Based on observation, interview, and record review the facility failed to ensure 1 of 5 sampled residents (Resident 61) reviewed for Pressure Ulcers (PUs), received the necessary treatment and services, consistent with professional standards of practice to prevent new ulcers from developing. Resident 61 experienced harm when they developed a facility acquired coccyx (tailbone) and inner left knee PU when staff did not consistently implement ordered pressure offloading measures and the resident was not consistently repositioned in bed. This failure placed all other residents at risk for PU development, and a diminished quality of life. Findings included . According to the CMS PU coding guide, a PU is defined as an observable, pressure-related alteration of intact skin with non-blanchable redness of a localized area usually over a bony prominence; may include changes in skin temperature, tissue consistency and/or sensation. A Stage II PU presents as a partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough or bruising. <Resident 61> According to the 11/21/2023 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 61 was usually able to make themselves understood and usually able to understand others. The assessment showed Resident 61 was totally dependent on two staff for physical assistance with moving to and from a lying position, turning side to side, and positioning the body while in bed. The MDS showed Resident 61 had a diagnosis of a long term degenerative neurological disorder that affected both the motor system and non-motor systems. According to the MDS, Resident 61 was at high risk for developing PUs. Review of Resident 61's Physician Orders (PO), dated 08/21/2023, showed an order for heel protective boots to both feet on at all times while in bed for pressure relief and for staff to check the placement of the boots every shift. Review of Resident 61's PO dated 12/15/2023, showed an order to place a rolled blanket between legs to offload pressure. Review of a 01/31/2024 weekly skin assessment showed Resident 61 had a new 1-centimeter (cm) X 2.5 cm Stage II PU on their coccyx. Record review of Resident 61's revised Care Plan (CP), dated 02/06/2024, showed a new Stage II PU coccyx wound developed on 01/31/2024. The CP showed interventions for staff to assist Resident 61 to re-position in bed frequently to reduce pressure, place a pillow or rolled blanket between legs to reduce pressure from crossed legs, and apply heel protective boots on both feet, when in bed. Observations on 01/30/2024 at 10:08 AM, 12:09 PM, and 2:21 PM, on 01/31/2024 at 8:38 AM, 10:26 AM, and 3:22 PM, and on 02/01/2024 at 8:28 AM, 10:55 AM, 12:18 PM, and 2:20 PM showed Resident 61 lying on their back, unable to turn and reposition on their own to offload pressure. Resident 61's legs were crossed with their knees pressed together and no rolled blanket was present to prevent pressure. Resident 61 did not have pressure reduction boots on as ordered by the physician during the observations on 01/30/2024 and 01/31/2024. Resident 61 was not observed to independently shift their weight or move their body on their own. A wound care observation and interview on 02/05/2024 at 11:15 AM showed Resident 61 lying in bed on their back with their legs crossed and no blanket between their knees to reduce pressure. Staff L (Registered Nurse) stated Resident 61 should have a pillow or rolled blanket between their knees and their protective boots on, but they did not. During wound care, Staff L and Staff N (Certified Nursing Assistant) observed a new pressure area developed to Resident 61's inner left knee. Staff N stated Resident 61 often refused care, refusals should be documented in Resident 61's medical records, and they should notify the Resident Care Manager (RCM) of refusals. Staff N stated they did not document or notify the RCM of Resident 61's refusals but should have. During an interview on 02/05/2024 at 8:26 AM Staff E (RCM) stated Resident 61 should have a rolled blanket between their knees, be repositioned every two to three hours, and protective boots should be on at all times. Staff E stated the CNA was responsible for carrying out these tasks and the Nurse would check to ensure they were done each shift. Staff E stated there was no documentation to support Resident 61 refused, so they were unsure if interventions were implemented. Staff E stated if residents refuse cares the floor staff is expected to document that and notify the assigned nurse or RCM. Reference WAC: 388-97-1060 (3)(b). