**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 18> Review of the resident's medical records showed they admitted to the facility on [DATE] with diagnoses to include a stroke (when the supply of blood to the brain is reduced or blocked completely, which prevents brain tissue from getting oxygen and nutrients) with right sided weakness and diabetes (a condition that affects your blood sugar levels and can cause serious complications, including delayed wound healing). The 05/30/2024 comprehensive assessment showed the resident's cognition was severely impaired and was dependent on the assistance of two or more staff for activities of daily living. The assessment further showed the resident was incontinent of their bowel and bladder, was at risk for developing PIs, and had an unhealed stage four PI. The 08/21/2023 comprehensive admission assessment showed the resident's skin was intact and was at risk for developing PIs. During a concurrent observation and interview on 06/04/2024 at 8:41 AM, Resident 18 was observed lying in bed, with the head of their bed elevated and had an alternating air mattress (APM, a therapeutic bed designed to prevent pressure sores and injuries by inflating and deflating air cells within the mattress in a rhythmic pattern). The resident had a blank stare, did not respond when spoken to, but followed movement with their eyes. Staff K, Nursing Assistant (NA), entered to assist the resident with their breakfast and stated the resident had declined in their health and had not been speaking for about a month. Review of Resident 18's medical record from 11/2023 through 06/12/2024 showed the resident's ongoing PIs as follows: • 11/11/2023, skin breakdown to the crease of the buttocks that was three centimeters (cm, a type of measurement) by 0.2 cm. Cleanse the wound and cover with an appropriate dressing and change per manufacturer's recommendations and PRN (as needed). (nursing progress notes showed this was a partial thickness opened wound, Stage 2 per NPIAP guidelines). • 02/07/2024, partial thickness, opened area to the right buttock, two cm by one cm. Cleanse, apply barrier cream, and place non-adhering dressing if resident is willing. Resident is allergic to adhesives. One time a day ensure written documentation had been completed. • 02/15/2024, full thickness, unstageable opened area to the right buttock, four and a half cm by four cm. Cleanse, skin prep to edges, cover with dressing, assess daily, and change per manufacturer's recommendations. • 02/15/2024, open area to the coccyx (tailbone), five cm by 0.2 cm. Cleanse, apply calmoseptine (a brand of skin barrier cream), apply non-adhering dressing, assess daily. One time a day ensure written documentation had been completed. • 03/05/2024, initiated an APM, to be monitored every shift (115 days after skin integrity began to deteriorate). Review of the 03/22/2024 through 06/06/2024 wound care provider notes and recommendations showed: • 03/22/2024, initial wound assessment, right buttock, 3.3 cm by 7.2 cm by two cm depth, 6.8 cm undermining, and the wound had visible muscle, tendon/ligament, and tissues exposed. The wound had 90 percent debridement (the process of removing dead skin and foreign material from a wound to reduce the risk of infection and promote healing), had heavy drainage, was macerated (when skin is in contact with moisture for too long and looks lighter, wrinkly, and wet) and had a strong odor. Treatment orders were to place a non-bordered adhesive foam over the wound and change the dressing daily and PRN for accidental removal, saturation, and/or soiling (order was inaccurately transcribed into the electronic health record and did not include to cover the wound with a foam dressing and change daily and PRN). • Recommendations: • 03/22/2024, consider a temporary foley catheter (a tube placed into the bladder and carries the urine outside of the body into a bag connected to the tube) for moisture management due to incontinence (was not ordered or followed up on). • 03/22/2024, obtain labs, comprehensive metabolic panel ([CMP] measures 14 different substances in your blood), complete blood count ([CBC] provides information about the cells in your blood), high-sensitivity C-reactive protein (CRP-H, measures inflammation in the body. Normal range is zero to five milligrams per Liter [mg/L, a unit of measure]), showed an elevated level at 38.3 mg/L, and the erythrocyte sedimentation rate (ESR, helps detect inflammation and infection. Normal range is zero to 20 millimeters per hour, [mm/hr, a unit of measure]) was elevated at 56 mm/hr. (Labs were obtained on 03/28/2024, six days after ordered and there was no documentation of the facility provider notification or wound care provider regarding abnormal lab results. • 03/22/2024, obtain an electromagnetic radiation ([X-ray] of the sacrum (a large triangular bone at the base of the spine), a quick, painless test that captures images of the structures inside the body, especially the bones) imaging to rule out osteomyelitis (an infection