**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the necessary care and services to prevent the development of pressure injuries and to implement wound treatment measures consistently to avoid worsening of pressure injuries for 1 of 3 residents, (Resident 46) reviewed for pressure injuries. Resident 46 experienced harm when they developed a pressure related fluid filled blister to the left heel and a pressure injury to their right lateral malleolus (the bony prominence on the outside of the ankle joint) that had both slough and eschar present in the wound. These failures also placed the resident at risk for pain, infection, and other medical complications. Findings included . Review of the National Pressure Injury Advisory Panel (leading expert in pressure injuries/wounds), September 2016, defined pressure injury stages as follows: Stage 2 Pressure Injury is a partial thickness skin loss with exposed dermis (the top inner layers of skin) and may be present as an open ulcer with a red or pink wound bed or as an intact or ruptured blister. Stage 3 Pressure Injury is a full thickness loss of skin, in which adipose (fat) tissue is visible in the ulcer. Slough (dead tissue) and or eschar (dried blood and tissue) may be visible, granulation tissue and epibole (rolled or curled under edges) may include with undermining (a pocket of dead space under the visible wound edges) and tunneling (a passageway under the wounds surface which may be shallow or deep and impairs wound closure). Review of an undated facility policy titled, Skin Integrity, showed the facility would provide care consistent with professional standards of practice to prevent pressure injuries, promote healing, and prevent infection. <Resident 46> Review of the medical record showed Resident 46 admitted to the facility on [DATE] with diagnoses of a right femur (thigh bone) fracture, severe dementia (an umbrella term for loss of memory and thinking skills that has various causes), severe protein calorie malnutrition ( a condition where there is an insufficient intake of both protein and calories to meet the body's needs), reduced mobility (difficulty or inability to move around freely, easily, and without pain), and heart disease. The comprehensive assessment dated [DATE] showed Resident 46 required maximum assistance of one to two caregivers for bed mobility and transfers and had severe cognitive impairments. An observation of Resident 46 on 06/09/2025 at 8:24 AM, showed a small frail-appearing person lying on their back in their bed with no observable pressure relieving mattress, devices, or footwear to assist with pressure relief in place. Resident 46's eyes were open, though they did not speak or respond when spoken to. Review of Resident 46's facility admission notes dated 05/21/2025 showed the resident had no pressure injuries present on admission to the facility. Review of a nursing note in Resident 46's electronic medical record dated 06/03/2025 at 7:53 AM, showed a licensed nurse (LN) noted a new pressure related blister to Resident 46's left heel. The note further stated the resident was placed on alert charting, to monitor the area, and to float the heels (elevate the heels off the bed surface) when in bed. An additional nursing note dated 06/03/2025 at 7:57 AM stated in part, LN spoke with the resident's representative to notify of the pressure related blister to the left heel, who asked that facility staff monitor Resident 46 closely for any open areas on their lower extremities, as they had issues in the past of not healing well. Review of a nursing note dated 06/05/2025 at 1:18 PM, an LN wrote, while providing wound care LN noted new wound on the right lateral malleolus (ankle), wound care provided, new wound care orders are in place. Review of skin and wound assessment notes showed on 06/03/2025 a blister to the left heel was measured as 5.1 centimeters (cm) (a unit of measure) in length by 4.6 cm in width and described as a fluid filled blister taking up the majority of the left heel. Further review of skin and wound assessment notes showed on 06/05/2025 a right malleolus pressure injury was measured as 1.6 cm in length by 0.7 cm in width and described as having both slough and eschar present in the wound. Review of a Braden Scale assessment (an assessment tool used to assess a patient's risk for developing pressure injuries) completed on the admission date of 05/21/2025 showed a score of 11, indicating Resident 46 was at a high risk for developing pressure injuries. Review of Resident 46's Treatment Administration Records (TARs) for May 2025 and June 2025, showed beginning 05/26/2025 an order was written for LNs to do a complete skin assessment with a narrative (a written assessment of the skin's condition) every day shift on Mondays for skin monitoring. There were no LN initials that showed these assessments were completed on 05/26/2025, 06/02/2025 or 06/09/2025. Further review of Resident 46's TARs showed beginning 06/03/2025, the LN staff were to monitor the pressure related blister to the left heel, to float the heels when in bed, and to apply a heel protector to the left foot when up in their wheelchair every shift. Observations of Resident 46 on 06/10/2025 at 8:16 AM showed them being assisted with breakfast in the dining room. There was no heel protecter in place on the left foot. Observations of Resident 46 sitting at the north nurse's station in a wheelchair on 06/11/2025 at 11:08 AM and 06/12/2025 at 8:47 AM showed there was no heel protector in place on the left foot. Observations of Resident 46 lying on their back in bed on 06/12/2025 at 11:33 AM and 2:05 PM showed the heels were not floated and both heels were pressed into the mattress. Observation of dressing wound changes on 06/12/2025 at 2:26 PM with Staff Q, Registered Nurse (RN), showed the left heel blister was reddish/orange in color, had opened and drained of fluid and measured 5.0 cm by 4.8 cm. The wound to the right ankle showed a pinkish white wound bed with red tissue surrounding the wound and measured at 1.2 cm by 0.7 cm. During an observation and interview with Staff B, the Director of Nursing (DON), on 06/13/2025 at 6:11 AM showed Resident 46 lying on their back in bed with a foam wedge placed under the resident's knees to raise the heels, though both heels were pressed into the mattress. The DON stated the staff did not place the wedge correctly so the heels would float off the mattress and needed more education on how to do so. The DON also pressed on Resident 46's right heel and stated it felt mushy (a feeling of softness or sponginess indicating a potentially early sign of pressure injury development). An observation of Resident 46 on 06/13/2025 at 8:21 AM, showed them sitting in their wheelchair at a dining room table with regular shoes on their feet. Review of Resident 46's care plan on 06/13/2025 showed there was no problem opened for the development of the pressure injuries to the heel and ankle, or that any interventions were put into place to prevent new pressure injuries from occurring or to prevent the current pressure injuries from getting worse. Reference: WAC 388-97-1060(3)(b) This is a repeat citation from Statement of Deficiencies dated 03/12/2024 and 05/22/2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide adequate supervision, assess, monitor, and revise care plan interventions for efficacy, and ensure care planned interventions were consistently followed to prevent avoidable repeated falls for 4 of 5 residents (Residents 21,19, 41, and 29) reviewed for falls. Resident 21 who had 14 falls between 04/13/2025 and 05/23/2025, experienced harm when they had an unwitnessed fall, was found on the floor lying on their left side at the end of their bed, required transfer to the hospital, and was diagnosed with a fracture of the L1 vertebra (the first top bone in the lower back) and required a back brace that supports and stabilizes the spine. Resident 19 fell while unsupervised and experienced harm when they sustained a laceration on their forehead, required transfer to the emergency room (ER) and sutures. Resident 41 fell 17 times in the facility since admission, 