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure 1 of 6 sampled residents (Resident 61), reviewed for Pain Management received the necessary treatment and services as ordered to manage pain with wound care. Resident 61 experienced harm and self-reported severe levels of pain during wound care when the facility failed to consistently premedicate the resident with ordered as needed pain relieving medication 30-60 minutes prior to dressing changes. This failure placed all other residents at risk for potentially unnecessary pain during wound care, and a diminished quality of life. Findings included . <Facility Policy> Review of the facility policy titled Pain Assessment and Management, dated October 2022, showed pain management included recognizing the presence of pain, and developing and implementing approaches to pain management. This policy showed that behaviors such as resisting care, yelling out, or decreased participation in physical/social activities were included when recognizing pain. <Resident 61> According to the 11/21/2023 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 61 was usually able to make themselves understood and usually able to understand others. The assessment showed Resident 61 was totally dependent on two staff for physical assistance with moving to and from a lying position, turning side to side, and positioning the body while in bed. The MDS showed Resident 61 had a diagnosis of a long term degenerative neurological disorder that affected both the motor system and non-motor systems. According to the MDS, Resident 61 was at high risk for developing PUs. This assessment showed Resident 61 did not receive their as needed (PRN) pain medication during the assessment period. Record review of a Physician Order (PO) initiated upon admit to the facility on [DATE] showed an order for Resident 61 to receive a PRN pain medication 30-60 minutes prior to their wound dressing change. Record review of Resident 61's 01/10/2024 Care Plan (CP) showed Resident 61 had acute pain related to wound. This CP showed staff were instructed to Pre-medicate Resident 61 with PRN pain medication 30-60 min prior to a wound dressing change with a goal of Resident 61's satisfaction with pain management by decreased or no vocalizations related to pain. Record review of Resident 61's medication and treatment administration records showed Resident 61 was not premedicated with pain medication prior to wound care for 24 of the 31 wound dressing changes done in August 2023, 15 of the 21 wound dressing changes in September 2023, 13 of the 16 wound dressing changes in October 2023, 23 of the 24 wound dressing changes in November 2023, 16 of the 19 wound dressing changes in December 2023, and 23 of the 24 wound dressings changed in January 2024. During an interview on 01/30/2024 at 12:08 PM Resident 61 stated they did not experience constant pain but experienced severe pain when the staff would change their wound dressings. Review of Resident 61's MARs for August 2023 to January 2024 showed greater than 286 behavioral episodes which included yelling out, cursing, feeling anxious, agitation, and restlessness for Resident 61 were documented. In an observation and interview on 02/05/2024 at 11:15 AM, Resident 61 appeared calm without any signs of pain during their wound dressing change. Staff L (Registered Nurse) and Staff N (Certified Nursing Assistant) repeatedly stated this is so unusual for them, they are never this calm and compliant with their wound dressing changes. Staff L and Staff N stated Resident 61 normally yelled out and would often refuse care. Staff L stated the pain medication must have helped that they gave them an hour ago. Both Staff L and Staff N stated when a resident yells out and refuses care, those are signs that they were in pain. During an interview on 02/05/2024 at 8:23 AM Staff E (Resident Care Manager) stated the nurse should premedicate Resident 61 30-60 minutes prior to their wound care as directed in Resident 61's CP and PO's. Staff E stated Resident 61 was not receiving the PRN pain medication prior to wound care as directed by the PO's but should have been. Reference WAC: 388-97-1060(1). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide supervision and ensure care was provided to residents at the level of care they were assessed to require for 2 of 3 residents (Residents 33 &34) reviewed for falls. The facility failed to ensure incident investigations were completed thoroughly to identify the root cause of the incident, update the incident investigations and incident log to reflect when an injury occurred, for 3 of 3 residents (Resident 33, 34 & 35) reviewed for falls. These failures caused harm to Resident 33 who fell out of bed and experienced a fractured nose, required stitches to a lacerated forehead, bruising and a cervical spine injury that required surgical repair, and caused harm to Resident 34 who sustained a fractured sternum and clavicle from a fall, and placed all residents at a potential risk of harm related to avoidable falls, the potential for continued incidents, injury, pain and diminished quality of life. Findings included According to the facility policy titled, Falls and Fall Risk Management, revised 03/2018, facility