in the bone) (imaging obtained on 03/22/2024 but not addressed with the wound care provider until 04/18/2024). • 04/12/2024, referral for infectious disease specialist (this was not ordered or followed up on). • 04/18/2024, vascular study referral to be completed at the hospital due to discoloration to both lower extremities and treatment guidance. (Notes showed this referral was not followed up on until 05/30/2024, 42 days later). • 04/18/2024, obtain a re-culture of the wound or polymerase chain reaction quantitative analysis (a test that can detect the presence of specific bacteria) of right buttock tunneling (culture not obtained until 04/22/2024 (four days after ordered, positive for infection on 04/25/2024 and started antibiotic treatment on 04/26/2024 (eight days after ordered). • o04/18/2024, wound vac (negative wound pressure therapy, a technique using a suction pump, tubing, and a dressing to remove excess exudate and promote healing in acute or chronic wounds) recommended (was not ordered or followed up on). • 04/18/2024, magnetic resonance imaging ([MRI, a painless test that produces very clear images of the organs and structures inside your body) to assess bone level involvement in the wound (was not ordered or followed up on). • 04/25/2024, once antibiotic treatment is in place for 72 hours, initiate the wound vac (was not ordered or followed up on). • 05/02/2024, please provide update on lab order recommendations and repeat imaging to the sacrum. Please start wound vac if available. • 05/23/2024, wound care provider inquiring about the initiation of the wound vac for the right buttock wound, since it had not been started and Unable to locate updated labs/imaging, or updates on vascular study to the legs. Despite the wound care provider's recommendations above, there was no follow-up on the foley catheter, wound vac, or the infectious disease referral from 03/22/2024 through 06/06/2024. Review of Resident 18's lab results, obtained on 05/06/2024, showed an abnormal CRP-H level at 34.1 mg/L and no ESR had been obtained per the wound consultant's recommendations. Review of Resident 18's 02/06/2024 Braden skin assessment (a tool used to assess a person's risk for PIs using a scoring system) showed the resident had a score of 11 which placed them at high risk (score of 10-12 was high risk) for pressure injuries. A concurrent observation and interview on 06/07/2024 at 10:48 AM, during Resident 18's right buttock wound dressing change, showed a dressing, saturated with brownish exudate being removed. The wound was unmeasured (nursing staff stated they measured once a week) and observation showed an opened wound, with depth, undermining, tunneling, and visible bone in the wound bed. The wound was cleansed, barrier cream applied to the edges of the wound, packed with three sheets of calcium alginate (a biodegradable dressing made from seaweed that absorbs exudate and forms a gel), and covered with a foam dressing. Staff K stated they recalled going on vacation in October 2023 and when they returned the wound to the right buttock was present. Staff K stated the wound was dime size when they first observed it and the wound had never resolved, it only got bigger. During an interview on 06/11/2024 at 10:31 AM, Staff G, LPN/TN, stated when Resident 18's initial PI started they should have had an APM put into place to prevent further skin breakdown and a weekly head to toe skin assessment. Staff G recalled the foley catheter had been discussed, but did not know why one was not initiated, it would have helped with the moisture. Staff G stated they understood Resident 18 was treated with antibiotics for the infection to their right buttock PI in order to prepare them for use of the wound vac but did not know if the facility provider agreed. Staff G could not recall having a provider observe/assess the right buttock PI when they worked prior to the wound care provider's first visit. Staff G stated they had protocols for wounds, and they would enter orders that were not specific like change per manufacturer's recommendations, so they could have the freedom to change it as needed. Staff G stated they did not contact the facility provider prior to changing the type of dressing used or the duration of the days it needed to be changed prior to the wound care provider's recommendations on 03/22/2024. Staff G was unaware the order for daily dressing changes given by the wound care provider were entered incorrectly and Staff G did not complete daily documentation with Resident 18's PI dressing changes as ordered. During an interview on 06/11/2024 at 11:34 AM, Staff B, DNS, stated the charge nurse was responsible for reviewing the wound care provider notes and communicating with the facility providers on cultures, labs or imaging that was recommended, and all communication with the providers should have been documented. At times the facility provider did not agree with what the wound care provider ordered so they would have to wait for them to answer which trying to get clarification