12 unwitnessed, from either their wheelchair or bed, and experienced harm when they sustained head trauma, bruising and/or skin tears. Resident 29 experienced harm when they fractured their left fifth toe when they were left unattended in the bathroom, staff were unavailable to provide transfer assistance, they attempted to self-transfer from the toilet and fell. Findings included . Review of the 09/21/2022 Fall Assessment and Management policy showed the facility would identify and document residents' risk factors for falls and establish individualize resident centered fall prevention plans .by identifying underlying medical conditions that may increase injuries from falls .a link between increasing episodes of falls and recent changes in medication regime pharmacy review of medications that could relate to fall risk as well as medication side effects. Care plan individualized interventions will be monitored for effectiveness and modified to increase effectiveness. Review of the Facility's Policy titled, Accident Hazards/Supervision/Device dated 06/2023 showed the facility will provide an environment that is free of accident hazards as is possible and provide supervision and assistant devices, [drop seat wheel chairs(the back seat of the wheelchair tilts back while the front of the wheelchair seat tilts up), Front wheel walkers, manual wheel chairs and nonskid foot wear] to residents to avoid preventable accidents. <Resident 21> Review of the medical record showed the resident admitted to the facility 04/05/2025 with diagnoses including end stage renal disease (when your kidneys have permanently stopped working), muscle weakness and repeated falls with fractures. The 05/16/2025 comprehensive assessment showed Resident 21's cognition was moderately impaired and required assistance of one to two staff members for ADL's. Further review showed Resident 21 had a history of falls prior to admission that resulted in fractures and had two falls resulting in minor injury and no falls with major injury after admission to the facility. Observations on 06/09/2025 at 11:53 AM, 1:40 PM, 2:19 PM, showed Resident 21 lying in bed with his door open and curtain closed. Resident 21 was not visible from the hallway. Review of the care plan dated 04/05/2025 showed that Resident 21 had no care plan in place for being a fall risk and had no interventions to prevent falls. Record review of the fall investigations for Resident 21 showed Resident 21 had a fall on 04/13/2025 with no care plan in place for interventions to prevent falls. Additionally Resident 21 did not have a fall care plan put into place until 04/17/2025 (four days after the first fall). Review of the care plan dated 04/17/2025 showed Resident 21 was at high risk for falls related to deconditioning, gait/balance problems and self-transferring without asking for assistance. Further review showed interventions which included the call light to be within reach and to have appropriate footwear/non skids socks on when transferring. Additionally, there was no intervention for self-transferring in Resident 21's care plan. Review of the facilities reporting log showed Resident 21 had 14 falls between 04/13/2025 and 05/23/2025, nine of which resulted in injuries to Resident 21. Record review of a facility investigation dated 05/04/2025, showed Resident 21 had an unwitnessed fall and was found on the floor lying on their left side at the end of their bed. Resident 21 was able to move all extremities without pain. Resident 21 stated they had pain in their back and neck. When turning Resident 21 to their back to assist them to a sitting position, Resident 21 yelled out in pain and stated their left hip and ankle hurt. Resident 21 agreed to go to the hospital for evaluation. Further review showed the conclusion for Resident 21 was the resident was attempting to self-transfer, care plan reviewed and updated. Review of the care plan showed no updates or interventions were made from the fall on 05/04/2025 that resulted in a major injury. Review of the hospital Discharge summary dated [DATE] showed Resident 21 sustained a fracture of the L1 vertebra (the first top bone in the lower back) and required a TLSO (a back brace that supports and stabilizes the spine) brace with specific instructions to wear when out of bed with instructions on how to apply the brace. Review of the May 2025 orders showed there was no order placed for the nurses to monitor or to place the TSLO brace for Resident 21. During an interview on 06/12/2025 at 1:51 PM Staff P, Registered Nurse, stated they had found Resident 21 on the floor on 05/04/2025 and had sent them to the ER for evaluation. Staff P further stated they should have witness statements written by the staff but were unsure if that happened. Staff P stated they received the TSLO orders from the hospital. Staff P further stated they did not write an order for the brace or collect any witness statements for the fall. During an interview on 06/12/2025 at 11:20 AM, Staff B, Director of Nursing Services (DNS), stated the process for unwitnessed falls with injuries was to call the state hotline and to update the care plan with new interventions. Staff B stated they were aware there were not any witness statements or care plan updates completed for Resident 21's fall on 05/04/2025 and they recognized they have issues with investigations. Staff B stated the process for transcribing orders from the ER was the nurse receiving them were to place them on the Medication Administration Record (MAR) and Treatment Administration Record if necessary. Staff B stated the process was not followed for Resident 21. <Resident 19> Review of the medical record showed the resident admitted to the facility on [DATE] with diagnoses including Dementia (decline in mental ability), osteoporosis (brittle bones which increase bone fracture risk), thrombocytopenia (low blood platelets which lead to increase bleeding and bruising), Myeloproliferative disease (blood cancer) and history of falls. The 04/16/2025 quarterly nursing assessment showed Resident 19 was cognitively impaired with ability to respond yes or no to questions and required substantial assistance of one person to stand and transfer to and from their wheelchair. Review of the 01/31/2025 fall incident report showed Resident 19 had an unwitnessed fall at 2:45 PM in their room which showed Resident 19 sitting against the wall on their buttocks. The conclusion was that Resident 19 fell asleep and slid out of their wheelchair and should be laid down after meals or stay at the nurse's station for supervision. Review of the 05/19/2025 fall incident report showed the resident had an unwitnessed fall at 8:40 AM. Resident 19 was on their right side on the floor with their left eye closed shut and bleeding from the back of their head. The paramedics (emergency medical assistance) arrived and placed a cervical collar around Resident 19's neck to keep the neck in one position. Resident 19 sustained a laceration (jagged wound caused by trauma) on their upper forehead by their scalp which required six sutures. There was no additional information about how long the resident was on the floor. Additionally, there was no conclusion or updates to the care plan completed. Review of the June 2025 MAR showed the resident was on an anticoagulant (blood thinner). Review of the 06/23/2021 care plan showed the Resident 19 was at high risk for falls due to deconditioning, gait/balance issues and unawareness of their boundaries. The care plan interventions included laying the resident down after meals, keeping the bed in a low position, reviewing information on past falls, attempting to determine cause of falls, and keep the resident at the nurse's station. During an observation on 06/09/2025 at 8:00 AM, Resident 19 was seated in their wheelchair at a table in the assisted dining room for breakfast and was being fed by a Nursing Assistant (NA). Resident 19 was unable to move their arms up a to hold their utensils . During an observation and concurrent interview on 06/09/2025 at 9:37 AM, after breakfast the resident was seated in their wheelchair alone in their room parked by