staff would implement a resident centered fall prevention plan to reduce specific risk factors for each resident identified at risk or with a history of falls. When underlying causes of falls could not be identified facility staff were to try various interventions, based on the nature of the fall, until falls were reduced, stopped, or the reason for the continued falls was identified as unavoidable. Facility staff with the physician's input would identify and implement interventions to minimize serious consequences of falls. Facility staff would monitor each resident's response to interventions implemented and re-evaluate current interventions, change interventions, and include the physician to determine possible causes for falls that was not previously identified. According to the facility policy titled, Reporting and Investigating - Abuse, Neglect, Exploitation or Misappropriation, revised 09/2022, showed the individual who conducted the investigation should review documents and evidence, review the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and after the incident, observe the alleged victim, interview the staff reporting the incident, interview any witnesses to the incident, interview the resident and/or the resident's representative, interview staff members on all shifts who had contact with the resident during the incident, interview the resident's roommate, review all events leading up to the incident and document the investigation completely and thoroughly. A follow up investigation report would provide sufficient information to describe the results of the investigation, and indicate any corrective actions taken. <Resident 33> According to the 05/02/2023 Quarterly Minimum Data Set (MDS), an assessment tool, Resident 33 was able to make their own decisions and needs known, had diagnoses including severe narrowing of the cervical spinal canal causing muscle weakness and new onset quadriplegia (paralysis of all limbs), arthritis of the right shoulder, and carpal tunnel syndrome (pain and numbness in the hands, wrists and forearms) affecting both wrists. The MDS assessed Resident 33 to require extensive assistance of two staff members for bed mobility, transfers, and dressing. Resident 33 was assessed to require extensive assistance of one staff member for personal hygiene and eating, and was totally dependent on two staff members for toileting and transfers. Review of a 02/14/2023 facility Fall Risk Evaluation showed Resident 33 was assessed at moderate risk for falls due to certain medication use and had no history of falls. A 02/14/2023 fall Care Plan (CP) showed the goal for Resident 33 was to have no falls in the facility and injuries would be minimized if the resident sustained a fall. Interventions directed staff to monitor the resident's need for toileting, encourage the resident to wear non-skid socks, and to call for assistance when transferring. A self-care deficit CP, dated 02/14/2023, was reviewed on 06/02/2023 and showed Resident 33 required two person total dependence for bed mobility and one person total assist for toileting. Review of Resident 33's CP showed revisions were made on 03/21/2023 that changed Resident 33 from a two person extensive assist with bed mobility to a one person extensive assist with bed mobility. The facility provided no documentation that supported Resident 33 had a drastic improvement in condition to require less staff assistance with bed mobility on 03/21/2023, the date Resident 33's CP was changed to a one person extensive assist with bed mobility. The same self-care deficit CP was reviewed on 06/05/2023 and showed that on 05/15/2023, two days after Resident 33 experienced a fall, the bed mobility status was changed to one person extensive assistance with bed mobility and toileting. Review of a provider encounter note, dated 03/21/2023 showed Resident 33 was evaluated for mobility and ADL (Activities of Daily Living) dysfunction, worsened pain to their right shoulder that was aggravated by a recent hospitalization and immobility. The note showed Resident 33 would continue to work with occupational therapy (OT) on ADL functional mobility training (helps improve overall coordination and mobility). Review of a 03/21/2023 Nursing Progress Note (NPN) showed facility staff documented Resident 33 had swelling to their right hand, was being monitored for pain medication effectiveness, and recently started on two medications to help with their increased right shoulder pain. Review of a 04/21/2023 Physical Therapy (PT) discharge summary showed Resident 33 had a goal to safely perform bed mobility tasks with minimal assist. The resident's baseline performance for bed mobility on admission was total dependent on staff, and as of 04/21/2023, their discharge date from PT, Resident 33 required moderate assistance. The discharge summary showed Resident 33 was discharged from PT