood cells in the body making the person more prone to infections and bacteria) precautions and the cost of chemo. CC1 explained the resident would only need chemo once a month and would be receiving that at the cancer clinic and transportation would also be arranged. Staff C reported the facility was still unable to accept the resident back after receiving this information. During a telephone interview on 10/24/2023 at 10:15 AM, CC1 stated Resident 2 was currently inpatient at the hospital as the facility refused to re-admit the resident after sending them to the ER on [DATE]. CC1 stated the hospital communicated with the facility on 09/24/2023 to discuss them re-admitting the resident once able, but they were told that the facility would not be able to take the resident back due to them receiving chemo, and the facility would not want to pay for the chemo treatments. CC1 stated they explained to the admission coordinator the resident would be receiving their chemo treatments at an outside facility, and it would not cost the facility anything and they had even scheduled transportation to and from the appointments. CC1 stated the admission coordinator said they did not have a neutropenic room for the resident to stay in, and CC1 then explained that was not a requirement for this resident, but the facility continued to refuse admission after receiving this information. CC1 stated after this facility refused to take the resident back, they began looking for another facility and the resident was currently on a waitlist for another local SNF. Review of a hospital discharge planner note, dated 10/30/2023, showed Resident 2 cannot return to the facility due to refusing to accept pt [patient] back. Resident 2 was currently on a wait list for another SNF, and currently had an option of discharge to a trailer on a friends property. At 4:03 PM, showed an updated note that the friend, who was at the resident's bedside, could offer the trailer, expressed concerns the resident would be alone in the trailer, could not provide any medical or activities of daily living care needs (dressing, toileting, bathing, etc.), and would like a back-up plan for Resident 2's discharge. During an interview on 11/03/2023 at 12:30 PM, Staff C stated they were familiar with Resident 2, and they had accepted the resident back to the facility, but the hospital never sent additional requested information over. Staff C was unable to provide any documentation in the resident's clinical record to confirm these interactions/conversations with the hospital, stating I do not document all communications with the social workers at the hospitals, that's impossible. Staff C stated the last thing they remember seeing in EPIC (hospital health information site) was Resident 2 was waiting for an available bed at another facility and was unable to access the resident's record through EPIC at the time of this interview. During an interview on 11/08/2023 at 11:47 AM, CC2, Resident 2's family member, stated the resident really wanted to return to the facility since they had been there since June 2023, they really liked being there. CC2 stated Resident 2 was very upset about not being allowed to return and felt it was because they would be starting chemo. CC2 stated this whole situation caused a lot of stress to Resident 2 as they felt they had nowhere to go, and they felt the only option they were going to have would be to discharge to a trailer on a friend's property with no assistance and that was not a safe option. CC2 stated that Resident 2 was still in the hospital is actively passing away at the time of this interview. CC2 the facility never notified them regarding Resident 2 being sent to the hospital, it wasn't until the hospital called them that they knew Resident 2 had been admitted . During an interview on 11/08/2023 at 3:30 PM, Staff A, Executive Director, stated to their knowledge the facility can admit residents to the facility that received chemo outside of the facility. Staff A stated they were new to the facility, and it was discovered shortly after they started the previous admission coordinator was denying a lot of admissions. Staff A stated, We do not deny people, we are here to work with the hospitals and should be able to care for most residents, obviously there are a few conditions we are not equipped to handle like ventilators or in house chemotherapy. Staff A was unable to provide any further information as to why Resident 2 was denied re-admission to the facility but agreed they should have been able to re-admit even with receiving chemotherapy at an outside facility. Refer to CFR 483.15(c )(3)(i)-(iii), (c )(4)(i)(ii), (c )(5)(i)-(v), F-623 Notice before transfer. Refer to CFR 483.15(d), (d)(1)(i) - (iv), (d)(2), F -625 Notice of bed-hold policy and return. Refer to WAC 388-97-0120 (4)(b) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility staff failed to conduct a thorough investigation for potential neglect for 1 of 3 residents (Resident 1) who experienced a fall, was on the floor and staff was reported to not come to their assistance or communicate the fall timely to licensed staff. This caused harm to Resident 1 when they did not receive timely assistance after falling and experienced a hospitalization for a fractured (broken) left elbow and left hip. The facility failed to thoroughly investigate the fall to rule out abuse/neglect which placed residents at risk for inappropriate corrective actions, ineffective