their bed. The skin on their upper forehead close to their scalp and hair line had a four-inch scar line with scattered small pinpoint black/brown scabbed areas to the scar line. Resident 19 was very soft-spoken when asked questions about their care and could not verbalize events that led up to their last fall on 05/19/2025. Resident 19 had asked to go to bed but was unable to transfer without assistance. The resident's bed was not in a low position. Resident 19 had a bruise on their lower right forearm. During an observation on 06/10/2025 at 8:45 AM, Resident 19 was seated in their wheelchair in front of nurse's station against the front wall. During an observation on 06/10/2025 at 9:10 AM, Resident 19 was still in their wheelchair against the front wall, there were no staff at the nurse's station. Resident 19 stated they were tired and started to tilt, leaning to the right of their wheelchair. During an observation on 06/10/2025 at 10:30 AM, Resident 19 was still seated in their wheelchair against the wall and leaning to their right side. During an observation and a concurrent interview on 06/11/2025 at 10:57 AM, Staff T, Restorative NA, stated Resident 19 gets tired easily and cannot sit up for long. Staff T stated Resident 19's falls were due to sitting in their wheelchair in their room for too long. During an interview on 06/12/2025 at 7:53 AM, Staff B stated Resident 19's incident report was incomplete. Staff B stated staff did not follow the care plan for Resident 19 <Resident 41> Review of the medical record showed the resident admitted to the facility on [DATE] with diagnoses including Parkinson's Disease (neurodegenerative disease with brain deterioration that affects body movements by slowing movements and causes tremors and balance issues), reduced mobility, and frequent falls. The 05/10/2025 comprehensive assessment showed the resident was cognitively impaired but able to make their needs known, required substantial assistance with transfers to and from wheelchair and toileting. Resident 41 used a manual wheelchair with a drop seat for mobility. The comprehensive assessment showed Resident 41 wandered around the facility in their wheelchair and had multiple falls. During an observation and concurrent interview on 06/09/2025 at 9:00 AM, Resident 41 was in their room seated in their wheelchair by their bed. The call light cord and button was under the resident's bed where they were unable to reach it. The wheelchair was stuck between their bedside table and the resident was unable to move themselves. During an interview Resident 41's stated that they wanted to go home and felt that staff did not listen to them. Resident 41's right hand had dark purple and green bruises between the thumb and index finger. The resident's right wrist on the top of the forearm to mid upper arm showed bruising brown and light green in color. Resident 41's left hand showed scattered green-yellow bruising from the top of their hand to the elbow. The resident raised their pant leg on the right leg and there was light blue green bruising from the outer lateral side of the mid-calf area to the left knee to mid-thigh. Resident 41's left leg had bruising blue green in color over their knee to mid-thigh area. When asked how they got the bruising Resident 41 stated they had fallen many times. Review of the 01/31/2025 care plan showed Resident 41 was at high risk for falls related to confusion, deconditioning, gait and balance problems, Parkinson's, psychoactive (medications that affect mood and behavior) drug use, and history of falls. Interventions included call light in place within reach, bed in low position, [NAME] wheelchair (tilt in space wheelchair) for positioning and body alignment, do not leave the resident alone in the bathroom, bed against the wall, fall mat by bed and review past falls and review root cause and effectiveness of interventions. The last update on fall interventions was 02/04/2025. During an observation on 06/09/2025 at 10:30 AM, Resident 41 was seated in front of the nurse's station by the right side of the wall. The resident was seated in their low wheelchair with the drop seat and using the woodened hand rail to pull themselves along the wall. from behind the south nurse's station Resident 41 was unable to be visualized due to their low-profile wheelchair. During an observation on 06/10/2025 at 9:45 AM, Resident 41 was in their wheelchair with drop seat leaning forward and using their feet to mobilize the wheelchair. Resident 41 was in and out of other resident's rooms and holding on to the handrail in the hallway standing up. There were no staff observed to be supervising the resident. During an observation on 06/10/2025 at 3:07 PM, Resident 41's wheelchair showed the back side of the wheelchair was loose and uneven. The left armrest was completely down and the armrest and side panel on the right was in the upright position. The resident was leaning forward and started to fall forward but caught themselves in the doorway of the south dining room. There were no staff observed to be supervising the resident. During an interview on 06/10/2025 at 1:49 PM, Staff V, Registered Nurse (RN) stated they were at the nurse's station on 06/03/2025 when Resident 41 was seated in front of the South Nurses station. Resident 41 was seated in their wheelchair for about 20 minutes and slipped out of the wheelchair onto the floor and hit their right elbow and sustained a skin tear. Staff V stated they picked Resident 41 up with assistance and put them back in the wheelchair. Staff V was unaware that Resident 41 was in a drop seat wheelchair or if the resident was positioned correctly. Staff V stated Resident 41 falls frequently and there is nothing else they can do to update the interventions of the care plan. During an observation on 06/11/2025 at 4:10 PM, Resident 41 was yelling from their room help, help in a loud tone and repeatedly asked staff to get them out of bed. Staff observed near Resident 41's room, did not respond to the residents' call for assistance. The surveyor entered Resident 41's room, and observed the resident seated close to the edge of the bed with the bottom part of their body out of the bed. During an interview on 06/11/2025 at 4:30 PM, Staff Z, NA, stated they requested a one on one (one person assigned to supervise a resident) for Resident 41 in the evening related to the resident having increased behaviors with falls and not enough staff to provide supervision. Staff Z stated if Resident 41 was assisted in bed too early they would fall out of bed. During an interview on 06/11/2025 at 4:45 PM, Staff N, RCM, RN, stated Resident 41 becomes restless and wanders around the hallway in the late afternoon. Staff N stated after they leave in the afternoon there were not enough staff to supervise Resident 41. During an interview on 06/13/2025 at 1:00 PM, Resident 41's Resident Representative (RR) stated they were very concerned about the care Resident 41 had received at the facility and the number of falls with bruises and skin tears. The RR stated they had given many interventions that would help Resident 41 such as snacks, quiet areas, conversation, music and phone call to the RR to speak to Resident 41. The RR stated they felt the facility was resistant to any suggestions they offered. Review of Resident 41 fall incident reports from 02/03/2025 through 06/03/2025 showed Resident 41 had sustained 17 falls from either the wheelchair or their bed and had sustained either head trauma, bruising and/or skin tears. Review of the incident reports showed 12 falls were unwitnessed. During an interview on 06/12/2025 at 7:53 AM, Staff B, DNS, stated Resident 19's incident reports were not complete and did not meet the requirements. Staff B stated staff did not follow the care plan for Resident 19 and did not thoroughly investigate to determine if interventions were effective. <Resident 29> Review of Resident 29's medical record showed the resident was admitted to the facility on [DATE] diagnoses to include polyneuropathy (a disease affecting the peripheral nerves in the body, causing weakness, numbness and burning pain), muscle weakness, unsteadiness