**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure treatment and care was provided in accordance with professional standards of practice and the comprehensive, person-centered care plan for 5 of 5 residents (Residents 54, 11, 38, 36, and 13) reviewed for quality of care, in the areas of constipation/urinary bladder assessment, fluid restrictions, and timely implementation of physician orders. Resident 54 experienced harm when they did not have a bowel movement for four days and did not have a timely urinary bladder assessment, that resulted in pain, constipation, a small bowel obstruction (a blockage in the intestines), and a urinary bladder infection that required hospitalization. These failed practices placed residents at risk for a delay in treatment and unmet care needs. Findings included . Review of the facility policy titled, Bowel Routine for Preventing Constipation, dated 09/23/2023, showed that scheduled medicines for bowel routine helps with regular bowel movements. Being constipated can make residents feel ill. Constipation can be a side effect of pain medication and other medications. Things that make constipation worse were not drinking enough fluids, some anti-nausea medications and eating less than normal. Prevention of constipation is easier than treating it. The goal was to have a bowel movement every three days. Before each shift, the licensed nurse was to obtain a bowel list in the computer. If there were no bowel movements and/or no medium normal bowel movements, the licensed nurse would initiate the bowel protocol. <Constipation/Urinary Bladder Infection> <Resident 54> Review of the medical record showed the resident admitted to the facility with diagnoses including diarrhea, urinary retention, falls with fractures, and high blood pressure. Review of the 06/16/2024 comprehensive assessment showed Resident 54 was cognitively impaired but able to make most needs known. Resident 54 needed staff assistance and oversight for transfers and assistance to the bathroom. During an observation on 07/15/2024 at 9:00 AM, the resident was lying in their bed with eyes closed, and stated they had pain in their lower back and stomach. Resident 54 stated they felt bad and preferred to just rest. Review of the July 2024 Medication Administration Record (MAR), showed Resident 54 received a narcotic pain medication on 07/15/2024 at 6:16 AM. The 07/15/2024 8:02 AM MAR entry showed a narcotic pain medication was ineffective. Resident 54 received additional doses of the narcotic pain medication on 07/15/2024 at 4:25 PM, and on 07/16/2024 at 1:20 AM, 10:04 AM, and 6:34 PM. During an observation and concurrent interview on 07/16/2024 at 10:00 AM, showed Resident 54 was in bed lying on their left side and stated they had pain in their lower back that was very uncomfortable. The resident also stated they felt ill. The resident stated they were unable to eat food. Review of the July 2024 MAR showed on 07/16/2024 at 1:06 AM, the resident complained of general pain all over and a narcotic pain reliever was given. During an observation and concurrent interview on 07/17/2024 at 8:39 AM, Resident 54 was in bed with their eyes closed and a plastic basin beside them. The resident stated they had been nauseated and throwing up since the previous night. The resident's breakfast tray at their bedside was untouched and the resident stated they were not hungry. The plastic basin at the bedside contained some vomitus of yellow type of fluid. The resident stated they were miserable and complained of right upper side pain. Staff I, Licensed Practical Nurse (LPN), gave a medication for dizziness and nausea. During an observation on 07/17/2024 at 11:55 AM, Resident 54 stated they had tenderness and sensitivity in their right side, severe pain, and their stomach and back hurt. The resident stated they were feeling worse. During an interview on 07/17/2024 at 12:00 PM, Staff E, Charge Nurse, was asked to look at Resident 54. Staff E then documented that the resident was in pain and nauseated and called for an order from the provider for an anti-nausea medication to give to the resident. Staff E asked Resident 54 if they had their gall bladder and the resident stated it was removed. There was no documentation of further assessment in the medical record and there were no other licensed nurse assessments. The resident complained of pain and a narcotic pain reliever was given to the resident. Review of Resident 54's bowel movements showed the resident had not had a bowel movement since 07/14/2024 and still had no bowel movement on 07/18/2024. Additionally, the resident had been nauseated and did not eat or drink many fluids. There were no bowel protocols initiated or thorough assessments of Resident 54's complaints of pain. During an interview on 07/18/2024 at 11:51 AM, Staff O, Nursing Assistant (NA), stated the resident would say they had a bowel movement, and they did not. Staff O stated that morning, the resident did not have a bowel movement when they took Resident 54 to the bathroom. Staff O stated they told the nurse that the resident was constipated and in pain. Staff O stated the resident got more confused when they were in pain. Staff O stated the resident probably had an impaction. Review of the July 2024 MAR, showed an entry on 7/18/2024 that the resident received Colace (a stool softener) at 6:20 AM. There were no entries of a bowel movement. Review of a nursing progress note dated 07/18/2024 at 12:53 PM, showed Resident 54 was transferred to the hospital for abdominal pain. Review of the 07/18/2024 hospital emergency department notes showed the resident had nausea and vomiting with a small bowel obstruction and a urinary tract infection. Review of the 07/22/2024 hospital physician's progress note showed the resident had an abnormal heartbeat and had to be cardioverted (a procedure where electroshock and medications are used to convert irregular heartbeats back to normal). <Fluid Restriction> <Resident 11> Review of Resident 11's medical record showed the resident was admitted with diagnoses including dementia, chronic kidney failure (chronic disease of the kidneys causing kidney failure), and congestive heart failure (a condition in which the heart doesn't pump enough blood to meet the needs of the body which can lead to fluid overload). Review of the most recent comprehensive assessment, dated 6/11/2024, showed the resident was cognitively impaired and exhibited poor judgement and decision-making skills. Review of a physician's order dated 06/11/2024, showed the resident had orders to restrict their daily fluid intake to 1800 milliliters (ml - a unit of fluid measurement). The orders showed nursing was allotted 1080 ml and dietary 720 ml, including meals. During multiple observations on 07/15/2024 at 9:30 AM, 07/16/2024 at 8:40 AM, 07/17/2024 at 8:30 AM, 07/18/2024 at 1:00 PM, and 07/19/2024 at 10:15 AM showed Resident 11 had a pitcher containing 950 ml of water on their bedside table. The bedside water was not calculated in their current fluid restrictions and put them potentially over 950 ml per day. During an interview on 07/17/2024 at 11:46 AM, Staff G, Registered Nurse, stated Resident 11 was not on an official intake monitoring. Staff G stated the resident was on a slightly restricted fluid intake which did not require monitoring. Staff G further stated they were not aware that Resident 11 had a water pitcher at their bedside as their fluid intake was already calculated and did not include any additional fluids. <Resident 38> Review of the medical record showed Resident 38 was admitted to the facility on [DATE] with diagnoses including congestive heart failure, high blood pressure, and anxiety. The 06/16/2024 comprehensive assessment showed Resident 38 required partial/moderate assistance of one staff member for activities of daily living (ADLs). The assessment also showed Resident 38 was cognitively intact. An observation on 07/15/2024 at 1:15 PM, showed Resident 38 sitting in a recliner in their room. There was a 32-ounce cup of water on the bedside table. Resident 38 stated the staff came by and filled it up a few times a day. Resident 38 stated they had access to fluids throughout the day and did not know if they had a fluid restriction. Review of a physician order dated 06/25/2024, showed Resident 38 had an 1800 ml fluid restriction (720 ml from dietary and 1080 ml from nursing). Review of Resident 38's fluid intake records dated 06/26/2024 through 07/15/2024, from dietary and nursing, showed Resident 38 exceeded the maximum recommended fluid intake 15 out of 20 days. During an interview on 07/23/2024 at 8:34 AM, Staff E, Charge Nurse, stated fluid intake was monitored by the floor nurses. They stated Resident 38 was non-compliant with fluid intake and a risk/benefit with education should have been completed. Staff E stated the physician should have been notified. Review of Resident 38's medical record showed there was no documentation that risks and benefits were discussed with the resident. There was no documentation of a risk/benefit form or that the resident's physician had been notified. <Physician Orders> <Resident 13> Review of the medical record showed Resident 13 was readmitted to the facility on [DATE] with diagnoses including heart failure, iron deficiency anemia, and hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormone, disrupting such things as heart rate and body temperature). The 04/29/2024 comprehensive assessment showed Resident 13 required substantial assistance of one to two staff members for ADL's and had a severely impaired cognition. Review of a physician progress note dated 02/05/2024 at 3:23 PM, showed orders for lab work, that included rechecking Resident 13's thyroid stimulating hormone [(TSH) a test that measures the amount of thyroid hormone in the blood), iron studies (blood tests that measure the amount of iron in the blood and other cells), and a medication change. Review of Resident 13's medical record showed no results for the ordered lab work, and the medication change had not been completed. During an interview on 07/22/2024 at 10:28 AM, Staff E stated Resident 13 often refused to have lab work completed. Staff E stated they typically tried to get the labs twice, then another nurse would try. Staff E stated it looked like that process had not been done. During an interview on 07/22/2024 at 11:27 AM, Staff D, Resident Care Manager, stated all provider notes were reviewed by the charge nurse. Any new orders would be updated by the end of the day by the charge nurse. Staff D stated when a resident refused to have lab work done by facility staff, they would send them out to the lab for completion of the orders. Staff D stated they did not see the medication change or the completed lab work in the record. During an interview on 07/22/2024 at 2:10 PM, Staff C, Assistant Director of Nursing Services, stated the process for obtaining lab work for difficult residents included multiple attempts at different times by different staff. If the staff were still unable to obtain the sample, the facility would send the resident out to the lab to obtain the sample. Staff C stated they did not see documentation on