care planning, repeat incidents, injury, and the potential for unidentified abuse or neglect. Findings included . According to the Washington State Reporting Guidelines for Nursing Homes (Purple Book), dated October 2015, A thorough investigation is a systematic collection and review of evidence/information that describes and explains an event or a series of events. It includes guidelines for prevention and protection, incident identification, investigation and reporting for nursing homes, the facility investigation should end with the identification of who was involved in the incident, and what, when, where, why, and how the incident happened including the probable or reasonable cause. Review of facility policy titled, Accidents and Supervision to prevent Accidents, dated 11/28/2017 and revised 10/15/2022, showed: - Identification: Post incident, the facility is to identify additional medical, environmental, staff issues/training, and/or other items that may impact additional falls/residents. - Supervision (Falls): If a fall occurs, manage the fall, then conduct a root-cause analysis to assist with updates to the fall prevention plan. When reviewing the incident for root-cause, evaluate the casual factors leading to the resident fall as that may also assist in developing and implementing relevant, consistent, and person-centered interventions to prevent future occurrences. Resident 1 admitted to the facility on [DATE] with diagnoses that included repeated falls, impaired mobility, right side rib fractures, stroke (when the blood supply to part of the brain was interrupted or reduced), and dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). The discharge Minimum Data Set (MDS - an assessment tool) assessment, dated 06/24/2023, showed Resident 1 required two-person extensive assistance with bed mobility, transfers, dressing and toileting. The resident's cognitive section was not completed and left blank. Review of the facility's State incident reporting log on 06/30/2023, showed Resident 1 had an incident on 06/26/2023 that resulted in a fracture. Review of the facility's investigation, dated 06/26/2023, showed the facility initiated an investigation, after receiving communication from a local hospital informing the facility that Resident 1 had been admitted to the hospital on [DATE] after the resident sustained a fall in the facility. The investigation stated the hospital determined Resident 1 had acute fractures to their left hip and left elbow. The facility's investigation found that Resident 1 sustained a fall during the evening of 06/23/2023 which had not been investigated at the time of the fall, Nursing Assistants (NAs) assisted Resident 1 up from the floor, and the resident did not have a nurse assess them after the fall occurred. Review of a witness statement, dated 06/24/2023, and included in the facility's investigation conducted on 06/26/2023, showed Staff H, NA, documented they observed Resident 1 on the floor on 06/23/2023 at 3:30 PM and Staff G, NA, was standing next to the resident. Staff H documented they observed the resident 15 minutes prior to the fall sitting in their wheelchair attempting to stand. Review of a witness statement, dated 06/24/2023, and included in the facility investigation conducted on 06/26/2023 showed Staff G documented they observed Resident 1 half lying and half sitting on the floor attempting to get up. Staff G documented staff members walked by the resident without offering assistance. Staff G stated immediately [Staff G] and my co-worker had talked to the nurse, and they seemed very busy, and we waited for them [the nurse]. Staff G documented Resident 1 was attempting to get up, asked their partner (Staff H) to assist them to get the resident up off the floor and back into their wheelchair. Review of an undated witness statement, included in the facility investigation, Staff C, Licensed Practical Nurse (LPN), showed they were approached by Collateral Contact 1 (CC 1), Resident 1's family member, asking if Resident 1 had a fall in the facility. Staff C replied to CC 1 that no staff member had reported to them that Resident 1 had fallen in the facility. Review of a progress note, dated 06/24/2023 at 2:18 AM, showed Staff C documented Resident 1 was found to have an abrasion to the left lateral (side) elbow, measuring approximately 1.5 centimeters (cm) by 2 cm in size, the area was bleeding and swollen. Staff C documented the area was cleansed and a dressing was applied. Further review of the clinical record showed there was no documentation that indicated Resident 1 fell while in the facility. In an interview on 06/29/2023 at 3:30 PM, Staff C stated while working on 06/23/2023, a NA requested the licensed nurse to come to the dining room to assess Resident 1, who had an area on their elbow that was bleeding. Staff C went to the dining room, assessed the residents left arm and noted there was a skin tear that was bleeding, swollen and required treatment. Staff C stated this injury had not been observed earlier in their shift and initiated a skin injury incident investigation. On 06/23/2023, CC 1 approached Staff C and asked if Resident 1 had fallen because another staff member had reported to CC 1 that the resident did have a fall. Staff C stated, No, I am not aware they fell. Staff C stated on 06/24/2023 at 12:00 PM, they received a text from Staff D, LPN/weekend supervisor, who asked if Resident 1 fell on [DATE] and Staff C replied they were