from the providers (Medical Director and other attending physicians/providers) had caused some delays in the management of Resident 18's PI. Staff B further stated they would have expected an APM be placed when Resident 18 started with skin issues in November 2023 and that was not done. During an interview on 06/11/2024 at 1:16 PM, Resident 18's Representative (RR), stated they were not asked or informed about a wound vac being used to heal the resident's pressure injury. The RR stated that if the wound vac could heal the wound and Resident 18 could be kept comfortable at the same time, that is what they would want. During an interview on 06/11/2024 at 2:08 PM, Staff D, Attending Physician, stated they had observed the right buttock wound once but did not document on it and did not give orders at that time for wound management. Staff D stated they would expect the wound care provider's recommendations be communicated with the facility provider or a call made to the on-call attending physician so that treatment could be started as soon as possible. Staff D stated they were not aware of the recommendation for the wound vac. During an interview on 06/12/2024 at 10:10 AM, Staff H, LPN/TN, stated when the order was not specific to a certain dressing and showed per manufacturer's recommendations they did not get clarification from any provider and would use the same type of dressing they removed from the previous dressing change. Staff H stated they would assess skin weekly for residents with a high Braden score and did not know why Resident 18 did not have an APM applied until 03/05/2024. Staff H stated they were not aware the wound care provider's order was incorrect but understood that if there was not as much drainage as before they were okay to not change the PI dressing daily. Staff H further stated they understood the wound vac was ordered but never came and did not know why (the wound vac was never ordered). Staff H stated Resident 18 did not have an allergy to adhesive dressings they just did not like them and thought they were uncomfortable. During an interview on 06/12/2024 at 12:34 PM, Staff I, Charge Nurse, stated they were responsible for reviewing the wound care provider's notes and processed dressing changes, cultures, imaging, and labs when they received them and was not aware of, nor had they communicated with the facility provider regarding Resident 18's recommendations for NWPT, MRI, or the foley catheter. Staff I stated they were not aware the order for the right buttock PI was incorrect and did not update the order after each visit if it remained the same. During an interview on 06/12/2024 at 12:44 PM, Staff C, Resident Care Manager, stated their normal process would be to initiate an APM when the resident was a higher risk for skin issues or started to develop skin issues and could not recall why this was not done for Resident 18. Staff C stated they were unaware the wound care provider requested a foley catheter be used to manage Resident 18's moisture and did not know why the order had not been completed. During an interview on 06/12/2024 at 2:35 PM, Wound Care Provider, stated the DNS communicated that there were stipulations in place and would need permission from the facility providers for labs, cultures, antibiotics, and imaging. The wound care provider stated they would ask the nursing staff about their recommendations and preventative measures and was told by the staff they were being held up by the facility providers. The wound care provider stated they would have expected the staff to follow their dressing recommendations as they were written and to have communicated any recommended changes. The wound care provider further stated they felt the preventative measures could have been used during palliative care (aimed at optimizing quality of life and mitigating suffering among people with serious, complex, and often terminal illnesses) and would continue to make wound care recommendations and it would be up to the facility to implement them. Reference: WAC 388-97-1060(3)(b) Based on observation, interview, and record review, the facility failed to ensure residents received timely treatment and care in accordance with professional standards of practice to prevent facility acquired pressure injury (PI) and worsening of PIs for 2 of 3 residents (Residents 49, and 18) reviewed for PIs. Resident 49 experienced harm when they developed a stage 4 medical device-related PI (MDRPI) to their right lower leg from an immobilization brace (a rigid medical device that holds a joint or bone in place to aid in restricting movement of the injured area to assist with healing) that became infected and resulted in extreme pain. Resident 18 experienced harm when they developed a right buttock PI that worsened, became infected, and required antibiotic treatment. These failures placed residents at risk for medical complications, and unmet care needs. Findings included . Review of the National Pressure Injury Advisory Panel's (NPIAP, the leading expert in PIs/wounds) guidelines