that missed lab draw in the system. Staff C stated the Charge Nurse was responsible for reviewing physician notes after they round in the facility. They stated the physician typically entered their own orders into the system, but the charge nurse should go back and review the notes to make sure those orders were completed. Staff C stated they did not see that the medication order had been changed and that the charge nurse should have caught that. <Resident 36> Review of Resident 36's medical record showed they were admitted to the facility on [DATE] with diagnoses including fracture of left leg, peripheral vascular disease (PVD-a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and diabetes (a group of diseases that result in too much sugar in the blood). The 04/16/2024 comprehensive assessment showed Resident 36 was dependent on two staff members for ADLs and mobility. The assessment also showed the resident had an unstageable (full-thickness tissue loss covered by dead tissue and/or scab) pressure injury (PI-localized injury to skin and underlying tissues) and an intact cognition. Record review of Resident 36's wound assessment dated [DATE], showed the provider's plan was to refer the resident to an outside wound care clinic to establish care and receive further treatment for their unstageable pressure ulcer (PU-injury to skin and underlying tissue resulting from prolonged pressure) on their left heel. Further review of Resident 36's record showed a signed, 05/29/2024, physician's order for the referral to the outside wound care clinic. Review of Resident 36's medical record showed their first appointment with the outside wound care clinic was on 07/18/2024, 50 days after the physician referral. During an interview on 07/15/2024 at 1:29 PM, Resident 36's Representative (RR), stated the resident had developed their left heel pressure wound since they had been at the facility and were waiting for an appointment to see the outside wound clinic for treatment. The RR stated the plan was to have Resident 36 move back home with them when their PU was healed. During an interview on 07/18/2024 at 11:09 AM, Staff E, Charge Nurse, stated the process for referrals for residents was reviewing the providers notes, filling out an order slip and having the provider sign it. They would then give the order slip to Staff K, Medical Records, to complete the referral. Staff E further stated that 07/18/2024 was Resident 36's first appointment to the wound clinic and the delay was on the facility but was unsure why there was a delay. During an interview on 07/19/2024 at 10:39 AM, Staff K stated they sent in four different resident referrals, including Resident 36's, to the outside wound clinic in early June 2024. Staff K stated all the residents were scheduled in June for their appointments and were unsure why it took so long for Resident 36 to be scheduled. Staff K stated they did not call the wound clinic to inquire about the delay, as it was their process to have the wound clinic call the facility when they were ready to schedule. Reference: WAC 388-97-1060(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the necessary treatment and services to prevent the occurrence of an avoidable pressure ulcer (PU-injury to skin and underlying tissue resulting from prolonged pressure) and implement wound care and services timely to avoid worsening of a PU for 3 of 5 residents (Residents 48, 108, and 13) reviewed for PU's. Resident 48 experienced harm when the facility failed to follow physician orders to ensure healing of their avoidable Stage 4 PU (a full thickness tissue loss of tissue with exposed bone, tendon, or muscle) to their coccyx (tailbone) and obtain pain control measures during wound care. Resident 108 experienced harm when the facility failed to recognize and modify treatment of an unstageable PU (full thickness skin and tissue loss to which the extent of the tissue damage cannot be seen) on their left great toe and a Stage 2 PU [partial thickness skin loss with exposed dermis (the top inner layers of skin)] on their left heel. These failures placed residents at risk for PU development, continued deterioration of pressure ulcers, infection, and pain. Findings included . Review of the National Pressure Injury (ulcer) Advisory Panel (leading expert in pressure ulcer/injuries/wounds) guidance, dated September 2016, defines pressure ulcer/injury stages as follows: • Stage 1 Pressure Injury has intact skin with a localized area of non-blanchable erythema (redness). • Stage 2 Pressure Injury is partial thickness skin loss with exposed dermis (the top inner layers of skin). • Stage 3 Pressure Injury is full thickness loss of skin, in which adipose (fat) tissue is visible in the ulcer. Slough (dead tissue) and/or eschar (dried blood and tissue) may be visible, granulation tissue and epibole (rolled or curled under edges) may be present, with undermining (a pocket of dead space under the visible wound edges) and tunneling (a passageway under the wounds surface which may be shallow or deep and impairs wound closure). • Stage 4 Pressure Injury is full thickness loss of skin and tissue, with exposed or directly palpable fascia (a layer of connective tissue), muscle, tendon, ligament, cartilage, or bone in the ulcer. Epibole, undermining and tunneling often occur. • Unstageable Pressure Injury is full thickness skin and tissue loss to which the extent of the tissue damage cannot be seen. Review of the facility's policy titled, Pressure Injury Prevention and Management, dated 02/14/2024, showed the facility would provide treatment and services to heal pressure ulcers and prevent the development of additional pressure ulcers. The policy also showed an avoidable pressure ulcer meant the resident developed the pressure ulcer at the facility and did not .implement interventions consistent with resident needs, goals and professional standards of practice .monitor or evaluate the impact of interventions . and/or revise the interventions. <Resident 48> Review of Resident 48's medical record showed they were admitted to the facility on [DATE] with diagnoses including Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), Chronic Inflammatory Demyelinating Polyneuropathy [(CIDP) - a disorder that damages the protective layer of nerves, causing weakness, numbness, and pain in the limbs), and diabetes (a group of diseases that results in too much sugar in the blood). The 07/01/2024 comprehensive assessment showed Resident 48 required maximal assistance of one to two staff members for activities of daily living (ADLs) and dependent of two staff members for transfers. The assessment also showed Resident 48 had moderately impaired cognition. Review of Resident 48's 04/05/2023 admission comprehensive assessment. showed they did not have a PU and were at risk of development of PUs. Review of the 01/03/2024 comprehensive assessment showed the resident had an unstageable (full-thickness tissue loss covered by dead tissue and/or scab) PU. Further review of the resident's 04/05/2024 comprehensive assessment showed the resident had a Stage 4 PU. Review of Resident 48's 12/13/2023 skin/wound evaluation, showed the resident had an in-house acquired unstageable coccyx (tailbone area) PU that presented with slough covering the wound bed. Additional review of Resident 48's skin/wound evaluations showed their coccyx PU was documented as a Stage 4 and not an unstageable PU. Review of Resident 48's 03/01/2024 Staff GG, Advanced Registered Nurse Practitioner, (ARNP) note, showed nursing management confirmed a wound vac (a machine that helps wound healing by pulling wound edges together) had been ordered for the resident. Further review of the medical record showed no documentation that the wound vac had been ordered. Review of Resident 48's physician orders showed a referral, dated 04/25/2024, to obtain a surgical consult to evaluate and treat their Stage 4 coccyx PU (56 days after the practitioner's note that a wound vac had been ordered). Further review of the medical record showed no documentation the resident had a surgical consult. An observation and interview on 07/16/2024 at 9:02 AM, showed Resident 48 lying in their bed, on their back, with pillows under each side of their rib area. Resident 48 stated they had been to the wound clinic yesterday, their bottom was very sore, and their pain was a 10 out of 10 on the pain scale (a measurement of pain, 0 no pain and 10 is severe pain). Resident 48 stated that if they did not move their position much, their pain would remain a 5 out of 10. Resident 48 further stated when the nurses changed their wound dressing on their bottom, they did not provide pain medications before or after and it was a painful process. During an interview on 07/16/2024 at 2:12 PM, an outside wound care consultant (OWCC), stated Resident 48's first appointment with the wound clinic was on 06/17/2024 (53 days after the surgical consult was ordered). The OWCC stated Resident 48 stated they were in pain during their wound care treatments at the facility. The OWCC stated during the treatment at the wound clinic, the resident did moan and groan during the clinic treatment. The OWCC continued to state that the provider at the wound clinic had ordered a wound vac on this appointment and called the facility nursing director for instructions for submitting the wound vac order. During an observation and interview on 07/17/2024 at 8:54 AM, Resident 48 was lying in bed on their back with the head of their bed up. Resident 48 stated they had a wound dressing change earlier that morning and it was very painful, above a 10 on the pain scale. Resident 48 stated they told the nurse it hurt, yet they did not receive pain medication. During an interview on 07/17/2024 at 9:23 AM, Staff Y, Nursing Assistant (NA), stated they assisted the nurses with wound dressing changes. Staff Y stated Resident 48 would complain of pain during the wound dressing change. During an interview on 07/17/2024 at 9:51 AM, Staff I, Licensed Practical Nurse (LPN), stated Resident 48's pain medications consisted of scheduled Tylenol (a medication to treat mild to moderate pain) 1000 milligrams (mg-unit of measure) three times a day. During an observation and concurrent interview on 07/17/2024 at 10:19 AM, Staff G, Registered Nurse (RN), and Staff Q, Infection Control Nurse (ICRN), performed Resident 48's pressure ulcer dressing change. Staff Q stated they had been performing the pressure wound treatment for a month and stated the wound had remained the same. Staff Q stated that healing was slow. During the pressure wound treatment, Resident 48 yelled out in pain when Staff Q was measuring the wound tunnelling. Staff Q continued with the wound care treatment and did not address Resident 48's pain. After the pressure wound treatment, Resident 48 stated to Staff G and Staff Q their pain during the procedure was a 12/10 and Tylenol did not help with their pain during the procedure. Staff Q and Staff G did not acknowledge Resident 48's complaint. During an interview on 07/17/2024 at 10:56 AM, Staff G, stated they were aware the PU wound dressing changes were painful for Resident 48. Staff G stated the resident should