not aware the resident had a fall. In a telephone interview on 06/30/2023 at 11:10 AM, Staff F, LPN/Staff Development, stated while they were walking down the hallway on 06/23/2023 around 4:00 PM, they heard someone yell that someone was on the floor and that's when they observed Resident 1 on the floor with Staff G sitting next to the resident. Staff F stated they did a quick visual check of Resident 1 and did not notice anything significant. Staff F instructed Staff G not to move the resident, and they would find Resident 1's nurse. Staff F stated they walked through the facility and upon returning to where Resident 1 fell, they observed Resident 1's nurse, Staff C, where the resident was found on the floor and did not see the resident on the floor. Staff F assumed Resident 1's fall was being managed by Staff C and left the facility and went home. Staff F stated they did not complete a witness statement or speak to Staff C directly, and stated this was a mistake on their behalf. Staff F further stated that they received a text message from Staff B, Director of Nursing Service (DNS), on 06/24/2023 at approximately 12:00 PM, to ask if they were aware that Resident 1 fell yesterday evening. Staff F replied to Staff B, No, any injuries? Staff B replied Yes, the CNA [NA] is trying to feed us a line, likely to cover up cuz [because] they had picked the resident up off the floor, after a recent in-service saying not to. Staff F asked Staff B who the NA was, and Staff B stated that the NA was Staff G. In a telephone interview on 06/30/2023 at 12:22 PM, CC 1 stated they were informed by an unnamed staff member that Resident 1 fell on [DATE]. CC 1 stated they returned to the facility the morning of 06/24/2023, asked about the fall, and facility staff were unable to confirm if Resident 1 fell on [DATE], but CC 1 was informed an x-ray had been ordered of the resident's left elbow for an injury of unknown cause. CC 1 stated Resident 1 had increased pain and CC 1 was tired of waiting for the x-ray technician to come to the facility and notified staff they were signing Resident 1 out of the facility and took the resident to the emergency room (ER). CC 1 stated the hospital determined Resident 1 had sustained a left elbow and left hip fracture and would probably require surgery. In a telephone interview on 06/30/2023 at 12:55 PM, Staff E, LPN, stated they worked a double shift (the day and evening day shift) on 06/24/2023 and were responsible for Resident 1. Staff E stated that Staff J, LPN, said they heard Resident 1 had a fall but there was no paperwork filled out to indicate the resident fell the previous day, 06/23/2023. Staff E asked Staff G if Resident 1 fell Staff G replied yes, they had. Staff E asked Staff G if they assisted the resident up off the floor without the nurse. Staff G stated they had because no one would help them. On 06/24/2023 at 10:07 AM, Staff E assessed Resident 1's left elbow and noted that it was black/blue/purple in color and swollen and requested an x-ray be ordered to rule out injury and or infection. In a telephone interview on 06/30/2023 at 2:41 PM, Staff H stated while working on 06/23/2023 they were walking down the hallway when they observed Staff G standing next to Resident 1, who was sitting on the floor and leaning to their left. Staff G asked Staff H if they could stay with Resident 1 while they went to tell the nurse about the fall, and they did. Staff H reported that they, along with Staff G, waited with Resident 1 for approximately 30 minutes and the nurse never came to assess the resident. Staff H stated Resident 1 was reaching up, grabbing Staff H and Staff G saying, Get me up, get me up, so after no one came to help them, Staff G asked Staff H's help to assist Resident 1 up from the floor. Staff H stated they knew this was against facility protocol and they should not have gotten the resident up without a nurse. During a telephone interview on 07/12/2023 around 2:15 PM, Staff B stated they communicated with Staff E on 06/24/2023, to obtain an x-ray for Resident 1's elbow. Staff B stated that they (Staff B) along with Staff E tried to talk with other staff to determine if there had been a fall involving Resident 1 the day before. Staff B confirmed messaging with Staff F on 06/24/2023 to see if anyone had reported to them that Resident 1 fell on [DATE], and stated the NA was trying to feed them a line, because they assisted the resident up from the floor without the nurse's knowledge. Staff B stated the facility initiated a fall investigation on 06/26/2023, after confirming with the hospital documentation and facility staff statements that Resident 1 had a fall on 06/23/2023. During an interview on 07/12/2023 at 4:30 PM, Staff A, Administrator, stated on the morning of 06/24/2023, unsure of the time, Staff D, the weekend supervisor, called to notify them an x-ray was ordered for Resident 1's elbow and that staff were upset as the family took the resident out of the facility. Staff A explained to Staff D that families had the right to take residents out as long as they signed them out of the facility. Staff A stated later that day they verified via the local hospital secured information site (EPIC) that Resident 1 was in the ER without any further information related to why the resident was in the ER Staff A stated they checked the site again the following day (06/25/2023) and it continued to show that Resident 1 was in the ER. On 06/26/2023, upon arriving at