for maximum potential achieved and the resident would be referred for a restorative program. Review of a provider encounter note, dated 04/21/2023, showed Resident 33 had a recent illness, continued feeling fatigued, and their therapy progress was slow and interrupted by their illness. Resident 33 told the provider they were frustrated that their insurance, cut me off, of therapy services. Review of 04/24/2023 facility Restorative Referral Form showed Resident 33 was at risk for decline in functional mobility and precautions included that Resident 33 was unable to use their bilateral (both) upper extremities functionally and the restorative goal was to increase Resident 33's function with repetitive movement and to maintain upper extremity strength. Review of a facility Therapy Screen document, dated 04/25/2023 ,five days after Resident 33 was discharged from PT services, showed, Resident 33 was screened for recent declines in ADL's, self-feeding, and ROM (range of motion) and strength. Therapy documented they would pursue evaluation and treatment orders for OT and start restorative services. Review of a provider encounter note, dated 05/09/2023, showed Resident 33's progress was slow and interrupted by a recent illness, and recommendations to continue therapy services with goals for modified independence with mobility, ADL's, and transfers. Review of a NPN, dated 05/13/2023, showed at 9:05 AM that day Staff E (Registered Nurse) heard a loud crash and screaming, and found Resident 33 face down on the floor. Staff D (Nursing Assistant Registered) told Staff E they tried to change Resident 33's brief, turned them, and the resident rolled out of the bed and fell to the floor. Resident 33 was observed with a nosebleed and a laceration to their forehead. Resident 33 was sent to the hospital for further evaluation. Review of the May 2023 facility incident reporting log showed no documentation of Resident 33's fall with injury on 05/13/2023. Review of a facility investigation, dated 05/18/2023 showed Staff B (Director of Nursing) documented Resident 33 was at risk for falls and required one person extensive assistance with toileting and bed mobility. Staff B concluded the fall on 05/13/2023 was unavoidable because the staff member could not break the fall as they were standing on the opposite side of the bed. The investigation did not determine if the Staff D (Nursing Assistant Registered) was following the CP or the MDS when the fall occurred, or if the MDS or the CP were accurate. MDS showed Resident 33 required two person assist with bed mobility and was dependent on staff for toileting and the CP showed two person assist with bed mobility and one person assist with toileting. In an interview on 05/24/2023 at 12:51 PM Resident 33's Collateral Contact (CC) stated the resident broke their nose and required stitches to their forehead due to the laceration. An x-ray at the hospital showed swelling in the neck area, where Resident 33 had surgery a few months prior. The CC stated that facility staff always used two people when changing the resident in bed and now suddenly the resident was a one person, that was not accurate the resident was pretty much a quadriplegic and could barely move. During an interview on 05/25/2023 at 12:05 PM Staff F (Shower Aide) stated Resident 33 was a two person assist with bed mobility and transferred out of bed with a mechanical lift. Staff F stated the resident would try to help but still required assistance from staff for daily tasks like eating. In an interview on 05/25/2023 at 12:07 PM Staff B stated Resident 33 sustained a nosebleed and a laceration to the forehead, but no nose fracture was identified at the hospital. Staff B stated they did not speak with hospital staff or obtain hospital records. Review of the May 2023 bed mobility ADL documentation by Certified Nurses Assistants (CNA) showed on 05/04/2023, 05/05/2023, 05/06/2023, 05/07/2023, 05/09/2023, 05/11/2023, and 05/12/2023 staff documented Resident 33 required total staff assistance with bed mobility. In an interview on 06/14/2023 at 1:30 PM Staff D stated they worked with Resident 33 for almost two weeks and on 05/13/2023 they checked Resident 33's CP and it showed one person assist for toileting the resident in the bed. Staff D gathered their supplies and Resident 33 wanted to turn towards their stronger right side and while providing incontinence care the resident raised their left leg to turn and rolled off the bed. During an interview on 06/05/2023 at 3:00 PM, Staff B stated Resident 33 was a one person extensive assist with toileting since the middle of February 2023. When asked who assessed the resident or changed the CP, Staff B stated it changed the date when the record was closed on 05/15/2023. Staff B was asked why there were differences between the MDS, which showed Resident 33 was two person assist with bed mobility and