have pain medication prior to the dressing changes and their current pain management was not effective. During an observation, interview, record review, on 07/17/2024 at 2:12 PM, Resident 48 was in their bed, on their back, and the head of their bed elevated. Resident 48 stated their pain level was an 8/10 on their bottom where their wound was. Resident 48 stated they did not receive any additional medication for pain. Review of Resident 48's Medication Administration record showed they were administerd Tylenol 1000 miligrams (unit of measure) at 8:00 AM, 12:00 PM and their next dose was due at 6:00PM. During an interview on 07/17/2024 at 2:27 PM, Staff G stated they did follow up with Resident 48 for their pain after the earlier wound care. Staff G stated when they asked the resident how their pain was, Resident 48 just looked at them and gave no response. Staff G stated the resident received scheduled Tylenol for pain and the upcoming dose was close to being administered. During an interview on 07/18/2024 at 9:29 AM, Resident 48's Representative, (RR), stated the resident's PU had developed at the facility and had been worsening without improvement. The RR stated Resident 48 did complain of pain during the wound care treatments and the resident was not provided any additional pain medications. Resident 48's RR stated they had observed the resident decline in their health, as the resident did not want to get out of bed and participate in any activities or visit outside like they used to due to their pain. During an interview on 07/19/2024 at 8:53 AM, Staff D, Resident Care Manager, stated Resident 48's coccyx PU healing had stalled (stopped making progress). Staff D also stated they had performed the resident's wound dressing changes, and they were aware Resident 48 was in pain during the wound care, as the resident would grunt and tell them to be careful. Staff D stated pain medications had not been administered before or after the wound care and they had not requested any additional pain medication from the provider for Resident 48. During an interview on 07/19/2024 at 12:10 PM, Staff E, Charge Nurse, stated the process for referrals was to send to the referral to medical records for completion. Staff E stated they were unaware of Staff GG notes dated 03/01/2024, for Resident 48's ordered wound vac that was confirmed by nursing management. Additionally, Staff E stated they were aware of the order placed for the surgical consultation referral on 04/25/2024 but did not follow-up and was unsure of the outcome of the referral. <Resident 13> Review of the medical record showed Resident 13 was readmitted to the facility with diagnoses including Alzheimer's disease, dementia with behavioral disturbance (a progressive disease that destroys memory and other important mental functions, with agitation, physical aggression, wandering, and hoarding), and weakness. The 04/29/2024 comprehensive assessment showed Resident 13 required substantial assistance of one to two staff members for ADLs and had a had a severely impaired cognition. Record review of a nursing progress note dated 06/22/2024, showed Resident 13 had two deep PU along their outer right foot, one slightly above their lateral (to the side of or away from the body) ankle and one along the outer middle of the right foot, with a red circle slightly below their pinky toe. The provider was notified and ordered float feet using pillows and monitor. Record review of a physician order dated 06/24/2024, showed Apply Opti-Foam (a foam dressing used to cover the wound and reduce friction) to right lateral foot on all three sites, every day shift, every three day(s) for wound care. During observations on 07/15/2024 at 10:10 AM, 07/16/2024 at 9:26 AM, 07/18/2024 at 2:03 PM, and 07/19/2024 at 10:30 AM, showed Resident 13 lying in bed on their right side with their right outer foot against the mattress. Their feet were not floated on pillows and there were no padded boots on their feet. A concurrent observation and interview on 07/16/2024 at 3:15 PM, showed Resident 13 sitting in their wheelchair in their room. Staff R, RN, removed the resident's sock from their right foot. There was a foam dressing on the outer middle right foot. There was no dressing on the outer right ankle or toe wounds. Staff R peeled back the foam dressing and exposed a dime size area on the outer middle right foot that had yellow slough and a small amount of drainage. The right ankle had a dime size reddened area, and a red area at the base of the right small toe. Staff R stated they tried to float the resident's feet on pillows or put the padded boots on, but the resident kicked them off. Staff R stated they had asked Staff D, Resident Care Manager, for a specialized air mattress several weeks ago but was unsure why the resident did not receive one. Record review of a skin and wound assessment dated [DATE], showed new wounds were identified as pressure, deep tissue injury, and facility acquired. The wound on the outer right foot measured 0.94 centimeters [(cm) a unit of measurement] long and 0.63 cm wide. The surrounding tissue was fragile with erythema (an abnormal redness of the skin) and pain/tenderness to the touch. There were additional areas of concern on the right ankle and outer base of the right small toe. There were no measurements of these additional wounds. The document showed there was no dressing applied to the wound area, and the residents' feet were to float on pillows. Review of a skin and wound assessment dated [DATE], showed the outer right foot wound measured 15 cm in length and 1.91 cm in width. The wound was described as a deep pressure sore with the middle open. The surrounding tissue was described as fragile with erythema. The document showed the deep pressure sores were painful to the touch. Treatment orders showed the primary dressing was foam and to float both feet with pillows. The progress was described as deteriorating. Review of a skin and wound assessment dated [DATE], showed the outer right foot wound had measured 13.42 cm long and 1.3 cm wide. The wound was 80% slough with a light amount of exudate (fluid that leaks out of blood vessels into nearby tissues). The treatment included use of a foam dressing and float both feet using pillows. The progress was described as deteriorating. Review of a nursing progress note dated 06/22/2024, showed Resident 13 refused to float their feet on pillows and nursing staff placed their feet in padded boots for pressure relief. During an interview on 07/22/2024 at 11:22 AM, Staff D stated Resident 13 was non-compliant with the use of pillows and padded boots. Staff D stated an air mattress might help - they could probably use one. Staff D stated there were additional interventions that could have been implemented besides the pillows and padded boots. During an interview on 07/22/2024 at 2:05 PM, Staff C, stated the provider had reassessed the wound that day and were changing the treatment to a medicated ointment and gauze dressing. Staff C stated an air overlay mattress would be beneficial since Resident 13 was non-compliant with the pillow positioning or padded boots. Staff C stated if interventions for pressure relief were not working, they expected the staff to notify the physician and advocate for the resident for increased interventions. During an interview on 07/22/2024 at 3:17 PM, Staff B, DNS stated they would have expected nursing staff to report the concerns with non-compliance with the pressure relieving interventions. Reference: WAC 388-97-1060(3)(b) This is a recurring deficiency previously cited in the Statement of Deficiencies dated September 14, 2023. <Resident 108> Review of the medical record showed the resident resided at the facility for many years. Resident 108's last readmission was 07/01/2024, with diagnoses including dementia (cognitive impairment), heart disease, kidney disease, diabetes (when the body does not enough produce insulin-a hormone that regulates blood sugar), and pressure ulcers to the resident's left heel and left great toe with ongoing cellulitis (bacterial infection of the skin layers) to their left heel/foot. The 07/04/2024 comprehensive assessment showed that Resident 108 was cognitively impaired but could make their needs known, such as pain. Resident 108 required assistance to transfer to and from different areas, such bed to wheelchair, bathing, oral care and personal hygienic care. During an observation and concurrent interview on 07/16/2024 at 9:50 AM, Resident 108 was in bed and watching television. Their left foot had a dressing over it and the foot was elevated on a pillow. The resident stated they were sleepy and wanted to take a nap. During an observation on 07/17/2024 at 9:02 AM, Staff Q, during a wound dressing change, removed the old dressing on the resident's left heel. The resident's left heel PU wound bed was white in color (could not visualize the wound bed). Additionally, the skin that surrounded the wound was red with extremely dry with flakey skin. The treatment was applied, and the dressing covered the left heel PU. Staff Q then cleansed the resident's scabbed left great toe and applied the treatment. Staff Q stated that the resident's pressure ulcer to the left great toe had gotten worse and had not improved. During an observation on 07/17/2024 at 9:27 AM, Resident 108 complained of significant pain in their left heel. The resident became restless and moaning that their foot was cold and freezing. Staff Q went to the get Tylenol and gave it to the resident. Staff Q stated they did not pre-medicate the resident before the dressing change. Continuing the 07/17/2024 observation at 10:20 AM, Resident 108 was pleading and crying in pain in their left foot and for someone to help them. The Director of Nursing Services (DNS) was notified and obtained a physician's order for a narcotic pain reliever for the resident. During an interview on 07/17/2024 at 10:50 AM, Resident 108 stated the pain increased in intensity from intermittent to constant stabbing pain. During an interview on 07/17/2024 11:40 AM, Staff C, Assistant Director of Nursing Services (ADON), stated the resident had developed a left foot PU to their heel due to their shoes being too tight on their left heel and it rubbed against their heel. The resident was not to wear the shoes again, but the tight shoes were not removed from Resident 108's room and the resident continued to wear them. This was around the end of January 2024. The Resident Representative (RR) was notified of this, and the facility asked them to bring different shoes for Resident 108. The RR brought new shoes according to Staff C, but the new shoes were open toe shoes and rubbed against the large great toe, which caused another PU to the left great toe that had not improved. The left heel pressure ulcer and the left great toe pressure ulcer were acquired at the facility. Staff C stated the left great toe PU was discovered around 02/25/2024. Review of the 02/06/2024 interdisciplinary meeting notes, showed the resident developed a Stage 2 pressure ulcer on their left heel. Additionally, the 02/05/2024 and 02/06/2024 nurses progress note showed the RR was notified that Resident 