on feet and repeated falls. The 06/07/2025 comprehensive assessment showed the residents' cognition was intact and required one staff assistance with transfers and toileting and had falls since admission. Review of the care plan dated 06/09/2025 showed Resident 29 was at risk for falls related to weakness and an unsteady balance. Further review showed interventions which included a toileting schedule, evaluate for proper attention to safety, have the call light within reach and reinforce use of the call light. Additionally, to reinforce the use of appropriate footwear for safety with transfers. An observation and concurrent interview on 06/09/2025 at 8:51 AM, Resident 29 was in their night gown, no shoes or socks on sitting in their wheelchair. Resident 29 stated the call lights will stay on forever and they needed help with getting dressed but were told they could do this themselves. The resident stated they could not stand on their own and their hands nor their knees worked. Resident 29 stated I would not be here if I didn't need the help. The resident stated the staff helped them on the toilet and never came back, so they tried to transfer themselves into their wheelchair after waiting a long time and had a fall. They stated the incident happened a month ago in their restroom and they had to yell for help. Additionally, they broke their left fifth toe in the fall. Review of the facilities incident reporting log dated 04/23/2025 showed Resident 29 was found in the bathroom lying on their stomach after a fall in their restroom that resulted in a fracture to their left fifth toe. During an interview on 06/12/2025 at 3:38 PM, Staff Z, NA, stated there were many residents who were a high risk for falls. Staff Z stated they had informed the administration and the nurses about the need for more staff supervision to decrease the falls, but they have not seen any results and the residents continue to fall. Staff Z stated they keep certain residents at the nurse's station to keep a close eye on them but sometimes that doesn't work. During an interview on 06/10/2025 at 2:54 PM, Staff N, RCM, stated when they were coming into work the morning of 04/23/2025 they were walking down the hall and heard someone yell help me. Staff N stated upon entering Resident 29's room, they found the resident lying on their stomach in the residents bathroom. Staff N stated they assisted the resident up, started an incident report, and placed resident on alert charting. Staff N stated there was bruising noted to Resident 29's left lateral ankle and left toes, and the resident had complained of pain to their left fifth toe. Staff N stated an x-ray was taken on 04/28/2025 (five days after the incident) and showed Resident 29 had a latent injury of a fractured left fifth toe. During an interview on 06/12/2025 at 10:35 AM, Staff B stated that their expectation was for staff to follow the care plan and ensure resident safety. Reference: WAC 388-97-1060 (3)(g) Cross reference F725 Sufficient Nurse Staffing; and F610 Investigate Alleged Violations This is a recurring citation from the Statement of Deficiencies dated May 22, 2024

**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/pressure injury (PU/PI) and to implement wound treatments timely to avoid worsening of a PU/PI for 3 of 3 residents (Residents 20, 41, and 60), who had multiple co-morbidities with an increased risk for PU/PI, reviewed for PU/PI. Resident 20 experienced harm when they developed a Stage II PI (partial thickness skin loss with exposed top inner layers of skin) to their right buttock and an unstageable (a pressure injury that is a full thickness skin and tissue loss to which the extent of the tissue damage cannot be seen) wound to their left buttock, and expressed significant pain and discomfort. These failures placed the residents at risk for development or worsening of PU/PI, pain, infection, and a decreased quality of life. Findings included . Review of the National Pressure Injury Advisory Panel (leading expert in pressure injuries/wounds), September 2016, defined pressure injury stages as follows: • Stage 1 Pressure Injury has intact skin with a localized area of non-blanchable erythema (redness). • Stage 2 Pressure Injury is a partial thickness skin loss with exposed dermis (the top inner layers of skin). • Stage 3 Pressure Injury is a full thickness loss of skin, in which adipose (fat) tissue is visible in the ulcer. Slough (dead tissue) and or eschar (dried blood and tissue) may be visible, granulation tissue and epibole (rolled or curled under edges) may include with undermining (a pocket of dead space under the visible wound edges) and tunneling (a passageway under the wounds surface which may be shallow or deep and impairs wound closure). • Stage 4 Pressure Injury is a full thickness loss of skin and tissue with exposed or directly palpable fascia (a layer of connective tissue), muscle, tendon, ligament, cartilage, or bone in the ulcer. Epibole undermining and tunneling often occur. • Unstageable Pressure Injury is a full thickness skin and tissue loss to which the extent of the tissue damage cannot be seen. Review of an undated facility policy titled, Skin Integrity, showed the facility would provide care consistent with professional standards of practice to prevent pressure injuries, promote healing, and prevent infection. <Resident 20> Review of the medical record showed Resident 20 admitted to the facility on [DATE] with diagnoses including respiratory disease, obesity, diabetes (a long-term condition in which the body has trouble controlling blood sugar level in the body), and hemiplegia (a condition that causes a severe loss of strength or paralysis on one side of the body). The most recent comprehensive assessment, dated 05/01/2024, showed Resident 20 required total assistance of two staff members for bed mobility, transfers, bathing, dressing and toileting, and was cognitively intact. Review of an admission nursing assessment dated [DATE], showed Resident 20 was admitted to the facility with no skin breakdown noted. Review of a nursing progress note dated 05/04/2024, showed a skin assessment was completed on Resident 20 and no skin issues were found. Review of a nursing progress note dated 05/07/2024 showed, shearing (skin abrasions) was noted on both the left and right buttock, each measuring two centimeters (cm, a unit of measure) round. The areas were cleansed and covered with a foam dressing. A new order had been received to change the dressings every other day (QOD) and as needed (PRN). Review of Resident 20's physician orders and Treatment Administration Records (TAR's) for the month of May 2024, showed on 05/09/2024 an order was received to change the dressings to the left and right buttocks pressure wounds QOD and PRN by cleansing the wounds and applying a thin layer of 50/50 Anasept/collagen powder (a specialized absorbent wound filler) to the wounds and then covering with a foam dressing. A concurrent observation and interview on 05/13/2024 at 11:10 AM, showed Resident 20 sitting in a wheelchair in their room. The resident stated their bottom hurt real bad from sores (pressure injuries) on it and asked to be put back to bed for relief from the pain. The resident stated they got the sores after they admitted to the facility and had not had any previous skin breakdown. Observation of the wounds during a dressing change on 05/16/2024 at 10:26 AM by Staff E, Assistant Director of Nursing (ADON), showed two distinct wounds on the right and left buttocks and a darkened area on Resident 20's coccyx (tailbone) area. The removed dressing showed a moderate amount of yellow colored drainage and the wound bed on the right buttock had partial thickness skin loss and was red in color. The wound on the left buttock was larger in size and had whitish colored slough covering the center of the wound with red partial thickness skin loss surrounding the center of the wound. Staff E took photos and measurements of the wounds for weekly wound assessment documentation and stated they would place the document for review in Resident 20's medical record when completed. During the same