dependent on staff for toileting and the CP showed the resident was a two person assist for bed mobility, and a one person assist for toileting, and that CNA's documented using two staff members for bed mobility and toileting. Staff B stated Resident 33 toilets by being changed in the bed. When asked if bed mobility occurs when staff change a resident in bed, and Staff B replied, yes. Staff B was asked if the MDS was wrong and replied, no. Staff B was asked if the CP was wrong and stated, no. Staff B stated if I were the staff I would change them by myself. Staff B was asked why Staff D didn't turn the resident towards them when rolling them in bed, instead of away from them, and Staff B replied that Staff D should have but didn't turn the resident safely. Staff B stated the MDS and CP should match and be updated. Observations and interview on 06/12/2023 at 3:30 PM showed Resident 33 in bed, was unable to use their arms to call for staff assistance, and had to use a voice command on their cell phone to call for the nurse. Resident 33 stated It all started in January when I fell at home, after repeated falls and the fire department responding multiple times to pick me up from the floor they took me to the emergency room. I went to the facility from the hospital, on the day of my fall [05/13/2023], I requested staff assistance to have my wound dressing changed and possibly use the bedpan, one staff member responded but they didn't go get a second person to help, and I should have said something. The staff member turned me to the right, I am not sure how I fell but I landed on my face. Resident 33 stated the facility used two people to turn/change them in the bed from the beginning, was never told the CP changed to only one person assistance, and thought they should always use two people because I am not a small person. Resident 33 stated after the fall they required a surgical repair of the neck and now can't hold anything or barely move. Resident 33 was observed attempting to lift their left arm but was unable to significantly lift their left arm. Review of hospital documents, dated 05/25/2023, showed Resident 33 presented to the hospital on [DATE] with significant signs and symptoms of a central cord syndrome (most common form of an incomplete spinal cord injury), had a severe fall with a flexion/distraction type (horizontal fracture of spine) of injury and a cervical spinal cord bruise. Resident 33 underwent surgical repair on 05/22/2023 for central cord syndrome with possible cervical fracture of C4-C5. <Resident 34> According to the 02/16/2023 Quarterly MDS Resident 34 was able to make their own decisions and needs known, admitted to the facility after a fall from a ladder that resulted in left humerus (upper arm) fracture. Resident 34 had diagnoses including a left tibia (larger bone in lower leg) and left leg fibula (smaller bone in lower leg) fracture, unsteadiness on feet, and cancer. The MDS assessed Resident 34 to require supervision of one staff member when ambulating in their room, supervision and set up help from staff when walking in the facility. The MDS showed the resident used a walker and was assessed as not steady but able to self stabilize their balance when walking. Review of a self-care deficit CP, dated 11/09/2022, showed Resident 34 was a fall risk and was independent with their walker for ambulation. Review of a facility Fall Risk Evaluation, dated 05/11/2023, showed Resident 34 scored a low risk for falls as staff documented the resident had no history of falls. This was the first fall risk evaluation completed for Resident 34, after experiencing a fall at home and after being admitted to the facility for a fall six months ago. Review of a NPN dated 05/11/2023 at 1:20 PM showed Resident 34 had a witnessed fall in the parking lot when the resident tried to walk on the grass with their walker, got stuck and fell. Review of a Provider note, dated 05/11/2023, showed Resident 34 was walking outside alone with their walker, lost their balance and fell. Resident 34 complained of occasional pain in their left leg and the pain was managed with pain medications. Review of the May 2023 facility incident reporting log showed Resident 34 had a fall that occurred on 05/11/2023 and sustained no injuries. Review of a NPN, dated 05/11/2023, showed Resident 34 was observed with swelling to the left clavicle and complained of increased pain when moving or touching the area. A physicians order (PO) was received for a two view x-ray of the left clavicle. A witness statement, dated 05/11/2023, showed a staff member was sitting in their car, heard a noise, and saw Resident 34 laying on the road next to their walker. A second witness statement, dated 05/11/203, showed a staff member saw Resident 34 outside a window walking by themselves and it looked like the walker got stuck and they fell. A third witness statement, dated 