108 needed larger sized shoes. Review of the 01/26/2024 Clinical Skin and Wound Evaluation (CSWE), showed identification of a Deep Tissue Injury [(DTI) - purple or maroon area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear] to the left heel. The 07/17/2024 CSWE showed the left heel was a Stage 2 PU. Additionally, the CSWE, dated March 26, 2024, showed the DTI to the left great toe. The 07/17/2024 showed Resident 108's left great toe PU had not improved. The updated care plan dated 07/08/2024 through 07/23/2024, showed the resident had acquired two PUs to the left foot, an unstageable PU to the left great toe, and a Stage 2 PU to the left heel. The resident's care plan goal was to have intact skin, free of redness, blisters, or discoloration by/through the review date. A Velcro boot to the left foot and air overlay for the mattress were added to the care plan. There were previously no identified PU on the care plan. There was a statement to use the preventative measures policy for checking feet for diabetes. Review of the 03/27/2024 wound nurse health status note showed the wounds to the left heel, left great toe, and the middle of the left foot was red/purple in color with swelling. There was suspected cellulitis (a bacterial infection of the skin that becomes red, swollen and painful) to the toe and an antibiotic was ordered for seven days. The resident had to change their shoes. Review of the 04/22/2024 nursing progress note showed wounds to Resident 108's left great toe and left heel since March 2024. They had progressively gotten worse to the point of needing further treatment that day. The resident had cellulitis and was sent to the emergency room for treatment. Review of a 07/11/2024 x-ray showed the resident's left foot had osteomyelitis (infection of the bone spreading from nearby tissue.) During an interview on 07/16/2024 at 9:40 AM, Staff B, Director of Nursing Services (DNS) stated Resident 108 had declined and saw a physician who recommended amputation of the left foot due to the decline. Staff B stated the resident's RR would probably not want Resident 108 to have that surgery. During an interview on 07/19/2024 08:26 AM Staff D, stated Resident 108's PU started on the heel due to the resident's tight shoes. The podiatrist (foot doctor) worked on the residents' foot and there were no preventative interventions to keep the shoes away from Resident 108 or from having the shoes placed on the resident's feet. The RR was the one who removed the shoes from the resident's room. The resident had edema (swelling) and continued to have edematous feet, which caused tightness of the shoes. The new shoes that were brought by the resident's RR were used and continued to be placed on the resident's feet, which resulted in the left great toe's skin break down and PU.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the assessed level of supervision required to prevent avoidable accidents for 1 of 1 resident (Resident 54) reviewed for falls with injuries. Additionally, the facility failed to identify active smokers, and the level of supervision required to smoke safely, for 3 of 3 residents (Resident 214, 216, and 212) reviewed for smoking. Resident 54 experienced harm when they fell while using their front wheel walker with a right sided platform attachment (a support that attaches to the walker to support the forearm and shoulder) when walking to the bathroom unsupervised that resulted in a laceration above the right eyebrow and fractured right ribs. The failure to identify potential hazards and implement adequate supervision placed the residents at risk for falls, injury, and an unsafe living environment. Findings included . <Fall With Injury> Review of the policy titled Fall Prevention Program dated 09/05/2023, showed the facility was to ensure each resident would be assessed for fall risk and receive care services in accordance with their individualized level of risk to minimize their likelihood of falls. <Resident 54> Review of the medical record showed Resident 54 was admitted to the facility on [DATE] with diagnoses including osteopenia (a reduction of bone mass that causes brittle bones), therapy after a significant fall with multiple fractures of the right wrist, lower spine and the lower pelvic bone, thrombocytopenia (a low platelet count which can lead to excessive bleeding during an injury), high blood pressure and a urinary bladder infection. The 06/16/2024 comprehensive assessment showed the resident was impaired cognitively but able to voice their needs. The resident needed help/partial assistance with activities, such as directions on use of their walker. Resident 54 was impaired physically on one side due to a previous fracture and had unsteadiness when walking. The resident was frequently incontinent of bladder. During an observation and concurrent interview on 07/15/2024 at 9:00 AM, Resident 54 was lying in their bed moaning. The resident was curled up and complained of right upper side and back pain. There was a laceration over their right eyebrow and a Velcro wrist brace to their right wrist. The resident's head of the bed was up, and the resident's wheelchair was located by their bed within the resident's reach. The resident's walker was located on the other side of the resident's bedside table. The resident stated they had their walker by the bed and tried to get out of bed to go to the bathroom and fell. Review of the 06/12/2024 care plan showed Resident 54 required assistance with transfers, bed in a low position, hourly safety checks and a scheduled toileting program. The resident wore disposable briefs for dignity for bladder incontinence. The admission fall risk assessment dated [DATE], showed the resident was a moderate risk for falls. Review of the 07/01/2024 nurses progress notes, showed Resident 54 went to the emergency room (ER) for an unwitnessed fall and sustained a laceration over the right eyebrow, right hand, a bruise to the left knee and had returned to the facility. On 07/02/2024 the resident continued to complain of pain, and an x-ray was ordered. The results from the x-ray showed right rib fractures due to the 07/01/2024 fall. Review of the 07/01/2024 fall investigative report showed Staff L, Licensed Practical Nurse (LPN), entered Resident 54's room at 5:30 AM to give medications. Staff L observed the walker by the resident's bed with the bed control cord wrapped around the legs of the walker and the walker on its side on the floor. The resident was in bed on their side under a blanket. Staff L turned on the light in the room and saw blood on Resident 54's face and hands. The resident stated ouch when the nurse looked at the resident. The 07/01/2024 investigation showed the resident stated, after their fall, they placed themselves back in bed. The 07/01/2024 investigative report showed the last time the resident was observed was at 4:00 AM. Night staff had not heard or observed if the resident had fallen or was bleeding until Staff L entered the resident's room. The 07/01/2024 update to the care plan included a scheduled toileting program, a cue card placed on the resident's room which stated for Resident 54 to use their call light when needing assistance, and to continue safety checks. During an interview on 07/16/2024 at 11:40 AM, Staff P, Physical Therapy Assistant/Rehabilitation Director, stated the resident was on therapy for weakness and falls at home. Resident 54 was given a front wheeled walker with a platform attached to the right side of the walker for stability due to their fractured right wrist. Additionally, the resident had difficulty understanding how to use the platform on the walker to stabilize their right wrist and used poor judgement to safety in ambulation by not carefully walking purposefully, but hurried, and that was unsafe. Staff P continued to try to educate the resident on safety and not placing weight on right wrist, but it was not successful, and they discharged the resident from therapy. Nursing staff was notified. During an interview on 07/18/2024 at 8:58 AM, Staff O, Nursing Assistant (NA), stated Resident 54 had become weaker and now only used a wheelchair. Staff O stated when the resident was first admitted they used a walker and required assistance. Staff O stated that the resident needed more assistance after the fall on 07/01/2024. Additionally, Staff O stated that there was a conversation with the night NAs, and they assisted the resident to bed after the 07/01/2024 fall. During an interview on 07/19/2024 at 8:35 AM, Staff D, Resident Care Manager, (RCM), stated that Resident 54 was unsafe, used their walker in the room, did not wait for staff, and did not use their call light. There were two NAs on the east wing and two NAs on the west end at night, and it was hard to supervise due to the fact they were in two separate buildings. During an interview on 07/19/2024 at 9:02 AM Staff L, stated when they came to work on the morning of 07/01/2024, they went into the resident's room and found Resident 54 with blood on their face and arm. Staff L stated Resident 54 stated they fell on night shift while trying to use the walker to go by themselves to the bathroom. Resident 54 stated they did not use the call light and they usually did not use the call light. Resident 54 stated that the cord was wrapped around the bottom of their walker, and they tried to undo it and fell, hitting their head right above the eyebrow that caused a laceration, and then got back into bed. Staff L was asked if they observed the walker on its side on the floor with the bed cord wrapped around the legs of the walker. Staff L said they did not witness the placement of the walker and the cord around the legs of the walker, but just reported what the resident had stated. <Smoking Hazard> Review of a policy titled, Smoke Free Facility, dated 09/05/2023, showed smoking was prohibited in all areas of the facility and the facility grounds. Residents would be informed of the facility's smoke free policy during the pre-admission/admission process and would be required to sign acknowledgement of the policy upon admission. All residents would be asked about tobacco use during the admission process and those with a history of smoking would be further assessed to determine whether or not interventions were needed to help them cope with the smoke free policy. Review of an undated document titled, Memorandum of Understanding [([NAME]) a type of agreement between two parties that defines how each party will work together and lays out expectations and understandings] Regarding Smoking Policy for Residents at the [NAME] Odd [NAME] Home, showed smoking was not permitted anywhere on the premises. Cigarettes and lighters must be stored in a designated locked area when not in use. A risk/benefit form would be completed by a facility team member. A smoking assessment would be completed by a team member. <Resident 214> Review of the medical record showed Resident 214 was admitted to the facility on [DATE] with diagnoses including a urinary tract infection, kidney failure, and psychoactive substance dependence (a strong desire or compulsion to take/use alcohol, caffeine, nicotine, marijuana, and certain pain