observation, Resident 20 stated the wounds were always very painful and especially during the dressing changes. The resident made moaning sounds indicating the areas were painful when touched during the dressing change process. During an interview with Staff E on 05/17/2024 at 2:37 PM, while reviewing the wound assessment record and pictures completed on 05/16/2024, showed a wound on the right buttock measured and defined as a 1.0 centimeter (cm, a unit of measure) by 1.0 cm Stage 2 open pressure injury, and a wound on the left buttock measured and defined as a 3.98 cm by 3.1 cm open unstageable area, as a portion of the wound was covered by yellow/whitish slough and the extent of tissue damage could not be observed. A closed deep colored area measuring 2.0 cm by 0.5 cm at the top of the coccyx was also noted on the wound assessment record. Review of Resident 20's care plan showed a problem was opened on 05/08/2024, showing the resident had Stage 2 pressure injuries to both buttocks with the goal to be healed by the next review date. <Resident 41> Review of Resident 41's medical record showed they were re-admitted to the facility on [DATE] with diagnoses that included type 2 diabetes (a long-term condition in which the body has trouble controlling blood sugar and turning it into energy) and a Stage 4 pressure injury on their sacrum (located at the base of the spine) and osteomyelitis (an infection in the bone). Review of the most recent comprehensive assessment dated [DATE] showed Resident 41 was cognitively intact and required no assistance with decision making. During an observation and interview on 05/16/2024 at 9:16 AM, Resident 41 stated their air mattress (a specialized mattress that contains air cells or tubes which alternates to prevent pressure) was malfunctioning for a while and they could not get anyone to fix it. The resident pointed to the right side of the bed where a hard hyper inflated area was observed directly under their sacral wound and caused pain. Resident 41 stated that if the bed was not over inflated to 300 pounds it went flat and they would be sitting on the metal bed frame. It really needs to get fixed because the hardness pushes on my sore. Review of an outside wound care consultant (OWC) assessment note dated 04/25/2024 showed Resident 41's air mattress was malfunctioning and a referral to maintenance had been made to repair or replace the bed. Review of a OWC assessment note dated 05/05/2024 showed the OWC had again requested an air mattress replacement or removal of Resident 41's malfunctioning air mattress. The note stated the air mattress was putting inappropriate firmness under Resident 41's Stage 4 sacral pressure injury. During multiple observations on 05/14/2024 at 10:10 AM, 05/15/2024 at 2:10 PM, 05/16/2024 at 9:10 AM, 05/17/2024 at 3:30 PM, showed Resident 41 was using the same malfunctioning air mattress with the over inflated area putting pressure on their Stage 4 sacral wound set at 300 pounds to prevent it from going flat. An observation and interview on 05/19/2024 at 8:13 AM, showed Resident 41 laying on a non-air mattress (Sedona Medium Risk). The mattress did not include alternating air cells for pressure relief. Resident 41 stated I know it's not an air bed but at least it is not pushing on my sore. During an interview on 05/19/2024 at 9:00 AM, with a staff who requested to remain anonymous stated the malfunctioning air mattress had been reported for weeks, and nothing had been done about it until yesterday (05/18/2024). During an interview on 05/22/2024 at 11:12 AM, Staff B, Director of Nursing, stated they put Resident 41 on a non-air mattress on 05/18/2024. Staff B stated they were aware that the new mattress for Resident 41 was not an alternating air pressure relief mattress and would change the physicians order to discontinue the air mattress. The request for intervention of Resident 41's malfunctioning air mattress replacement took 23 days from the first noted documentation of the mattress malfunction on 04/25/2024. <Resident 60> Review of the medical record showed Resident 60 was admitted to the facility on [DATE] with diagnoses including surgical removal of left leg (below the knee) and peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). The 03/20/2024 comprehensive assessment showed Resident 60 required maximum assistance of one staff member for activities of daily living: set up assistance of one staff member for eating, oral, and personal hygiene. The assessment also showed Resident 60 had an intact cognition. Review of a nursing progress note dated 03/13/2024, showed Resident 60 was admitted with a deep tissue injury (a serious form of pressure injury that rapidly progresses to full thickness skin and soft tissue loss)/pressure injury to their right heel. Review of a progress note dated 04/18/2024 at 5:46 AM, by OWC, showed Resident 60's wound was improving with delayed wound closure. Non peeling eschar (dead tissue that forms over healthy skin, then over time, falls off) present. Keep clean and covered. Review of a progress note on 04/25/2024 at 5:30AM, showed OWC had assessed Resident 60's right heel wound and determined that surgical debridement (removal of damaged tissue from a wound) was necessary and had performed the debridement that day. The wound was then classified as a Stage 4 pressure injury. The OWC documented that the wound had a strong odor with purulent (thick fluid caused by infection) drainage. A wound swab was obtained to guide treatment options including antibiotics. Review of a PN on 05/02/2024 at 5:18 AM, showed the OWC had assessed Resident 60's right heel wound. The assessment showed the wound was deteriorating with severe exacerbation (an increase in the severity of the illness) and recommended labs and imaging to ensure no bone involvement was present. The OWC also documented that they and Resident 60's provider needed results of the wound swab to help guide treatment options including antibiotics. Additionally, the OWC had placed additional lab recommendations due to concerns of osteomyelitis, along with magnetic resonance imaging [(MRI) an imaging technique that is used in radiology to form pictures of the anatomy and physiological process inside the body] or x-ray. Review of the medical record showed the lab results for the wound swab were resulted on 04/26/2024 at 7:49 PM, and a report was generated on 04/27/2024 at 3:18 AM. Review of a nursing PN dated 05/08/2024 at 9:25 AM, showed Resident 60's right heel wound swab results were received and reviewed by the facility provider and antibiotics were prescribed, 11 days after the results were reported. Review of a progress note on 05/16/2024 at 5:18 AM, showed the OWC was unable to locate the wound swab results, inflammation labs, and imaging updates per their last progress note dated 05/02/2024. The OWC documented Please provide update on the following previous recommendations ., referencing the inflammation labs and imaging. During an interview on 05/20/2024 at 1:42 PM, Staff J, Resident Care Manger (RCM), stated they managed Resident 60's care. Staff J stated the results of the wound swab should have been in the record but could not find them. Staff J stated they were not aware of the 05/02/2024 recommendations from the OWC. They stated there was a nurse that had followed the wounds with the OWC during wound rounds, but since they left, they were not sure who followed those residents/wounds. During an interview on 05/20/2024 at 3:12 PM, the facility's Medical Director stated the facility should have followed up on the 05/02/2024 orders by the OWC. They stated they (the orders) were absolutely indicated for this resident. During an interview on 05/21/2024 at 4:29 PM, Staff B, Director of Nursing, stated they were unsure why the antibiotics were not ordered timely. Staff B stated they expected the nursing staff to contact the provider the same day the results were received to get a medication started. Staff B stated when the OWC made recommendations, the facility did not recognize them as orders. Staff B stated the nursing staff should have been reviewing the OWC's recommendations and forwarding