and definitions, dated September 2016, defined pressure injury stages as follows: • Stage 1 PI has intact skin with a localized area of non-blanchable erythema (redness). • Stage 2 PI is a partial thickness skin loss with exposed dermis (the top inner layers of skin). • Stage 3 PI 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 PI 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 PI is a full thickness skin and tissue loss to which the extent of the tissue damage cannot be seen. Further review of the NPIAP, Best Practices for Prevention of Medical Device-Related Pressure Injuries in Long Term Care, dated January 2020, showed the medical device should be assessed for the correct size, and fit regarding the individual. Also, the skin under and around the device should be inspected daily and repositioned. <Resident 49> Review of the medical record showed the Resident 49 was admitted on [DATE] with diagnoses including a fracture of their right lower leg bone, that did not require surgery but had a compression bandage (a stretchable cloth that applies pressure when wrapped around a limb to help reduce/prevent swelling) wrapped around a hard immobilization brace and an open non pressure related left foot wound. The 05/13/2024 comprehensive assessment showed the resident was cognitively intact and was able to make their needs known. Additionally, the resident was at risk for pressure injuries, but did not have any PIs during the assessment timeframe. Review of Resident 49's hospital wound care and discharge notes, dated 05/08/2024 showed they had an abrasion (a type of wound) to the left foot and a right lower leg fracture that required immobilization (no other open wound/injuries were noted in the resident's hospital records). Resident 49 was to follow up with their orthopedic provider (a doctor that specializes in injuries to the bone, muscles, joints, and soft tissues) due to their fractured right leg and showed no documented directives on whether the right leg's hard immobilization brace could be removed or had to stay in place. Review of Resident 49's physician's orders showed: • On 05/09/2024 resident's right leg fracture was to be assessed once a day and to ensure that the hard immobilization brace was on at all times. • On 05/16/2024 wound care provider was consulted for resident's left foot injury. Review of Resident 49's facility provider note dated 05/10/2024 at 2:05 PM, showed the facility staff needed to clarify the removal of the resident's right leg immobilization brace with the orthopedic provider (two days after the resident was admitted ). Review of a nursing progress note on 05/13/2024 at 2:46 PM showed, Staff G, Licensed Practical Nurse/Treatment Nurse (LPN/TN), stated that a call had been placed to the orthopedic provider for clarification of orders to Resident 49's right leg brace (five days after the resident was admitted ). Review of the wound care provider notes dated 05/16/2024 (eight days after the resident was admitted ) showed, Ace-wrapped (a type of compression bandage) immobilization brace on right upper leg has been in place since admission and has not been assessed .strong foul odor emanating (the source or what is producing something) from (Resident 49's) wounds . The wound care providers initial assessment, after removing the compression bandages/hard immobilization brace showed the resident had an infected Stage 4 MDRPI to the right/front lower leg from the immobilizing brace. Additionally, .culture was then obtained for concerns of wound infection ., and urgent follow-up with the orthopedic provider was recommended. During an interview on 06/12/2024 at 7:57 AM, when asked about the hard immobilization brace on their right leg, Resident 49 stated their pain when they first admitted was very minimal and then increased as the brace was kept in place around their leg. Resident 49 stated that it had gotten to the point that they were a 10 out of 10 on the zero to 10 pain scale (a method to measure an individual pain intensity, zero equals no pain and 10 is severe pain) and the immobilization brace was .cutting off circulation (how blood moves throughout the human body) . Resident 49 stated they were informing the nursing staff of the increasing pain in their right leg everyday but was told they could not take off the immobilization brace, even though it was hurting. Resident 49 stated that nursing staff told them their right leg would come out of the brace when they saw the orthopedic provider in two weeks. During an interview on 06/12/2024 at 9:52 AM, Staff N, Registered Nurse (RN), stated they had completed the admission assessment on Resident 49. Staff N stated they performed a full skin assessment but did not take off the compression wrap/immobilization brace to assess Resident 49's right leg because the resident did not have orders, when they came from the hospital, clarifying if the immobilization brace could be removed or not. Staff N stated the resident informed them that the compression bandage had recently been changed