medications). Resident 214 was able to make their needs known. An observation on 07/15/2024 at 3:45 PM, showed Staff V, NA, escort Resident 214 outside to smoke, off facility property. Resident 214 was observed sitting on their front wheeled walker, with cigarette ash falling onto their sweatpants. When Resident 214 completed their cigarette, they asked Staff V where to put the butt. Staff V stated they would have to throw it away when they returned to the building. Staff V escorted Resident 214 back to the building and waited for facility staff to open the locked door. Resident 214 and Staff V entered the building, Staff V walked towards the left upon entering and Resident 214 walked to their room to the right. During an interview on 07/15/2024 at 4:24 PM, Resident 214 stated Staff V had taken the extinguished cigarette butt, placed it in a glove, and threw it in the trash. Resident 214 stated they had their cigarettes and lighter in their pocket and had planned on smoking while at the facility. Resident 214 stated a man that works here took me out earlier today to smoke. During an interview on 07/15/2024 at 4:26 PM, Staff V stated they took the cigarette butt from Resident 214 and wrapped it in a glove, then threw it in the trash can (and pointed to a trash can at the NA charting station). Staff V asked, was that wrong? During an interview on 07/16/2024 at 9:29 AM, Resident 214 stated they did not know they could not smoke at the facility. They stated no one had asked to hold their cigarettes or lighter in a locked area for them. During an interview on 07/22/2024 at 10:45 AM, Staff D, RCM, stated the process for smoking included identifying current residents that smoked prior to admission. They stated they were aware that Resident 214 smoked cigarettes but did not know they were currently smoking. Staff D stated the facility policy disallowed for staff to escort residents outside to smoke. They stated they were not aware that Resident 214 had cigarettes and a lighter in their possession and had not asked that question on admission. They stated the process for securing cigarettes and lighters included placing them in a locked area until the resident was discharged for safety. Staff D stated my process should have been to ask if they had the cigarettes and lighter and discuss options. Review of the medical record showed an undated [NAME] for smoking had been completed with Resident 214. A smoking assessment was completed on 07/19/2024 at 4:06 PM, that showed Resident 214 required supervision while smoking and the facility needed to store the resident's lighter and cigarettes. <Resident 216> Review of the medical record showed Resident 216 was admitted to the facility on [DATE] with diagnoses including sepsis (a serious condition in which the body responds improperly to an infection), anxiety disorder, and tobacco use. The resident was able to make their needs known. During an observation and interview on 07/17/2024 at 2:05 PM, Resident 214 was observed standing in the doorway of their room with their walker and a cigarette and a lighter in their right hand. Resident 214 stated before that nurse comes back, I am going to sneak outside to smoke - before the alarm goes off. Resident 214 walked to the exit door at the end of the hall near room [ROOM NUMBER], placed the unlit cigarette in their mouth, pushed random buttons on the security keypad and waited for the door lock to release. They walked out of the facility with the cigarette in their mouth, lit the cigarette, and proceeded to smoke outside the facility door. Facility staff responded to the alarming door, Staff W, NA, silenced the alarm, observed Resident 214 outside smoking, and walked away from the door, without addressing the resident or smoking. Resident 214 finished smoking and was escorted back into the building by Staff C. During an interview on 07/17/2024 at 2:34 PM, Staff N, Registered Nurse, (RN), stated they were aware that Resident 214 was going outside to smoke. They stated Resident 214 was okay to smoke outside with family but was not told that they had to go off property. Staff N stated the facility was not storing the resident's cigarettes or lighter. Review of the medical record showed a smoking assessment was completed on 07/19/2024 at 4:13 PM, two days after Resident 214 was observed smoking independently on facility property. The assessment showed the resident required supervision for smoking, and the facility needed to store their cigarettes and lighter. There was an undated [NAME] for smoking in the record signed by the resident and Staff H. During an interview on 07/22/2024 at 11:03 AM, Staff D stated they were not aware that Resident 214 was actively smoking until they received that information during shift hand-off report. Staff D stated they allowed the resident to go outside several times on their shift and observed them going beyond the facility sidewalk. Staff D stated they did not know if Resident 214 had been assessed for safe smoking or if an assessment had been done to allow them to be outside alone. Staff D stated they were not aware that Resident 214 had cigarettes and a lighter. Staff D stated they should have looked at assessing for safety, ambulation, and the resident's cognitive status to ensure they were safe to smoke alone. During an interview on 07/19/2024 at 11:55 AM, Staff C, Assistant Director of Nursing Services (ADON), stated the process was to screen for smoking status during the referral process. They stated Resident 214, and Resident 216 snuck by. Staff C stated they could not have staff escort residents off property to smoke and there was no process in place to secure cigarettes and lighters for residents. <Resident 212> Review of the medical record showed Resident 212 was admitted to the facility 07/12/2024 with diagnoses including schizophrenia (a chronic brain disorder that causes delusions, hallucinations, disorganized speech, trouble thinking, and lack of motivation) and major depressive disorder. Resident 212 was able to make their needs known. During an observation on 07/22/2024 at 12:21 PM, Resident 212 approached Staff N at the medication cart and requested their cigarettes and lighter so they could go outside to smoke. Staff N stated they did not have them. During an interview on 07/22/2024 at 12:37 PM, Resident 212 stated the facility took their cigarettes on 07/21/2024. Resident 212 stated they went out on 07/21/2024 to smoke, and when returning to the facility, the staff stated they needed to take their cigarettes and lighter per state policy. Resident 212 stated they understood that they could not smoke on facility property and had not. They stated staff told them they could have their cigarettes whenever they wanted, but that had not happened yet. Resident 212 stated if they knew they would not have access to their cigarettes, they would not have allowed the facility to take them. Review of the medical record showed an undated [NAME] signed by the resident and Staff H, Executive [NAME] President of Marketing. A smoking assessment dated [DATE] at 1:16 PM, showed the resident did not need supervision for smoking and the facility did not need to store the resident's cigarettes or lighter. During an interview on 07/22/2024 at 3:33 PM, Staff H, stated when they reviewed the resident record before admissions, and read they were actively smoking, they let the hospital case managers know that the resident could not smoke in the facility. They stated they did not always look at the case managers notes prior to the residents arriving to the facility to ensure the non-smoking information had been discussed. They stated they reviewed the non-smoking policy during the admission process but did not know Residents 214 and 212 were actively smoking. They stated they were aware that Resident 216 was currently smoking. Staff H stated their process included reviewing the smoking policy and ensuring residents signed the [NAME] regarding smoking. They stated they informed the residents that their cigarettes and lighters would be placed in a locked cabinet and had placed Resident 216's items in a locked cabinet with the resident present. Staff H stated they had notified facility staff of Resident 214's and 216's smoking status after completing the admission paperwork and [NAME]'s. During an interview on 07/23/2024 at 8:17 AM, Staff A, Administrator, stated the facility staff needed to come together as a team to formulate a process for residents that smoke, that included completing the [NAME], the assessment, and communicating the policy to the resident, their representative, and the staff. Reference: WAC 388-97-1060(3)(g) This is a recurring deficiency previously cited in the Statement of Deficiencies dated September 14, 2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to recognize, thoroughly monitor, assess and take timely action in accordance with professional standards of practice for one of one resident (25) reviewed for bowel care and management. These failures resulted in harm to Resident 25 and potentially resulted in the hospitalization and subsequent death from sepsis secondary to pan-sensitive E. coli (a bacteria found in the human intestinal system) aspiration pneumonia (inhalation of gastric contents into the lungs). Findings included . Review of the document titled Resident Care Approaches/Protocols dated 06/15/2020, showed a list of care interventions that are considered routine unless noted otherwise on the residents' care plan.Bowel monitor; report to LN [Licensed Nurse] no BM [Bowel Movement] in two days or any changes in stool consistency or frequency, i.e. diarrhea. Notify of any change in bowel or bladder status. Additionally, it stated Constipation/Stool Approaches with the following interventions: .Nursing Assistant Certified (NAC) is never to remove stool manually, nurse to monitor effectiveness of laxative for BM, and nurse to assist resident with manual stool removal as needed. Resident 25. Review of the medical record showed the resident was readmitted to the facility on [DATE] with diagnoses to include non-rheumatic aortic valve stenosis (the narrowing of a heart valve); heart failure (weakening of the heart); Atrial fibrillation (irregular heartbeat) as well as constipation. A review of the resident's Minimum Data Set (MDS) assessment, dated 04/23/2022, identified the resident to have impaired cognition and memory, required one-person extensive assistance with cares and toileting. During an interview on 07/14/2022 at 3:22 PM, Resident 25 stated they had issues with constipation at times and sometimes felt when she asked for bowel medication, they [nursing staff] were slow to give it to her. She stated that feeling constipated was part of why she had a decreased appetite. Review of the Care Plan, dated 04/15/2022, showed the resident was at risk for constipation related to decreased mobility and lack of privacy with goals stated that the resident will have a normal, soft, and formed bowel movement at least every three days. The interventions included: encourage resident to sit on toilet to evacuate bowels if possible, follow facility bowel protocol for bowel management, monitor medications for side effects