them to the facility provider to create the orders. Staff B stated that process was not being followed. During an interview on 05/22/2024 at 11:15 AM, Staff C, [NAME] President of Clinical Operations, stated the OWC recommendations for additional labs and imaging should have been given to the facility provider for follow up. Reference: WAC 388-97-1060(3)(b) This is a repeat citation from Statement of Deficiencies dated 08/28/2023, 11/29/2023, and 03/12/2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure goods and services were provided to avoid a decline in condition for 1 of 1 resident (Resident 1), reviewed for neglect. The facility did not follow through with a physician referral in a timely manner for a diagnostic test magnetic resonance imaging (MRI, an imaging examination to determine an extent of an injury) and a referral to a neurologist (a physician that specializes in the function and treatment of the neurological system). Resident 1 experienced harm when they had a decline in some of their fine motor skills, had increased pain, and anxiety. These failures placed other residents at risk for unmet care services. Findings included . <Resident 1> Review of Resident 1's medical record showed the resident was admitted to the facility on [DATE] with diagnoses to include type 2 diabetes (a long-term condition in which the body has a hard time controlling blood sugar and using it for energy), osteoarthritis (a type of arthritis that occurs when the tissue on the ends of the bone wears down), and muscle weakness. Record review of Resident 1's most recent comprehensive assessment, dated 12/31/2023, showed the resident was cognitively intact. Review of Resident 1's care plan, dated 02/15/2024, showed the resident was independent with eating. Record review of a cervical spine (neck region) x-ray, completed on 07/14/2023, showed Resident 1 had changes in their cervical spine with moderate to severe degenerative disc disease (a condition of the discs/joints in the spine wearing out). Review of Resident 1's provider progress notes, dated 07/18/2023, showed the physician ordered an MRI of their neck and cervical spine related to the changes shown on the x-ray dated 07/14/2023. The provider documented changes in Resident 1's hands and arms, weakness, and increased pain. The provider notes also showed a referral was made to have a follow up appointment scheduled with a neurologist. Further record review of medical provider progress notes showed the following: • 07/20/2023 .Seen for neck pain and dizziness .MRI previously ordered . • 09/25/2023 .A recent cervical spine x-ray showed stenosis (a narrowing of the spinal cord with compression) .an MRI has been ordered but has not been done .The patient is having difficulty holding on to the implements (spoons and forks) to feed themselves .At this point it is important that we finish the work-up . • 10/03/2023 .The patient complains of cervical neck pain and muscle spasms that radiate into shoulders and arms .An MRI has been ordered which has not been done . • 10/19/2023 .The operating diagnosis is that the patient has a cervical spine compression fracture which should show up on an MRI .An MRI of the cervical spine has been ordered again with no results in chart .The patient states they have still not had an MRI and has not been seen by a neurologist. Patient states current anxiety is related to not knowing why they are getting weaker . • 01/08/2024 .MRI of cervical spine and neurology referral ordered need to be executed as they were ordered and never done. • 02/09/2024 .Patient reports pain everywhere .The MRI was not performed .the patient has not seen a neurologist . During an interview on 02/14/2024 at 11:10 AM, Resident 1 stated they had been having anxiety as the physician had ordered an MRI of their neck related to numbness, pain, and loss of function in their hands. I've been waiting months, and it still has not happened, I feel like I am getting worse each day. I dropped my fork this morning because I could not hold onto it. During an interview on 02/14/2024 at 11:45 AM, Staff C, Registered Nurse (RN)/Resident Care Manager (RCM), stated they were recently moved to the South hall where Resident 1 resided to assist with follow up as there was currently no RCM for the unit. During the same interview, Staff C stated they were aware of Resident 1's referral for an MRI and a neurologist consult which had been ordered months ago. Staff C further stated they had obtained a new order as the other order was no longer current and would set up the MRI and consult with a neurologist. Staff C stated they were informed that the MRI was not set up because the resident's insurance had denied it; however, the resident's current insurance did not require a pre-authorization and the MRI had not been denied. During an interview on 02/15/2024 at 11:50 AM, Advanced Registered Nurse Practitioner (ARNP) Consultant, stated they had been asked by Resident 1's Primary Care Provider (PCP) to assess Resident 1's neurological status. They stated they completed a neurological examination earlier in the day of Resident 1 and noted that the resident did have abnormal reflexes and weakness of their cervical area. The ARNP Consultant stated that an MRI and a follow up with a neurologist was definitely needed so that a plan could be developed for the resident's declining condition. In an interview on 02/15/2024 at 12:22 PM, Resident 1's PCP stated they had spoken to the facility nursing management numerous times about scheduling Resident 1 for an MRI and a neurology consult. The PCP stated they had concerns about the resident having permanent damage related to the lack of timely follow up by the facility. During a follow-up interview and concurrent observation on 02/15/2024 at 1:45 PM, Resident 1 stated they had been assessed by the ARNP Consultant earlier in the day and had been informed, It's been too long, and I might have damage to my neck which is probably not reversible. The resident demonstrated that they could not make a fist with their hands. I no longer enjoy playing cards, I can't pick up a penny or write my name. My hands just don't work anymore. During an interview on 02/15/2024 at 2:15 PM, Staff B, Director of Nursing Services, stated they were aware that Resident 1 had a referral for an MRI and neurology consult but they had been struggling with the resident's insurance company denying the test. We have been attempting to get the resident in, but it all has to do with their insurance company. Record review of facility's documented communication efforts provided by Staff B showed a lack of coordination regarding attempts to obtain Resident 1's MRI or neurology consult. Additionally, the documents showed the resident had a new insurance provider as of 11/01/2023. Record review of a progress note, dated 02/15/2024 at 6:40 PM, showed Staff C, RCM, had obtained new orders and had contacted outside centers to schedule Resident 1's MRI and neurology consult. The test imaging center for the MRI indicated they had been contacted once in January by the facility but could not schedule the MRI related to missing information. The imaging test center stated they would call the next day to schedule the MRI as a pre-authorization was not needed from the resident's current insurance company (which had been in effect since 11/2023). A neurology center was contacted and stated they would accommodate the resident in one to two weeks for a consult. Review of a follow up fax received by Staff B, which showed Resident 1 was scheduled for an MRI on 02/22/2024 and had a neurology consult on 02/29/2024. The follow up to the physician's original orders dated 07/18/2023 had taken over seven months to obtain. Reference: WAC 388-97-0640 (2)(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident was adequately assessed/monitored after an unwitnessed fall which resulted in a lack of timely diagnosis/treatment for a major injury and the resident experiencing unnecessary pain for four days, before they were hospitalized for their right hip pain, for 1 of 3 residents (Resident 2), reviewed for falls. Resident 2 was harmed when they