05/11/2023, showed Resident 34 was found sitting on the ground of the parking lot with the walker next to them. Review of the facility investigation, dated 05/12/2023, showed Resident 34 fell to their bottom while ambulating outside by themselves. Staff B documented that Resident 34's left shoulder is not painful and is moving per their normal, x-ray findings were similar to the previous x-ray and resident's old fracture .a second x-ray was requested and findings were similar to the previous x-ray. Staff B documented Resident 34's ambulatory status remained the same and Resident 34 was seen ambulating the halls with family or staff as usual. Staff B concluded that the x-ray revealed the chronic fracture from admission and the resident's pain, range of motion remain unchanged from prior to the fall. Review of a provider note, dated 05/12/2023, showed Resident 34 complained to the provider they could not bear weight on their left leg and had a grating sound heard when moving the left clavicle. The provider assessed the left clavicle area to be swollen and confirmed a grating sound was heard when the clavicle area was touched. The provider ordered a urgent x-ray of the left clavicle and pelvis to rule out a fracture. Review of multiple NPN's showed on 05/13/2023 Resident 34 continued to complain of pain with movement. On 05/14/2023 Resident 43 was assessed with swelling and pain to the left clavicle. On 05/15/2023 Resident 34 continued to complain of pain. Review of a Provider note, dated 05/16/2023, showed Resident 34's chief complaint was left sided sternum and clavicle pain and assessed the resident with a soft bulky area in the left sternum/clavicle region that was mildly tender to touch. The note showed the x-ray of the clavicle that was previously done was of the shoulder and recommended a new x-ray of the sternum be obtained. Review of the 05/20/2023 sternum x-ray results provided by the facility, showed an acute, non-displaced sternum fracture and an acute mildly displaced fracture of the left clavicle. Review of a Provider note, dated 05/22/2023, showed Resident 34 would need to see an orthopedic (bone) doctor, use a left arm sling, and limit physical and occupational therapy to only the legs and right arm movements. Review of a facility incident reporting log, requested on 06/07/2023 showed no indication the log was updated to reflect Resident 34's two fractures, no addendum to the original incident report to include the injures sustained on 05/11/2023, and no report was made to required entities about the substantial injury of two fractures that were identified on 05/20/2023. In an interview on 06/14/2023 at 2:10 PM, Staff B stated the facility reviewed the NPN in morning meetings, knew about the fractures but did not update the fall investigation or the facility log to reflect the two new sustained fractures from the fall. When asked how Resident 34 sustained a sternum and left clavicle fracture, Staff B stated they fell to their bottom and rolled to their side. Review of the facility investigation did not show if Resident 34 had been assessed for safety to ambulate alone or outside, and did not document the new fractures as a result of the fall, thoroughly determine circumstances and put preventative measures in place. <Resident 35> According to the 04/04/2023 Quarterly MDS Resident 35 was able to make their own decisions and needs know, had diagnoses including a brain bleed, diabetes, arthritis, abnormality of gait, muscle weakness, and a seizure disorder. The MDS assessed Resident 35 to require one person staff assistance with bed mobility, transfers, toilet use, and personal hygiene. Review of a 09/30/2022 fall CP directed staff to check on the resident between 10:00 PM-11:00 PM and offer assistance with toileting and bedtime routine, encourage the resident to call for assistance before transferring, and monitor the resident's need for toileting. The CP had interventions of a fall mat at the bedside and the bed in the lowest position to minimize injury from falls. Review of the May 2023 facility incident reporting log showed on 05/09/2023, 05/10/2023, and 05/24/2023 Resident 35 had falls, without injuries. <Fall 05/09/2023> Review of a NPN, dated 05/09/2023, showed at 12:45 AM on 05/09/2023 the nurse heard a loud noise and found Resident 35 on their back in front of their bed and the bedside table was observed flipped over to the side. Review of a Fall Scene Investigation Report, dated 05/09/2023, showed Staff H (Licensed Practical Nurse) documented NA- non applicable for question 14 which asked where the fall occurred, options included; next to the transfer surface (assess for postural hypotension- drop in blood pressure when changing posture), 10 feet from the transfer surface (assess balance), and greater than 15 feet from the transfer surface (assess strength and endurance). Review of a facility