of constipation, keep physician informed of any problems, and monitor/document/report to Medical Doctor (MD) PRN (as needed) signs and symptoms of complications related to constipation: new onset of confusion, sleepiness, inability to maintain posture, agitation, bradycardia (slow, low heart rate), abdominal distention, tenderness, guarding, rigidity; vomiting, small or loose stools, fecal smearing, diaphoresis (sweating), absent bowel sounds, or fecal compaction. Review of physician's orders, dated 04/20/2022, showed the resident received daily Bumex (water pill), digoxin (heart rate control medication) and medications for depression. Further review showed the resident had orders for three different oral laxatives as needed for constipation. Review of the bowel monitor and Medication Administration Record (MAR) for April 2022 showed no BM documented from 04/25/2022 to 04/28/2022, a total of four days. As needed constipation medication was given on 04/27/2022; three days of no BM before an intervention was taken. Review of the bowel monitor and MAR for May 2022 showed no BM documented for the following: *05/03/2022 to 05/10/2022, As needed constipation medication was given on 05/10/2022 and 05/11/2022; seven days of no BM before an intervention was taken. *05/18/2022 to 05/22/2022, As needed constipation medication was given on 05/22/2022; four days of no BM before an intervention was taken. *05/25/2022 to 05/29/2022, No as needed medication given during this time; four days of no BM with no intervention taken to treat constipation. *As needed constipation medication was given on 05/24/2022 per the resident's request. Review of the bowel monitor and MAR for June 2022 showed no BM (with the exception of small BMs) documented for the following: *05/30/2022 to 06/10/2022, As needed constipation medication was given on 06/01/2022 and 06/04/2022; three and six days of no BM before intervention was taken. No other follow-up documented. *06/11/2022 to 06/16/2022, No as needed medication was given during this time; six days of no BM with no intervention taken to treat constipation. *06/18/2022 to 06/24/2022, As needed constipation medication was given on 06/23/2022; five days with no BM before an intervention was taken. *06/24/2022 to 06/28/2022, As needed constipation medication was given on 06/27/2022; three days with no BM before an intervention was taken. Review of the bowel monitor and MAR for July 2022 until day of discharge, 07/16/2022, showed no BM (with the exception of small BMs) for the following: *07/01/2022 to 07/05/2022, As needed constipation medication was given two times on 07/05/2022; five days with no BM before an intervention was taken. *07/06/2022 to 07/12/2022, No as needed medication was given during this time; six days of no BM with no intervention taken to treat constipation. During an interview on 07/21/2022 at 12:53 PM, Staff B, Registered Nurse (RN)/Interim Director of Nursing Services (DNS), when asked about a facility house bowel protocol or program, she stated she had not been able to find a house bowel protocol since she had been there. She stated she was told that the nurses monitored the BMs and administered individual PRN bowel medication. In an interview on 07/21/2022 at 2:46 PM with Staff V, Licensed Practical Nurse (LPN)/Charge Nurse when asked about a house bowel protocol, she stated they did not have one. When she was asked to explain the process of bowel monitoring and intervention, she stated they used a Third Day List which was a list of residents who had not had a BM in three days or more. The list was created by the night shift Licensed Nurse (LN) who reviewed the bowel monitor documentation daily. This list was added to the nurses' report sheet and the intervention taken was based on the LN assessment of the resident. Each resident had their own PRN medications for constipation. Staff V stated her expectation would be the LN provide constipation intervention for any resident on the Third Day List and continue with follow up as necessary until they have effective results. Review of a clinic visit note, dated 06/20/2022, with the resident's outside primary care provider shows the physician's notation to include, .The only complaint that I can get from her is that she complains of constipation. She had been on MiraLAX [laxative] Monday, Wednesday, Friday half of a scoop [routinely] and apparently that was changed to PRN only. They [nursing staff from facility] did not send a MAR, so I do not know how frequently she has gotten any of her laxatives, but she wants to go back on a regular dosing. Review of a form titled Record of Outside Service, dated 06/20/2022, showed new written orders from the outside physician to include a.) please send MAR with patient to all visits, b.) Restart MiraLAX (½) scoop by mouth Monday, Wednesday and Friday in water or juice, c.) hold for diarrhea, d.) may continue (½) to 1 scoop by mouth everyday as needed for constipation. Review of the MAR for June 2022, showed the above routine MiraLAX order was started on 06/22/2022. During an interview on 07/18/2022 at 11:47 AM, Staff S stated that the resident was admitted to the hospital on Saturday 07/16/2022 with diagnosis of sepsis (the body's life-threatening response to severe infection). Review of the medical record showed no alert charting documentation for this resident in the days leading up to this hospitalization. During an interview on 07/20/2022 at 12:35 PM, Staff V stated the resident continued to be in the hospital on high-flow oxygen (alternative non-invasive respiratory therapy that uses a high concentration of oxygen to help reduce the effort needed for breathing) with diagnosis of sepsis from aspiration pneumonia (a lung infection caused by breathing food, liquid or secretions into the lungs). During a follow up interview with Staff V on 07/21/2022 at 2:46 PM, they stated this resident was not placed on alert charting as of the end of their shift on Friday 07/19/2022 (between 4:30-5:00 PM). In an interview on 07/21/2022 at 3:09 pm, Staff U, LPN said they were the nursing supervisor this past weekend and sent the resident to the hospital for altered mental status, multiple emesis (vomiting) and increased oxygen needs. They stated the NAC woke the resident and obtained vital signs in the afternoon. At that time, the resident was afebrile but seemed different from their baseline. When the resident started vomiting, they required more assistance to sit up on edge of bed (indicating weakness). Staff U stated she noted the vomit to be thick and brown in color. When asked if it appeared the resident had vomited while laying down, Staff U stated no. When asked if the resident had been laying flat, Staff U stated yes. Review of the medical record showed on the admission assessment dated [DATE], the resident was assessed to have no chewing or swallowing issues and the diet order dated 05/20/2022 was for regular diet, regular texture. Review of the care plan dated 04/15/2022, showed the resident had Gastro-Esophageal Reflux Disease [(GERD) a disease caused by the back flow of stomach acid into the throat usually causing a burning sensation] with interventions stated to .Monitor/document/report to MD PRN signs or symptoms of GERD: belching, coughing/choking when laying down, heartburn, nausea, vomiting, regurgitation . and to .keep HOB [head of bed] elevated. Encourage to stand/sit upright after meals. During an interview on 07/27/2022 at 10:39 AM, Staff S, Registered Nurse (RN) stated the resident complained of constipation often. When asked what circumstances occurred for Staff S to administer a PRN laxative, they stated either the resident would come to nurse and ask because they had hard stools, or the resident was on the Third Day List. When asked if the resident complained of stomach upset (nausea, vomiting), Staff S stated not very often. When asked if the resident showed difficulty with swallowing, Staff S stated no, the resident would take their pills whole, two at a time with a sip of water. In an interview on 07/27/2022 at 10:41 AM, Staff V stated constipation and toileting overall were frequent issues for the resident. They stated that the resident would ask for PRN bowel medication frequently and many of their falls occurred while using the bathroom. When asked how frequent the resident would request bowel medication, Staff V stated at least weekly if not more. When asked if the resident complained of nausea or vomiting, Staff V stated no. Review of the document titled Discharge Summary dated 07/23/2022, discharge diagnoses and hospital problems include: .Sepsis due to community acquired (developed outside of the hospital) pneumonia: Escherichia coli (a bacteria commonly found in the intestinal tract) in sputum, acute hypoxic respiratory failure (not enough oxygen in the blood for a person to breathe on their own) due to aspiration in the setting of community acquired pneumonia . The source of infection was determined to be respiratory when cultures resulted in E. coli and other cultures were negative. Furthermore, the discharge summary stated that a day after completing antibiotics, the resident's .condition worsened and [they] again had increased need for oxygen supplementation .it was elected to transition to comfort care .this AM [07/23/2022] at 0630 AM, they [the resident] died peacefully. During an interview on 07/27/2022 at 10:25 AM, with Staff WW, Medical Director, it was asked if E. coli was a common bacteria found in respiratory secretions or sputum. Staff WW stated no its not common although it is possible. When asked if it were possible for a person to inhale stomach contents while vomiting, Staff WW stated yes that could cause aspiration pneumonia. Reference: WAC 388-97-1060 (1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed A) to adequately supervise and initiate interventions for safe use of hot liquids for one of two dependent residents (74) who were dependent on staff to safely check temperature of hot liquids before giving them to residents. This failed practice resulted in harm for Resident 74 who sustained second degree burns (blisters) both thigh areas, and B) to assess risk factors and develop planned interventions to address resident falls for one of three residents (62) for accidents. This failed practice resulted in harm to Resident 62 who sustained a fall on their face from their wheelchair to the floor and sustained bruising and fracture to the left eyebrow. Findings included . Resident 74. Review of the medical record showed the resident was a long-term stay resident with diagnoses which included dementia, diabetes and heart failure. The 06/13/2022 comprehensive assessment showed the resident required extensive assistance for transfers, bed mobility and activities of daily living (ADLs) and had severely impaired cognition. Review of the resident's 06/26/2022 care plan showed the resident required assistance with eating and staff provided oversight and supervision for all meals in the dining room. The care plan showed the resident was at risk for injury from hot liquids. Review of an incident report dated 06/26/2022 at 10:44 AM showed the resident was seated in the lobby of the