experienced unrelieved pain and distress after the fall on 02/08/2024, required hospitalization on 02/12/2024, and was diagnosed with a right femur (thigh bone) fracture. These failures placed all residents at an increased risk for delay in care, poor health outcomes, and a worsening of their medical condition. Findings included . Review of the facility policy titled, Fall Assessment and Management, dated 09/21/2022, showed that after a resident fall, the assigned nurse would complete an incident assessment/evaluation and place it in the resident medical records. Additionally, the assessment would include the initial bedside intervention implemented at the time of the fall. < Resident 2> Review of the Resident 2's medical records showed they were admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems), dysphagia (difficulty swallowing food or liquids) following a stroke, depression, and dementia (an impairment of brain function, which causes memory loss, forgetfulness, and impaired thinking abilities). The comprehensive assessment, dated 12/31/2023 showed the resident had a severely impaired cognition, required supervision with rolling left/right in bed, and sitting/lying when in bed. The comprehensive assessment also showed Resident 2 had no presence of pain. Review of Resident 2's care plan, last updated 01/05/2024, showed the resident had an impaired cognitive thought process related to their dementia and .needs assistance with all decision making. The care plan documented the resident's risk for pain and showed, a goal for the resident to not have an interruption in normal activities due to pain ., with the following interventions; monitoring changes in the resident's usual routine, sleep patterns, decrease in functional abilities, decrease in range of motion, withdrawal or resistance to care .report to nurse any change in usual activity attendance patterns or refusal to attend activities related to signs/symptoms or complaints of pain or discomfort .monitor/record pain characteristics every shift and PRN [as needed]: Quality (e.g. sharp, burning; Severity (0 to 10 scale) [a verbal way for residents to communicate pain intensity]; Anatomical [specific orientation/part of the human body] location; Onset; Duration (e.g. continuous, intermittent); Aggravating [things that might make the pain worse] factors; Relieving factors . Resident 2 was assessed to require one staff assistance for bed mobility, one staff extensive assistance for upper/lower body dressing, one staff assistance for toilet use, and documented that the resident took a bath/shower two times a week on Mondays and Thursdays. Review of the facility's incident log for February 2024 showed that on Thursday 02/08/2024 at 10:32 PM, Resident 2 had a fall in their room which was logged and reported to the state on Monday 02/12/2024 (four days later). Review of the fall investigation, dated 02/12/2024, completed by Staff B, Director of Nursing Services (DNS), showed that on 02/12/2024 Resident 2 was in bed and has pain in Rt (right) hip with a possible recent fall. Resident foot is rotated out. The resident was noted to be alert but confused with severe cognitive impairment and was sent to the hospital after it was assessed that they had right hip pain and external rotation of their right leg (an assessment of the position of the affected leg, that is observed to be rotated outwards away from the body and can be an indication of a hip fracture). Staff B documented that .a report was made to (state agency) for injury of unknown source as no record of a fall was found in risk management (a comprehensive assessment completed after a fall) or documentation by nurses .on speaking with nurses on unit for Thursday (02/08/2024) it was found that resident had a fall in (Resident 2's) room during hand off of keys from evening shift to night shift with both nursing (Registered Nurses) stating the other (nurse) was to complete the incident report. Additionally, the investigation showed .fall occurred on 02/08/2024 with no reports of pain per staff even with turning and positioning throughout the time from the fall to the report the AM of 02/12/2024 .injury reasonably related to fall . Review of Resident 2's hospital emergency department note, dated 02/12/2024, showed the resident was brought into the hospital after a fall but that it was unclear when the fall happened .no report in the chart a fall but apparently oncoming crew (nursing home staff) was told that (Resident 2) did fall .no clear report regarding the fall. The physical assessment showed a shortened externally rotated right leg (when one leg on the body is observed to be shorter than the other and rotated outwards away from the body which can be an indication of a hip fracture) with pain at the right hip. Additionally, an x-ray of Resident 2's right hip showed a femur fracture. During an interview on 02/15/2024 at 12:27 PM, Staff D, Nursing Assistant (NA), stated they worked the day shift on 02/09/2024 (the day following Resident 2's fall), and was informed by Staff F, NA that Resident 2 was not getting up out of bed because they had a fall. Staff D stated they were helping Staff F, NA, with providing care to Resident 2 and normally the resident was moving around in their wheelchair, talking a lot, and required one staff for mobility in bed, but on the morning of 02/09/2024 the resident was not talking or moving around. Staff D stated, You could tell (Resident 2) was in a lot of pain, when they were assisting with turning/changing the resident while they were in bed, and that it was conveyed to the nurse on shift. Additionally, Staff D stated they also worked the day shift on 02/12/2024 and Resident 2 was the same as on Friday 02/09/2024, in pain, lying in bed and not talking like (Resident 2's) normal self. During an interview on 02/15/2024 at 12:47 PM, Staff E, Registered Nurse (RN), stated they had received report from the night shift nurse on the morning of 02/12/2024 that Resident 2 was acting out of (their) normal and that they must have broken their right hip because the resident was in pain and their right leg was shortened/externally rotated. Staff E stated that there was no report of the resident having a fall or a post fall assessment in the resident records. Staff E stated that Resident 2 was in a lot of pain when they attempted to lift the resident's right heel off the bed, while the resident yelled No, no, no, no. During an interview on 02/15/2024 at 12:55 PM, Staff F, NA, worked the day shift with Staff D on 02/09/2024, stated they were notified in a verbal report that Resident 2 fell and was in pain. Staff F stated that when they went into the resident's room to help with cares, the resident did not want to move at all and refused to get up, go to the bathroom, take a shower or to be changed in bed. Staff F stated that normally they were able to talk with the resident and get them out of bed and go to the bathroom. Staff F stated that at the end of their shift they needed to change the resident's brief and it was the first time that they had to change the resident's brief in bed. During the changing of the resident's brief, the resident was groaning, somewhat loud but did not ask the resident if they were in pain or communicate that with the nurse, because they assumed the fall was already being charted on by the nurse in the resident's medical record. During an interview on 02/15/2024 at 2:47 PM, Resident 2's Representative (RR) stated the facility informed them on 02/12/2024 that at some point (Resident 2) fell and was in a lot of pain. The RR stated the facility staff did not know when the resident fell, but that the resident was in pain and that they might have broken their hip in a fall. RR stated that Resident 2 was hospitalized and was found to have a right femur fracture. During an interview on 02/15/2024 at 2:56 PM, Staff I, RN, worked day shift on 02/08/2024 and 02/09/2024, stated they were completing handoff (a report from the off-going nursing to the on-coming nurse) with Staff G, RN, when Resident 2 had an unwitnessed fall in their room and was found on the floor, on their right side. Staff I stated the