facility, Staff A, checked EPIC, which showed Resident 1 was admitted to the hospital on [DATE] after a fall in the facility that resulted in a left elbow and left hip fracture. Staff A stated after reviewing that information, they immediately initiated an investigation for a potential fall but felt the resident had possibly fell while out of the facility with their family on 06/24/2023. During the facility investigation, Staff A stated three staff members failed to follow proper protocol for a fall in the facility and, as a result, their employment was terminated. Staff A stated the staff members failed to report and investigate an unwitnessed fall. This is a repeat citation from 2567 SOD dated April 5, 2022 Reference WAC 388-97-0640 (6)(a-c) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide two-person staff assistance with bed mobility while providing care, have ambulatory devices within reach for resident use, and consistently implement the care plan to prevent accidents/falls for 2 of 4 residents (Resident 2 and 1) reviewed for accidents. This failure caused harm to Resident 2 who fell out of bed and experienced a bump, bruises on their head, and a head injury and harm to Resident 1 who had a fall resulting in a left femur fracture (a broken bone). Findings included . <RESIDENT 2> Resident 2 was a long-term resident admitted to the facility on [DATE], with diagnoses to include developmental delay, unspecified disorder of the brain, obesity, and quadriplegia (paralysis of all four limbs). On re-admission to the facility on [DATE], additional diagnoses included disorientation, delirium (disturbance in mental abilities, confused thinking), unspecified psychosis (mental disorder), tremors and unspecified injury of head. A review of Resident 2's quarterly Minimum Data Set (MDS) assessment, dated 04/27/2023, showed the resident required extensive assistance of two staff for bed mobility, transfers, and dressing and was totally dependent on two staff for toileting. Review of the facility incident reporting log showed on 04/24/2023 at 7:00 PM Resident 2 sustained a fall in their room. The facility documented this resulted in injury (S30) which indicates surface layer of the skin. Actions taken by the facility following the resident's fall included staff training, care plan revisions, neuro checks, and therapy. Review of the facility's completed investigation for Resident 2's 04/24/2023 fall, showed that one Certified Nursing Assistant (CNA) was providing care to the resident in their bed, rolled the resident towards them, the resident was too close to edge of the bed, and rolled out. The investigation documented that Resident 2 hit their head on the bed during the fall, an ice pack was applied to bump/bruise to the left forehead for swelling and pain, they complained of a headache and had 2 episodes of vomiting. Lastly the investigation stated, NAC did not follow care plan, 1on 1 additional training provided. Review of Resident 2's current care plan, dated 05/16/2023, showed a focused area that the resident's had an activity of daily living (ADL) self-care performance deficit due to the resident's lack of expected normal physiological development in childhood, and was dependent upon staff for all ADL cares/needs. Interventions were in place for bed mobility however, the facility failed to include directive on how many staff were required to assist the resident with care, it only showed Dependent. Review of a progress note dated 04/30/2023 at 3:56 PM, Staff G, Licensed Practical Nurse (LPN), documented Resident 2 complained of dizziness while lying in bed. Resident has hematoma to left side of head related to prior fall on 04/24/2023. Observed swelling to left side of face, left side of jaw and under the left ear. Complained of tenderness to touch. On call provider notified and order received to obtain a 2-view x-ray to the left side of head related to hematoma expansion. Review of Resident 2's x-ray results dated 05/01/2023 showed it was negative for fracture and overall unremarkable. Review of Resident 2's provider progress note, dated 05/02/2023, showed Skilled Nursing Facility Monthly Follow up was completed by Staff H, Nurse Practitioner. This monthly follow up by the provider was a full head to toe assessment that did not mention the fall on 04/24/2023, or review of the x-ray results received on 05/01/2023. Review of a physician progress note, dated 05/16/2023 (3 weeks after the fall), showed Staff I, Medical Doctor (MD), had been alerted by nursing staff of Resident 2's fall that occurred 3 weeks prior that resulted in bump on the front of their head. Staff also reported progressive increase in confusion and reports of sadness since the fall. Staff I ordered a Computed Tomography Scan (CT which was a medical imaging technique used to obtain detailed internal images of for body) of the head to rule out a subdural hematoma (caused by head injury). Review of an Emergency Department note, dated 05/16/2023, showed Resident 2's CT scan showed no acute intracranial process identified and it could not exclude acute infarct (tissue death or necrosis due to inadequate blood supply to affected area). Further review of hospital records showed Active Hospital Problems, included delirium (confusion) and a head injury. During an interview in the facility on 05/23/2023 at 2:10 PM, CC 2, Resident 2's Representative/Power of Attorney, stated they were notified on 04/24/2023 their sister had fallen out