that day in the hospital. Staff N stated they called the hospital but were told they needed to clarify the orders with the orthopedic provider. Staff N stated that since they were not able to assess Resident 49's right leg skin, the process would be for the treatment nurse to complete the assessment. During an interview on 06/12/2024 at 10:36 AM, Staff H, LPN/TN, stated they were one of the TN that had briefly worked with Resident 49 after they were first admitted to the facility. Staff H stated that Staff G, LPN/TN, worked with the resident the most but they did remember Resident 49 complaining about the right leg immobilization brace and that it was rubbing on the resident's right leg. During an interview on 06/12/2024 at 10:44 AM, Staff G, stated there was some confusion after Resident 49 had arrived in the facility on if the resident's right leg immobilization brace should have been removed or left in place and that they were requesting confirmation from the orthopedic provider. Staff G stated they had not assessed the resident's right leg skin, under the compression bandage, until 05/16/2024 when the wound care provider came in and took it off (eight days after the resident had admitted ). Staff G stated the resident did have a lot of pain in their right leg from the fracture but did not know of any wounds on the resident's right leg until the brace was taken off. Staff G stated that after the hard immobilization brace was removed the resident had immediate pain relief and it seemed like the positioning of the brace was malformed (not having the expected shape) and not fitting correctly, with obvious pressure from the device on the resident's right/front lower leg.getting (Resident 49) out of the brace was significant (regarding the resident pain). During an interview on 06/12/2024 at 12:35 PM, Staff B, Director of Nursing Services (DNS), stated the correct process was not followed for Resident 49 and that nursing staff should have assessed the resident's skin under the compression bandage/hard immobilization brace and confirmed orders for the right leg brace. Staff B stated they had made some attempts to contact the orthopedic provider but were unsuccessful and at that point they should have communicated with the facility provider and or the medical director to clarify what intervention/orders they would have wanted to implement. Staff B stated that Resident 49 should not had to wait eight days to have their orders clarified and skin check completed on the resident's right leg. Staff B stated that the brace could have been too tight and that it was most likely to have caused the resident's right/front lower leg MDRPI that was assessed by the wound care provider. During an interview on 06/12/2024 at 2:55 PM, Wound Care Provider, stated they had been consulted to evaluate Resident 49's left foot injury but was informed of a foul odor and drainage that was coming from the resident right leg hard immobilization brace. The wound care provider stated the hard immobilization brace needed to come off on their 05/16/2024 visit and when they assessed Resident 49's right leg skin, they noted the resident acquired a stage four MDRPI. The wound care provider stated it was clear where the hard immobilization brace was applying pressure and made an indentation over the same place that Resident 49 developed the PI.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure accident prevention by identifying and evaluating potential accident hazards for 1 of 1 resident (Resident 4), reviewed for falls. Resident 4 had a mechanical lift recliner with a handheld remote, placed in their room without an evaluation to determine if they were safe to use it. This failure caused actual harm to Resident 4, who used the handheld remote to raise the lift recliner to its highest upright position, fell, and sustained a fracture to the right knee and tibia (the shinbone) from the remote lift chair. Findings included . Resident 4. Review of Resident 4's medical record showed the resident was re-admitted to the facility on [DATE] with diagnoses including significant history of falls with fractures, lung issues, and high blood pressure. Review of the 02/14/2023 comprehensive assessment showed Resident 4 was at moderate risk for falls, had issues with balance and walking, and required extensive assistance of two staff for transfers, toileting, and positioning. Resident 4 was alert with impaired cognition, but able to make their needs known. During an interview on 05/05/2023 at 10:15 AM, Staff F, Licensed Practical Nurse (LPN), stated Resident 4 was in pain and was on their way to administer a narcotic pain reliever. Upon entry to Resident 4's room with Staff F, Resident 4 was observed lying in their bed and had a long, velcro immobilizer on their right leg from the right thigh to the right lower leg. Resident 4 was on oxygen per a nasal cannula (plastic tubing used to give person oxygen). When asked how the right leg injury happened, Resident 4 stated they used the lift recliner remote to stand so they could