facility and was drinking coffee which accidentally spilled into their lap resulting in substantial . redness and three blisters to their right and left inner thighs. The wound area measured 16.6 centimeters (cm) was 6.5 cm in length and 3.3 in width. The incident report showed no pain assessment was conducted and no witness statements were obtained. Cold compresses were applied to the injured area throughout the shift. Review of a 06/28/2022 progress note showed the resident was at increased risk for burns due to their diagnosis of dementia, left hand weakness/shakiness and poor safety awareness. At that time (two days later) care plan interventions and updates showed to assist the resident as needed with hot beverages. The care plan was updated on 06/28/2022 to included that all hot beverages be placed in a firm cup with lid and staff were to add ice too cool down the liquid. During an observation and interview on 07/25/2022 at 3:38 PM, Staff HH, Certified Dietary Manager, stated that they had worked in dietary for four years. The process for coffee was that kitchen staff brewed the pot of coffee in the west wing satellite kitchen prior to each meal then the coffee was placed into two carafes. Staff HH stated that between meals the Nursing Assistants (NAs) were to heat coffee in the microwave because the coffee would cool down in the holding carafes. Staff HH stated that the satellite kitchen did not contain a thermometer for staff to test hot liquids nor had NA staff received training to ensure safety of hot liquids. During an interview on 07/25/2022 at 3:22 PM, Staff JJ, Licensed Practical Nurse (LPN) stated that they were working on the shift and had assessed the burns after the accident from hot coffee. The resident was seated in the lobby area when the burns occurred. [Resident 74] is always shakey (sic) on both sides (arms/hands) and was concerned why staff had served coffee at a temperature to cause the burns. Staff JJ stated they did not know which staff had served the coffee to the resident. During an interview on 07/25/2022 at 3:45 PM Staff II, NA stated that they (NA Staff) warm up coffee between meals for 35 - 45 seconds in the microwave, because the coffee cooled down in the carafes. Staff II stated there was no thermometer in the kitchen to ensure safety of beverages nor had they received training to temperature check those liquids heated in the microwave. During an interview on 07/26/2022 Staff KK stated they regularly worked on the west wing and had never received training on how long to heat up beverages in the microwave. We put in the microwave for 30 seconds or longer and that it (time in microwave) depended and varied on how long the coffee had been sitting in the carafes after meals. During an observation and interview on 07/26/2022 at 8:35 AM, Staff LL, NA stated they had worked at the facility for six years and had never been trained to temperature beverages from the microwave. Staff LL observed the area in the satellite kitchen with this surveyor and stated that the satellite kitchen did not have a thermometer. During an interview on 07/27/2022 at 8:55 AM, Staff RR, Designee stated that they would expect that staff follow policy and procedure and temp all food and beverages as indicated in the facility's policy. Staff RR stated the facility implemented a process where all staff would be trained to temperature check liquids and food to ensure resident safety. Resident 62. Review of the medical record showed the resident admitted to the facility on [DATE] with diagnoses of a stroke with left sided paralysis, high blood pressure and diabetes (condition where the body does not use glucose (sugar) properly). Review of the 06/02/2022 assessment showed the resident had some cognitive impairment, required extensive assistance with activities of daily living and was totally dependent with transfers to and from their tilt-in-space wheelchair with a Hoyer lift mechanical device. The resident was dependent on staff for mobility in their wheelchair. Review of the 06/01/2022 Fall report showed the resident was at far end of the dining room in their wheelchair. At 9:50 AM a resident notified staff that the resident had fallen in the dining room. The resident was found face down in a pool of blood. The resident stated the wheelchair slipped from under them and they hit their head. The dining room was not supervised by staff thus an unwitnessed fall. The resident had a blood pressure of 166/109, (normal 120/80), and their pulse was116, (normal 60-100). There was no assessment for mobility/risk for falls. Review of the 06/01/2022 Emergency Department physician's assessment showed the resident presented with swelling and bruising to the left eye due to a fall and wounds to the legs. The resident was dependent on their wheelchair for mobility. The resident had sustained a fracture of the left eyebrow area and was to have follow-up with another physician. The plan for left eyebrow fracture was to apply ice packs three times a day for the next three days. Continued the resident on Plavix (blood thinner) and aspirin. During an interview on 07/19/2022 at 12:39 PM, Staff H LPN stated the resident was baseline and knew of the fall on 06/01/2022. Staff H saw the resident last week and placed the resident on 30-minute checks. Staff H knew the resident had poor trunk control and was working with therapy but was unaware of the resident's fracture on the left eyebrow. During an interview on 07/20/2022 at 10:30 AM, the resident stated he had been in his room during mealtimes because they felt sick. They remembered the fall and stated they were reaching for something and fell on their face and it hurt a lot. During an observation and concurrent interview on 07/22/2022 at 10:51 AM, the resident was playing with their bed control putting the bed up and down, foot of the bed up and down, as well as the head of the bed up and down. The Resident's Representative (RR) was present in the room explained since the resident had a stroke, they fidget and had fidgeting devices to use to occupy them so they did not try to do things impulsively. The RR stated the resident fell because the staff had placed the resident and the wheelchair straight up instead of tilted back. Since the resident's center body core was not strong, he fell out of the wheelchair. The RR stated they were concerned about the resident's increased anxiety and increased impulsiveness. Reference: WAC 388-97-1060(3)(g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 39. Review of the medical record showed the resident readmitted to the facility on [DATE] with diagnoses of encephalopathy (damage or disease that changes the way the brain works), diabetes mellitus (sugar intolerance), hyponatremia (low salt), and bacteremia (bacteria in the blood). Review of the annual comprehensive assessment dated [DATE], showed the resident required two-person extensive assistance with transfers and bed mobility, and a one-person total assist with toileting due to long term placement of urinary catheter and colostomy. The resident was assessed to be without pressure ulcers, but at risk for the development of them. Further review of the medical record showed a progress note dated 06/24/2022 that stated, 60 day visit no changes. 2 open areas noted this afternoon on either side of the coccyx (tailbone). Covered with foam dressings, notified MD [medical director], gave orders to place dressings. The progress note and physician order of the same date were completed by Staff ZZ, Registered Nurse (RN)/Resident Care Manager (RCM). Review of the Skin and Wound evaluations showed no initial assessment of the open areas to the resident's coccyx, no documentation of size or dimensions of the open areas nor any follow-up assessments of these areas. The last entered Skin and Wound assessment was dated 04/14/2022 for the healed skin abrasion to the resident's left elbow. During an interview on 07/22/2022 at 10:22 AM, when asked what the process was for documenting a new skin concern, Staff EE, Quality Assurance Nurse (QAN)/Wound Nurse, stated once the Nursing Assistant (NA) verbalized the skin concern to the Licensed Nurse (LN), it is assessed, documented on a Skin and Wound Assessment, photo taken, doctor notified, and treatment orders obtained. Additionally, they said an incident report should be initiated. When asked if this process was completed for the open areas identified on the resident as of 06/24/2022, Staff EE stated, no, but it should have. In an interview on 07/22/2022 at 10:49 AM, when asked about the skin issues for Resident 39, Staff V, Licensed Practical Nurse (LPN)/Charge Nurse, stated the resident's coccyx area had been red and the previous treatment was application of moisture barrier cream. Staff V stated they were not certain of when the skin broke down and opened. When asked to describe the process of documenting a new or changed skin issue, Staff V said the expectation was the LN to take measurements, a picture, write a progress note or complete a Skin and Wound Assessment, notify the doctor, and obtain new orders if necessary. When asked if this process was done for the open areas next to the coccyx of Resident 39, Staff V stated they did not personally do it and if it was not in the chart, then probably not. Observed wound care performed on 07/22/2022 at 10:40 AM by Staff N, LPN. Noted Optifoam dressing (a type of wound dressing that has a sterile foam pad with surrounding adhesive applied to a wound to promote healing), a packet of moisture barrier cream, gauze, and normal saline on bedside table. No barrier between table and supplies. When asked if the wounds and surrounding skin looked moist, Staff N said yes. Glove change after cleansing the wounds. Observed Staff N spreading the moisture barrier cream directly on the foam of the dressing using a gloved finger. When asked if there was an order for barrier cream, Staff N said yes, some people (LNs) apply the barrier cream to the skin surrounding the wounds. When asked to clarify, Staff N said this is how they liked to do this dressing change. Reference: WAC 388-97-1060 (3)(b) Resident 84. Review of the medical record showed the resident was readmitted to the facility on [DATE] with diagnoses including dementia (cognitive impairment), hearing impairment, difficulty walking, falls and weakness. The 06/07/2022 comprehensive assessment showed the resident required extensive assistance of one to two persons with repositioning, transferring, and activities of daily living (ADL's). The resident had one Stage II pressure injury and was at risk for potential pressure ulcers related to their limited mobility and incontinence. Review of the medical record showed the resident was admitted to the hospital on [DATE] and readmitted to the facility on [DATE]. The readmission Nursing assessment dated [DATE] showed the resident had a Stage II pressure injury to the sacrum (back side of buttocks) no other skin issues were identified by facility. Review of a 07/08/2022 Incident report showed a Licensed Nurse documented Resident 84 had right heel wound greenish black in color and measured 3 cm (centimeters) x 1.5 cm. No other assessment of the heel was noted from 