of bed, and stated, I questioned the nurse on how that happened because my sister requires two people to move in bed and the nurse told them the NAC provided care to Resident 2 by themselves. CC2 also stated that they didn't believe that a doctor ever assessed Resident 2 after the fall out of bed on 04/24/2023, until they were sent out on 05/16/2023 for changes in behavior. On 05/23/2023 at 2:20 PM, Resident 2 was observed in bed, recently being re-admitted to the facility. Resident 2 was unable to answer questions related to the incident that occurred on 04/24/2023, where they fell out of bed, due to severely impaired cognition. During an interview on 05/23/2023 at 3:15 PM, Staff D, NAC, stated they were assisting Resident 2 in bed by themselves, when they rolled the resident towards them, they lost their balance and the resident fell off the bed. Staff D stated they assisted the resident to the floor and the resident hit their head on the bed. Staff D also acknowledged that it was not until after the fall they realized Resident 2 required two staff members assistance with bed mobility, stating I don't think I checked their [NAME] that day, I usually only review it if I have a new resident. During an interview on 05/23/2023 at 3:35 PM, Staff E, Registered Nurse (RN), stated CNAs used a [NAME] to get resident specific information for their care needs. Staff E stated that the resident had hit their head during fall, resulting in a bump and bruises to their forehead. Staff E stated that an ice pack was applied to bump on forehead, and pain medication was given for a headache and that Resident 2 also had two episodes of vomiting immediately after the fall. Staff E stated that Resident 2 required two-person assist with care in bed and transfers, stating They have always been a two person assist, and when the NAC told them Resident 2 had fallen out of bed and they were providing care alone, I educated the NAC immediately that [Resident 2] requires two-person assistance at all times. Staff E further stated, I think what happened was the resident was too close to edge of bed and when the aide rolled the resident towards them, they couldn't keep them in bed by themselves, and the resident rolled out, hitting their head on the nightstand next to the bed. <RESIDENT 1> Resident 1 admitted to the facility on [DATE] with diagnoses to include history of falls, infection/inflammation of internal orthopedic prosthetic device after a left ankle fracture, dementia with behavioral disturbances (a global term to describe agitation including verbal and physical aggression, wandering, and hoarding), anxiety disorder and major depressive disorder. Review of Resident 1's MDS assessment, dated 03/05/2023, showed the resident had severe cognitive impairment (a resident who had a very hard time remembering things, making decisions, concentrating, or learning) and required extensive assistance of two staff for bed mobility, and dressing, extensive assistance of one staff for toileting and supervision of two staff for transfers. Review of facility incident reporting log, dated 03/05/2023, showed Resident 1 had a fall in their room that resulted in a left femur fracture. Review of Resident 1's baseline care plan, dated 03/02/2023, showed a focus area of impaired mobility, was at risk for falls due to pain, had a recent surgical removal of orthopedic hardware, and a history of falls. Interventions directed staff to keep personal items and assistive devices in reach, ensure the bed brakes were locked, and keep the bed adjusted in a safe position when transferred. Review of the facility's completed investigation for Resident 1's unwitnessed fall with a substantial injury on 03/05/2023, showed Staff B, prior Director of Nursing Services (DNS), documented in the incident summary a care plan was initiated and at the time of the fall all care planned interventions were in place. Ambulation devices were not within reach in order to discourage use. Further review of the investigation information showed Staff J, RN, previous employee documented on a Post Fall Investigation form Floor was dry, walker and wheelchair not within reach. Review of a communication by Collateral Contact 1 (CC 1), a family member, on 05/08/2023, showed they were notified by the facility on 03/05/2023 at 7:00 AM that Resident 1 had experienced a fall, that had occurred earlier that morning, and had been told by the facility everything was OK. CC 1 arrived at the facility around 11:00 AM on 03/05/2023 and found Resident 1 in extreme pain. CC 1 said the family had directed the facility to send the resident to the emergency room immediately. CC 1 stated that Resident 1 required a total hip replacement following the fall. In an interview on 05/24/2023 at 1:50 PM, Staff C, Certified Nursing Assistant (CNA), confirmed nursing assistants (NAs also referred to as CNA's) used a [NAME] (care plans for nursing assistant's) to find resident specific information such as how the resident transferred, toileted, bed mobility status/requirements, assistive devices they may use/require, etc. Staff B stated, I make sure I check my residents [NAME]'s before I start my shift, everyday no matter what, you never know when things can change. Staff C stated they would never remove assistive devices that were on the [NAME] out of a residents reach to prevent resident use. Resident 1 no longer resided in the facility and was unable to be interviewed. Reference WAC 388-97-1060 (3)(g) .