go to the bathroom, fell, and vomited. Resident 4 refused the narcotic pain medication from Staff F who readjusted the resident for comfort. Staff F then stated they heard about a lift recliner being placed in Resident 4's room, but had no other information on how the process worked for placement and/or safety for furniture/devices. Review of the 05/04/2023 investigation report showed Resident 4 had an unwitnessed fall out of a lift recliner. Resident 4 was found on the floor, seated on their buttock, with the lift recliner in the highest upright position. Resident 4 was in quarantine for COVID-19 (an infectious disease causing respiratory illness with symptoms including cough, fever, new or worsening malaise (general feeling of discomfort/uneasiness), headache, dizziness, nausea, vomiting, diarrhea, loss of taste and smell, and in severe cases difficulty breathing that could result in severe impairment or death) at the time of the incident and on airborne precautions; the door was closed to Resident 4's room. Staff were instructed to check on Resident 4 every hours. On 05/04/2023 at 3:15 PM the pressure alarm that was placed in the lift recliner sounded and alerted staff to the resident's room. Resident 4 was found on the floor and had vomited. There was a bulge to the lateral side of the right knee and shortening of the right leg. Resident 4 was sent by ambulance to the local emergency room and sustained a closed fracture to the right knee and upper tibia of the right leg. The 05/04/2023 investigation report showed Resident 4's mechanical lift recliner had not gone through proper safety inspection process. The recliner arrived at the facility on 04/14/2023 and was checked for cleanliness and bugs. On 04/21/2023 the facility completed their mechanical check to ensure the lift recliner was operational and placed it in Resident 4's room. During an interview on 05/05/2023 at 11:40 AM, Staff O, Maintenance Director, stated they checked Resident 4's lift recliner to ensure it worked when they plugged it in and the remote worked. Staff O further explained they did not have anyhthing to do with making determination of the resident's safe use of the lift recliner, only the electrical functioning of the lift recliner. During an interview on 05/05/2023 at 11:00 AM, Staff B, Director of Nursing Services, stated the staff did not follow proper process for the use of the of the mechanical lift recliner. During an interview on 05/05/2023 at 1:50 PM, Staff Q, Social Services, stated there was no communication about the lift recliner being in the facility and the recliner would have needed to be evaluated by the therapy department before placed in the resident's room for their safety. Staff Q then stated the case manager would be notified before the lift recliner was placed in the resident's room. During an interview on 05/05/2023 at 2:00 PM, Staff C, RN Case Manager, stated they had noted the recliner was new to the room but did not question it. Staff C stated they were surprised Resident 4 used the remote of the lift recliner to an upright position because Resident 4 had never used the remote on their bed to reposition their bed. Reference WAC 388-97-1060 (3)(g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide adequate supervision for each resident to prevent avoidable accidents for 2 of 5 residents (1, 2) reviewed for falls with injuries. Failure to implement adequate supervision, consistent with residents' assessments and care plans placed residents at risk for falls, injury and a diminished quality of life. The failure caused harm for Resident 1 when they were left standing, unsupervised, at the grooming sink and fell hitting their head on the sink causing a scalp laceration requiring staples to close the wound at the hospital. Findings included . Record review of the facility's policy titled, Falls and Fall Risk, dated March 2018, showed that based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Medical factors that contribute to the risk of falls included heart failure, arthritis and balance/gait disorders. A possible resident centered approach included position-change alarms used to assist the staff identify patterns and routines of the resident to assist in fall prevention. Resident 1. Medical record review showed the resident was admitted to the facility on [DATE] with diagnoses to include respiratory failure, arthritis (the swelling and tenderness of one or more joints) and frequent falls. Review of the 11/03/2022 comprehensive assessment showed Resident 1 was cognitively intact and had heart failure. The resident required the extensive assistance from two staff for transfers and ambulation with a walker. Review of the fall care area assessment showed that the resident's balance was not steady and only able to stabilize with staff assistance when moving from a seated to standing position. Review of Resident 1's fall care plan dated 06/18/2020 showed the following fall precautions were: - Anticipate and meet the resident's needs, - Be sure resident's call light was