process after a resident had an unwitnessed fall was to complete a risk management report, full head to toe assessment of the resident, monitor neurological checks (a series of tests that assesses mental status, reflexes, movement and more, done to identify signs of disorders affecting your brain, spinal cord, and nervous system)/vital signs, notify the primary care provider (PCP)/DNS/RR and place the resident on alert charting (special documentation procedures/precautions that are initiated for a specific time period) for seven days. Staff I stated they did not complete a post fall assessment/risk management report for Resident 2, nor did they notify the PCP /DNS/RR, complete neurological checks, or initiate alert charting on the resident. Staff I stated they were not aware of Resident 2 having any pain on 02/09/2024, but that the resident did stay in bed all day, which was not the resident's normal daily routine. During an interview on 02/15/2024 at 3:16 PM, Staff B, DNS, stated that Resident 2's post fall assessment/risk management report was not documented, it was missed. Staff B stated that both Staff I and Staff G thought the other staff member would have completed the assessment, notify the PCP/DNS/RR, and have placed the resident on alerting/monitoring; so it was not done. Staff B stated they thought that Resident 2's femur fracture was related to their fall on 02/08/2024 or that Resident 2's fracture developed with turning and repositioning the resident in their bed, because not all nursing staff were aware of the resident's recent fall. Additionally, Staff B stated that the resident did not get up out of bed throughout the weekend (02/10/2024 and 02/11/2024) and was not assessed to be in any pain or discomfort until 02/12/2024. During an interview on 02/15/2024 at 6:24 PM, Staff J, NA, worked day shift on 02/11/2024, stated that Resident 2 was out of it and was not their normal self. Staff J stated that the resident would usually get up and out of bed on their own, and if the resident needed to have their brief changed in bed the resident would help and that Staff J was able to change their brief without another staff members help. Staff J stated that on 02/11/2024 they had to ask Staff K, Licensed Practical Nurse (LPN), to help turn and change the resident in bed because I couldn't even roll (Resident 2) by myself because he was in so much pain, and the resident kept saying ouch, ouch. Staff J stated they informed Staff K of Resident 2's pain with turning and changing them. Additionally, Staff J stated the resident was more confused than normal, refused to get up out of bed that day, and did not know that Resident 2 had a fall on 02/08/2024. During an interview on 02/15/2024 at 7:42 PM, Staff K, LPN, stated they did help Staff J with turning Resident 2 on 02/11/2024 but did not remember that the resident was in any pain. Staff K stated they were not aware that Resident 2 had a fall on 02/08/2024. Staff K stated the resident was not on alert charting, neurological checks, or other monitoring, which was what they would see for a resident with a recent fall. Staff K stated that Resident 2's fall was not passed on to them during handoff report nor did the staff see anything in the resident's medical records that indicated they had a fall. During an interview on 02/15/2024 at 8:48 PM, Staff H, NA, stated they worked on 02/08/2024 and assisted Staff L, NA, with turning and changing the resident during the night, because they were refusing to move after they fell. Staff H stated that Resident 2 reported pain in their right hip/leg area when changing the resident with Staff L, which was reported to Staff G, RN. Staff H stated that towards the end of their shift, when they were changing Resident 2's brief, the resident informed the staff member that it hurt when they moved. Staff H stated that Resident 2 usually transferred/moved around themselves and did not require two staff to help change the resident's briefs in bed, out of the ordinary for the resident and something was wrong. Review of Resident 2's February 2024 medication administration record showed the resident was ordered acetaminophen (a type of medication that can be used for mild pain) two tablets by mouth every four hours as needed for mild pain/discomfort. On 02/09/2024 Resident 2 was administered pain medication at 3:14 AM with documentation of a two out of ten on the resident pain scale, no documentation of pain characteristics (quality, location, onset, duration, aggravating or relieving factors) were noted. Review of a progress note, dated 02/09/2024 at 7:09 AM, showed Resident 2 was administered a gout (a type of arthritis that can cause inflammation, pain and swelling at joints on the body) medication, as needed for reported pain in right knee area. During an interview on 02/15/2024 at 11:36 PM, Staff G, stated they arrived early for their night shift on 02/08/2024 and assisted Staff I with responding to Resident 2's unwitnessed fall before their shift had started. Staff G stated, I did my own assessment of the resident (after Resident 2 fell) .I didn't document the fall assessment because I was not on duty yet and (Staff I) was the nurse that was on duty and suppose to document it. Staff G stated they did not remember Staff H or Staff L informing them that the resident was in pain when changing Resident 2. When Staff G was reminded of pain medication that was administered to the resident the morning of 02/09/2024, Staff G stated the pain medication was administered because the resident reported a headache and they forgot to document it. Staff G stated they did not notify the PCP or the RR of the resident's unwitnessed fall, nor did they monitor neurological checks or initiate alert charting on Resident 2. Additionally, Staff G stated that they observed the resident two times on each shift (02/08/2024 and 02/09/2024) and no others (licensed nurses that had taken care of Resident 2) reported anything to me about the resident having further pain or complications, so they were not concerned with further assessment of the resident. During an interview on 02/16/2024 at 8:09 AM, Staff M, NA, worked the night shift on 02/09/2024, 02/10/2024 and 02/11/2024 with Resident 2, stated that the resident remained in bed during those shifts. Staff M stated that Resident 2 was in so much pain they could not move in bed on their own and that Staff M had to perform all of the resident's cares, it was so painful that (Resident 2) would not move. Staff M stated that normally the resident would be up out of bed or have gotten into their wheelchair or would get up to go to the bathroom. Staff M stated they informed Staff K, who was the nurse on 02/09/2024, that it was out of the ordinary for the resident, to be lying in bed all day, not getting up or talking, and that Resident 2 was in pain when turning them in bed for cares. When performing care Staff M stated Resident 2 would cringe (to draw in or contract one's muscles involuntarily, as from cold or pain) every time when turned. Additionally, Staff M stated that Resident 2 was usually confused at times and not always able to state that they were in pain. During an interview on 02/16/2024 at 9:07 AM, when asked if they were aware of Resident 2's fall, the PCP stated, you mean the resident that had been there all weekend with a hip fracture lying in bed, yes. PCP stated they were made aware by nursing staff of Resident 2's condition on 02/12/2024, but that the original fall/incident had not been communicated on 02/08/2024. PCP stated they were informed by a nursing staff member that was paying attention, to Resident 2 on the morning of 02/12/2024 and assessed the external rotation of the resident's leg. PCP stated the nurse that reported Resident 2's condition did not know what had happened, or that the resident had a fall, whatever happened over the weekend, there was no documentation. Additionally, PCP stated they would have wanted to know the post fall assessment after Resident 2 had fallen so that a determination could have been made on whether the resident needed to go to the hospital right away. Reference: WAC 388-97-1060(1)(3)(g)