06/01/2022- 07/08/2022. Review of a 07/10/2022 Skin and Wound evaluation showed right heel wound measured area of 13.0 cm, length 5.1 cm, width 3.4 cm. The Treatment Administration Record (TAR) showed treatments to the heel started on 07/14/2022. During an observation on 07/14/2022 at 9:15 AM, Resident 84 was seated in a wheelchair, fully dressed, with their feet hanging off the foot pedals. The leg extensions of the wheelchair were not long enough to support the resident's leg/feet. During an interview on 07/14/2022 at 9:17 AM, Staff GG Physical Therapist (PT) was observed exiting the resident's room. Staff GG stated the that they were obtaining measurements to fit the resident for a new wheelchair to assist the resident with comfort and mobility and that the current wheelchair was too small for Resident 84. During a concurrent observation and interview on 07/19/2022 at 1:33 PM, Staff W, Licensed Practical Nurse (LPN) and Staff FF, Nursing Assistant (NA) were observed repositioning Resident 84 for wound care. Staff W cleansed a blackened area of dead tissue on the right heel. Staff W, then applied wound treatment/medicated pad and covered the gauze and secured with tape. Staff W changed gloves and removed old dressing to the sacrum with normal saline. Staff W changed gloves and the applied thin skin duoderm. Both staff members repositioned the resident on his side prior to leaving the room. During an interview on 07/20/2022 at 10:28 AM, Staff EE, Registered Nurse (RN), Quality Assurance Nurse (QAN) responsibilities: incident reports, wounds, skins assessments, falls and incontinence. Stated that Staff SS, Wound Care Specialist, Advanced Registered Nurse Practitioner (ARNP) takes care of our wounds here. Staff EE stated that I believe that those wounds could have been avoidable. We just got a new order change for wound care; the nurses were not using the correct dressing to the sacrum. During an interview on 07/21/2022 at 12:55 PM Staff B, Interim Director of Nursing Services (DNS) stated when they saw the pictures of the wound for Resident 84, I was wondering how this was a blister by the way it looked, I was just so surprised. During an interview on 07/21/2022 at 1:35 PM, Staff H, LPN, Charge Nurse stated they did not know how long the resident had the wound to the heel and stated I believe it was noted on the (July)11th. I'm not sure I was out of the facility until the 07/14/2022. I'm not sure when Staff SS was consulted but, was told that they had seen the resident's right heel and was taking of care of it. The sacral wound was noted on 06/01/2022 when the resident came back from a hospital stay of four to five days. Review of nurse progress notes dated 07/08/2022 showed the resident had a deep tissue injury to the right heel, the record showed there was no follow-up for treatment orders until 07/11/2022 (three days later). The wound was assessed and debrided on 07/14/2022 (seven days after the wound was found/identified). Review of the progress note dated 07/14/2022 showed that the wound care specialist determined that the wound to the right heel was Unstageable pressure injury and debrided the wound. Based on observation, interview and record review, the facility failed to ensure prevention of pressure injury development, worsening of existing pressures injuries and prevent the development of additionally pressure injuries for three of four residents (74, 84 and 39) reviewed for pressure injuries. This failure caused harm to Resident (74) when their pressure injury worsened to a Stage IV (four) pressure injury to their leg/ calf, a worsened pressure injury to the right heel and a new pressure injury to the left heel which resulted in pain and discomfort and potentially other medical complications. Additionaly the facility failed to identify, assess and develope wound treatment orders in a timely manner for two of two residents (84 and 39). These failures resulted in harm for Resident 84 and placed resident (84 and 39) at risk for avoidable and untreated pressure injuries and a diminished quality of life. Findings included . The National Pressure Ulcer Advisory Panel (NPUAP) Pressure Ulcer (Injury) Stages include: * Stage I: Intact skin with non-blanchable (skin does not turn white when pressed) redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. May indicate at risk persons. *Stage II: Partial thickness loss of dermis (the thick layer of living tissue below the epidermis) presenting as a shallow open ulcer with a red, pink wound bed, without slough (A layer of dead tissue separated from surrounding living tissue). May also present as an intact or open/ruptured fluid filled blister *Stage III: Full thickness tissue loss. Subcutaneous (under the skin) fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. * Stage IV: Full thickness skin loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes 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). *Unstageable: Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (a dry tan, brown or black scab) in the wound bed. Resident 74. Review of the medical record showed the resident was a long-term stay resident with diagnoses which included dementia, diabetes and heart failure. Review of the 01/03/2022 annual comprehensive assessment showed the resident exhibited no rejection of care, required two person extensive assistance with bed mobility, transfers, dressing, toileting, had functional limited Range of Motion (ROM) on the left side. The resident was assessed as at risk of pressure ulcers, and without pressure ulcers. According to the assessment the resident did have boggy left and right heels but wore protective boots to offload pressure. Review of the Resident's Skin and Wound evaluations showed: * An initial assessment dated [DATE] of a left heel pressure injury which measured 8.2 centimeters (cm), 3.9 cm in length and 2.9 cm in width. * An initial assessment of the right calf pressure injury dated 03/20/2022, measuring 2.0 cm in area by 2.4 cm in length and 1.2 cm in width as noted as Unstageable. * An incomplete initial assessment (only measurements) dated 03/04/2022 of a right heel pressure injury which measured 2.6 cm area, 2.2cm in width and 1.6 cm in width. Review of a 05/11/2022 order showed the resident was seen by a wound specialist for the right lateral calf wound which had worsened and was assessed as a Stage 4 pressure injury. Review of a 05/25/2022 wound specialist's assessment showed a request was given to nursing to start offloading that leg. Review of a 06/01/2022 wound specialists assessment showed it does appear nursing had the leg rests exchanged, possibly had more pressure prior to this. Review of a 06/06/2022 skin and wound note showed the wound to the calf was assessed at 4 cm area, 3 cm width with 2.5 cm undermining. The note showed the injury had necrotic (dead) tissue with bone and tendon exposed, foul odor, large amount of drainage. Additionally, a new area of pressure was identified below the initial injury which measured 4 cm by 2 cm was dark purple and non-blanchable. Review of the 03/25/2022 [NAME] (directive to Nursing Assistants) showed to place pressure reducing device: Boots (cushioned heel protection) on while up in wheelchair and to float right lower extremity at all times, no pressure to right lateral calf. During an observation on 07/20/2022 at 11:45 AM, the resident was observed in a wheelchair, assisted into the dining room for the noon meal. The resident's legs were elevated 45 degrees and pillows were observed beneath the knee and foot of the right leg. The resident's feet had socks on them, and the heels were resting on a pillow, no protective boots were on the resident's feet. During an interview on 07/20/2022 at 12:52 PM, Staff MM, Nursing Assistant (NA) stated that they had worked at the facility for five years and regularly cared for Resident 74. Staff MM stated that NA staff used a pillow under the residents heels and had been directed by nursing staff that it was more effective, for this resident, to use a pillow under the feet/heels rather than protective boots. During an interview on 07/20/2022 at 1:09 PM Staff EE Registered Nurse/ Wound Treatment stated the position of treatment nurse had been vacant for several weeks, and they had been hired into the position a week ago. Resident 74 had a large open pressure injury on their right calf that was slow healing, a reoccurring pressure areas to the left and right heels and blisters on the inner area of their thighs due to an accidental burn from hot liquid. Staff EE stated that the record did not show an incident report had been completed for the right calf, however an assessment showed the pressure injury was the result of an ill-fitting wheelchair where the resident's calf was pressing against the metal bar on the leg rest. Staff EE stated it was the facility's protocol to complete an incident report but was unsure why one had not been completed. When asked why the resident was not wearing the ordered boots for protection of the heels, Staff EE stated the boots were not effective and that staff placed a pillow under the heels instead. During an observation on 07/21/2022 at the noon meal, Resident 74 was observed in the dining room, legs elevated, feet rested on a pillow. During an observation on 07/26/2022 at the noon meal, Resident 74 was observed with legs elevated, feet rested on a pillow. During an observation and interview on 07/26/2022 at 9:30 AM, the resident was observed seated upright in a wheelchair in the common area near the central nurse's station. The upper part (near the knee) of the resident's calf was pressing against the metal frame of the wheelchair. The resident's feet had non-skid purple socks, no protective boots and both heels were resting directly on the wheelchair foot pads. On 07/26/2022 at 9:40 AM, Staff JJ, Licensed Practical Nurse (LPN) Agency Licensed Nurse (LN) wheeled the Resident 74 into their room and stated they would be providing wound treatment to the resident's calf injury. Staff JJ stated that the resident was given Tylenol prior to the treatment because the procedure was very painful, and the resident would yell out of threaten to hit Staff JJ. Staff JJ observed the resident's calf against the wheelchair frame and stated that the resident had a shower in the morning and was in a different wheelchair. Staff JJ stated that the resident's feet should have boot protectors on and that the calf should not be pressing against the metal frame of the wheelchair. Staff JJ looked about the room and stated that the protective boots were missing, and they did not know where they were. On 07/26/2022 at 9:47 AM, Staff JJ lifted the resident's leg to which the resident winced and moaned. As the treatment continued Staff JJ began irrigating the open wound, the resident began moaning and put their hand to their mouth, eyes squeezed shut stated ooooh, oh my God. At that time Resident 74 looked at Staff JJ and said, I'm going to punch you. During an interview on 07/26/2022 at 2:00 PM, Staff EE stated that when the wound specialist observed the wound, they stated nursing staff were not packing the wound well enough, which may have led to the worsening of the wound.