within reach and encourage the resident to use it for assistance, - Follow facility fall protocol, - Resident was not to be left unattended at any time (updated on 12/28/2022), - Resident seems to understand their limitations and had not attempted to self-transfer since admit. Review of a 12/11/2022 at 8:16 AM nursing progress note showed that Resident 1 fell while standing at the grooming sink that caused a substantial injury. They had bruising to their left hand extending up the left forearm approximately 15 centimeters (cm). There was bruising to the left upper arm approximately 20 cm in diameter. Blood was flowing from a laceration on the left temple that required compression. The resident was sent to the hospital for evaluation and treatment. Review of a 12/11/2022 at 11:24 AM nursing progress note showed the resident sustained a 2 cm laceration to the left temple requiring 2 sutures to close the wound. During a telephone interview on 01/27/2023 at 4:10 PM, Resident 1's Representative (RR 1) stated they were upset about the fall on 12/11/2022 and that It should not have happened, they all should know that [Resident 1] cannot be left standing alone. RR 1 stated the fall caused Resident 1 a head injury requiring an emergency room visit, stitches on the head, bilateral black eyes, extensive bruising on their left arm, edema, and pain in their hand. On 01/30/2023 at 10:34 AM, Resident 1 was observed in their wheelchair in their bedroom. They were dressed and well groomed. The bruising from the fall had faded to faint yellow. The resident stated they were not in pain, that they had a bad fall and went to the hospital; but they could not recall how it happened. During an interview on 01/30/2023 at 12:30 PM, Staff C, Nursing Assistant (NA) stated Resident 1's morning routine included standing at the grooming sink with their walker in front of them and the wheelchair locked behind them. Resident 1 liked to stand at the sink to brush their teeth and wash their face. One staff would stand next to them and hold the resident's gait belt (a safety device wore around a resident's waist, used by staff to provide stability during transfers or ambulation). Staff C stated they would not leave Resident 1's side because they were not steady on their feet. During a telephone interview on 01/30/2023 at 1:00 PM, Staff D, NA, stated that they were assisting with Resident 1's grooming the morning they fell. The NA stated while standing at the sink with Resident 1, their roommate needed to use toilet and tried to get up. The NA stated they left Resident 1 standing at the sink to assist the roommate to the toilet. When in the toilet with the roommate, they heard a crash and Resident 1 was on the floor bleeding. Staff D stated that they knew Resident 1 needed assistance with the gait belt to sit down safely. Staff D stated they should not have left Resident 1's side that morning. During an interview on 02/07/2023 at 12:45 PM, Staff E, NA, stated they would assist Resident 1 with morning care at the grooming sink. Staff E stated the resident would stand with the walker at the sink and the wheelchair would be locked behind them. Staff E stated they knew not to leave Resident 1's side because they did not have steady balance and would take their hands off of the walker to wash their face. Resident 2. Medical record review showed the resident was admitted to the facility on [DATE] from the hospital after a fall at home fracturing their pelvis (basin-shaped complex of bones that connects the trunk and the legs, supports and balances the trunk) and sacrum (a single bone located at the base the spine) and diagnoses to include history of stroke with left side hemiparesis (weakness on one side of the body) and an overactive bladder. Review of the 12/30/2022 facility Restraint Assessment and Consent Form showed Resident 2 consented to their bed against the wall as a fall precaution. Review of a 01/01/2023 at 3:58 PM progress note showed the resident self-transferred to the bed once and the nurse encouraged the resident to turn on the call light and wait for assistance. Review of the 01/03/2023 comprehensive assessment showed Resident 2 was cognitively intact, required the extensive assistance from two staff for transfers and was at risk for falls due to weakness and impaired balance. The resident had a urinary catheter (a hollow, partially flexible tube that collects urine from the bladder and leads to a drainage bag) in place. Review of the Mobility Assessment completed on 01/04/2023 at 1:52 PM by Staff F, Registered Nurse (RN), showed Resident 2 was considered high risk for falls due to their fall with fractures prior to admission and their left side hemiparesis related to a stroke. No recommendation for fall alarms. The resident was alert, oriented and able to demonstrate use of the call light. Review of a 01/04/2023 at 2:04 PM progress note showed the resident was forgetful at times and self-transferred to their bed once. The resident was reminded to use their call light. Review of a 01/05/2023 at 2:50 