incident investigation, dated 05/11/2023, showed Staff B documented Resident 35 preferred to sit at the edge of the bed, fell asleep, and slids down to the floor. There was a fall mat to prevent injury placed by the bed. Staff B concluded that the fall was unavoidable and related to the resident's condition, a therapy referral was made to evaluate for a possible chair for them to sit in or bolsters to the bed to help identify the edge of bed. The investigation did not provide details of how Resident 35 fell on the floor mat or the floor, where in front of the bed were they found, how many feet from the transfer surface, or how the bedside table ended up flipped over on the floor. <Fall 05/10/2023> Review of a NPN, dated 05/10/2023, showed around 10:00 AM on 05/10/2023 Resident 35 was found lying on their left side on the fall mat next to their bed. Resident 35 complained of mild pain to their left shoulder and left knee. An abrasion was found on the resident's left knee and Resident 35 told the staff it was from the fall on 05/09/2023. A 05/11/2023 PO showed an order for a half bolster (a long pillow to provide support) to be used when Resident 35 was lying down in bed. Review of the facility incident investigation, dated 05/11/2023, showed Staff B documented the investigation as the therapy director evaluated the resident for multiple falls over the last quarter and the therapy director wrote a note which explained the root cause of the falls, the way the resident lays down backwards from a sitting position and their feet are over the edge of the bed causing them to slip down. I like the idea of the half bolster, we will try it to ensure that it fits in a way that they can easily get out. Staff B concluded the investigation that the resident was evaluated by therapy and will have a half bolster to assist in identifying edges of the bed and avoid falls. The investigation did not address or determine the cause of the bruise found to Resident 35's knee. Review of provider note, dated 05/22/2023, showed Resident 35 complained of pain to the left knee that got worse with movement. Review of Resident 35's record showed 14 days after staff were aware of the abrasion to the left knee on 05/10/2023, a PO was placed on 05/24/2023 to monitor the abrasion for signs of infection or worsening. <Fall 05/24/2023> Review of a NPN, dated 05/24/2023 at 12:45 AM, showed the nurse heard a loud noise and found Resident 35 lying on their back in front of the bed. A skin assessment showed a scab from the old abrasion to the left knee broke off partially leaving an open area to the knee. Resident 35 told staff they were not sure if they hit their head. A provider note, dated 05/24/2023, showed Resident 35 was having severe pain to the left knee that radiated down the leg due to a fall, the resident fell asleep by watching television and fell forward, sustaining the abrasion to the knee. Review of the facility incident investigation, dated 05/24/2023, showed Staff B documented the investigation as; the resident preferred to sit on the edge of the bed, fell asleep, then slid down to the floor. Staff B concluded the resident experienced an unavoidable fall where they slid from the bed. The resident was non-compliant with how they sit in regard to safety. The investigation did not determine if Resident 35 fell on the floor mat or the floor, where in front of the bed were they found, and how many feet from the bed surface. A Pain Evaluation, dated 05/24/2023, showed Resident 35 had severe pain in the left lower extremity. The resident was often heard to have loud vocalization of pain when rising from a lying to sitting position. Review of a NPN, dated 05/25/2023, showed Resident 35 continued to complain of left leg pain. Review of a requested and updated incident reporting log on 06/07/2023 showed no updates to Resident 35's fall on 05/09/2023 with the abrasion to the left knee, after multiple complaints to staff about pain and documentation from providers assessing the residents pain. No addendum to the incident reports were observed to include the left knee abrasion. During an interview on 06/14/2023 at 2:30 PM, when asked where Resident 35 fell when staff documented in the front of the bed, Staff B replied, they fell on the fall mat. When asked how Resident 35 sustained a bruise to the left knee on the 05/09/2023 fall if they slid from the bed, Staff B stated there was a bed side table and maybe scrapped their knee. When asked how a half bolster would prevent the resident from sliding down if the PO was to be used only when lying in bed. Staff B replied that the bolster would help the resident identify the bed edges. The investigation did not address or determine how Resident 35 sustained a bruise on the knee, where the resident was found in accordance with the bed, and how the tray table was knocked over. REFERENCE: WAC 388-97-1060(3)(g) .