PM progress note showed Resident 2 self-transferred during day shift. Review of a 01/06/2023 at 8:52 AM progress note showed Resident 2 tested positive for COVID-19 (an infectious disease - causing respiratory illness with symptoms including cough, fever, shortness of breath, new or worsening fatigue, headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell.) Review of a 01/07/2023 at 2:48 AM Incident Investigation showed Resident 2 was found lying on the floor near their bed with no injuries found. The resident stated, I was having a party and reported they were getting up to get a drink of water and spilled the water pitcher. The resident was returned to their bed in the lowest position. Review of the 01/07/2023 fall care plan showed the resident's fall precautions were: - To anticipate and meet needs, - Be sure resident's call light was in reach and encourage them to use it for assistance, - Follow facility fall protocol, - Review past falls. Review of a 01/07/2023 at 12:54 PM progress note showed Resident 2's urinary catheter became separated from the collection bag and the catheter was discontinued at that time. Review of a 01/08/2023 at 1:21 PM progress note showed Resident 2's Representative (RR 2) stated that Resident 2 was not acting like themselves and requested an assessment for a urinary tract infection (UTI). An assessment was completed, and the resident denied the sensation of burning with urination. The plan was to monitor the resident for symptoms of UTI (a strong urge to urinate, burning feeling when urinating, urinating often and strong-smelling urine) and encourage fluids. Review of a 01/08/2023 at 2:34 PM Incident Investigation showed Resident 2 was found on the bathroom floor with their pants around their ankles and their walker nearby. No call light had been activated. The resident had a significant amount of blood from a deep laceration, exposing the skull beneath, on the left side of the forehead near the hairline that required compression. The resident stated they needed to go to the bathroom and lost their balance. Resident 2 was transported to the hospital for evaluation and treatment. Review of a 01/08/2023 at 5:35 PM progress note showed Resident 2 returned from the emergency department with 5 staples to their head laceration. Review of a 01/09/2023 at 9:02 AM progress note showed the Interdisciplinary Team met to review Resident 2's fall with injury and added sensor alarms to the resident's wheelchair and bed with the resident's and RR 2's consent. Resident 2's care plan was updated with this fall intervention at that time. Observation and interview on 01/30/2023 at 10:45 AM showed Resident 2 lying on their bed well-groomed and wearing make-up. Sensor alarms were noted on their bed and wheelchair. The left side of the bed was against the wall. Resident 2 stated they knew they needed to ask for assistance from staff to transfer or use the bathroom. While touching the healing laceration on their forehead they stated that it did not hurt much at all. During an interview on 01/30/2023 at 10:50 AM, RR 2 stated they had just been visiting prior to the resident's fall in the bathroom. They stated Resident 2 hit their head on the bathroom door and had to go to the hospital for staples. I kept reminding [Resident 2] they needed to call for assistance and not try to transfer alone. During an interview on 02/07/2023 at 1:30 PM, Staff F, RN/Therapy Coordinator, stated that fall interventions initiated on admission depended on the resident's assessment. Whether they fell prior to admission, if they were trying to self-transfer, or were impulsive. Staff F stated that after Resident 2's assessment the standard interventions were initiated like having the call light in reach and frequent used items in reach. The Resident's self-transfer progress notes and fall on 01/07/2023 were reviewed with Staff F and they stated that the fall on 01/08/2023 could have been prevented had the alarms been implemented sooner. On 02/07/2023 at 1:50 PM, Staff G, RN/Resident Care Manager, was asked for a copy of the Facility Fall Protocol that was listed as an intervention in both Resident 1 and 2's fall care plans. Staff G stated they could not find a copy. During an interview on 02/07/2023 at 2:30 PM, Staff H, RN, stated they were the previous Therapy Coordinator. When asked when the fall intervention of sensor alarms would be considered for a resident, Staff H stated that if the resident were attempting self-transfers, not calling for assistance and after a fall, they would implement sensor alarms with the consent of the resident and their representative. During an interview on 02/07/2023 at 5:00 PM, Staff B, RN/Director of Nursing, agreed that both Resident 1 and Resident 2's falls could have been prevented had the staff not left Resident 1's side at the sink and Resident 2's sensor alarms had been implemented when they started self-transferring. Reference: WAC 388-97-1060(3)(g) This is a repeat citation from the Statement of Deficiencies dated 11/29/2021 and 03/30/2022.