**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and resident interview, it has been determined that the facility failed to ensure that each resident receives adequate care to prevent an accident for 1 of 1 resident reviewed. The resident required two staff members to assist during care, one staff member was providing care, resulting in the resident falling out of bed, injuring multiple areas, including a facial injury requiring immediate transfer to the hospital and hospitalization, Resident ID #1. Findings are as follows:Record review of a facility reported incident submitted to the Rhode Island Department of Health on 7/18/2025 revealed Resident ID #1 rolled out of bed after morning care, and s/he was sent to Rhode Island Hospital via 911 for evaluation. Record review revealed the resident was originally admitted to the facility in November of 2023 with diagnoses including, but not limited to, anoxic brain damage (brain does not receive enough oxygen), seizures, and diabetes.Record review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident is dependent on staff for bed mobility and that two staff members are required to assist during this task.Record review of the MDS assessment dated [DATE] revealed the resident is dependent on staff during a shower or bath. Additionally, the MDS revealed that two staff members are required to assist during this task.Record review of the resident's care card (a documentation system that enables staff to reference key resident information that shapes their nursing care plan) revealed the resident is dependent for the following care areas: - Personal Hygiene with assist of 2 staff members - Shower or Bathe self with assist of 2 staff members - Roll left or right with assist of 2 staff members Record review of a nursing progress note dated 7/16/2025 revealed the resident fell out of bed, with some bleeding noted from the head and face. Additionally, the resident was sent out to the hospital for evaluation.Record review of the hospital documentation dated 7/16/2025 revealed the resident was evaluated for a 0.5-centimeter (cm) laceration near the right eyebrow, and an abrasion to the left elbow and right knee. During a surveyor interview on 7/21/2025 at 10:30 AM with Nursing Assistant, Staff A, she indicated that on 7/16/2025, she was providing care by herself and completed a full bed bath on the resident and then untucked the bed sheet in an attempt to change him/her. Staff A revealed she tried to pull the sheet off of the bed and the resident fell off the bed onto his/her bottom and then she witnessed the resident hit his/her head on the floor. Additionally, Staff A revealed that she normally works alone while providing care for the resident. She stated that she could not recall the information documented on the care card or MDS regarding the number of staff required to provide care for this resident.During a surveyor interview on 7/21/2025 at 1:55 PM with Licensed Practical Nurse (LPN), Staff B, he indicated that on 7/16/2025, Staff A requested help after the resident fell onto the floor. He entered room and described the resident as alert, and s/he had some blood on his/her face. Staff B called the rescue for the resident to be transported to Rhode Island Hospital for an evaluation. During a surveyor interview conducted on 7/21/2025 at approximately 2:30 PM with the Director of Nursing Services (DNS), she stated that staff may request assistance with care if they feel it is necessary. The DNS noted that the resident typically holds onto the bed rail to assist with turning during care. However, the DNS did not acknowledge that two staff members are required when providing hygiene or bed bath care, despite documentation in the MDS and care card indicating this requirement.Record review revealed that at the time of this survey, the resident remained in the hospital. Due to the facility's failure to follow the MDS Assessment and care card directives, Staff A provided care alone without the required assistance of a second staff member. As a result, Resident ID #1 fell from the bed to the floor, sustaining multiple injuries, including trauma to the face.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, resident and staff interview, it has been determined that the facility failed to provide necessary treatment and services, consistent with professional standards of practice to prevent new ulcers from developing for 1 of 1 resident reviewed, who was admitted to the facility for respite care, Resident ID #272. Findings are as follows: According to an article published in the National Library of Medicine titled, Pressure ulcers: Learn More - Preventing pressure ulcers, last updated on August 19, 2022, states in part, .Regularly changing a person's lying or sitting position is the best way to prevent pressure ulcers. Special mattresses and other aids can help to relieve pressure on at-risk areas of skin .Most pressure ulcers (bedsores) arise from sitting or lying in the same position for a long time without moving. Most people keep changing their position when they sit for a long time or are asleep, consciously or subconsciously. But people who are very weak, ill, paralyzed or unconscious move much less or not at all. This means that the parts of their body that they are sitting or lying on are constantly under more pressure .People who are confined to a wheelchair or have to stay in bed for a long time are at greater risk. Then it's critical to relieve pressure on the skin by regularly changing the position they sit or lie in. People who develop pressure ulcers often say that they can feel parts of their body becoming sore .It is also important to move if possible - even if you have to lie in bed or sit in a wheelchair. If you are able to sit up, leave the bed, or even walk a few steps with a bit of help, it ' s a good idea to do that as often as possible . Review of the facility policy titled admission of A Resident states in part, .obtain sufficient, accurate information that will be required to properly care for the resident . Record review revealed Resident ID #272 was admitted to the facility in January of 2025 with diagnoses including, but not limited to, reduced mobility and a history of poliomyelitis (a viral infection that causes nerve injury which leads to partial or full paralysis). Record review revealed a Brief Interview for Mental Status assessment dated [DATE] with a score of 14 out of 15, indicating the resident's cognition was intact. During a surveyor interview on 1/27/2025 at approximately 10:00 AM with the resident, s/he indicated that s/he had not been out of bed since his/her admission. Additionally, the resident revealed that s/he enjoyed sitting in his/her recliner at home. Furthermore the resident indicated that s/he had an uncomfortable area on his/her buttocks. Review of a hospital continuity of care form dated 1/16/2025 revealed activity instructions including, but not limited to, Bed and wheel chair bound, (if someone is bedbound, it means they are not able to move around safely or comfortably. They may need to help to get to and from the toilet, to sit up in bed or to move from the bed to a chair, and help to change their position in bed to prevent bed sores). Review of the .admission Screening Tool dated 1/16/2025 revealed the resident was admitted to the facility for a 2-3 month respite stay, due to his/her caregiver having surgery. Further review revealed the resident requires the assistance of two people for transfers. Additional review failed to reveal evidence that the resident had a wound upon admission. Review of the resident's care card, a document used by direct care staff for pertinent care information, revealed the resident was dependent on the assistance of two staff members for bed mobility and transfers. Review of a Norton Assessment (a tool used to determine a person's risk of developing a pressure ulcer) dated 1/23/2025 revealed the resident was chair bound with very limited mobility. Further review revealed the resident was at a moderate risk of developing a pressure ulcer. Review of a care plan dated 1/27/2025 revealed the resident was at risk for skin breakdown related to impaired mobility. Record review of an admission skin assessment dated [DATE] failed to reveal evidence of any open areas to the resident's buttocks. Record review of a skin assessment dated [DATE], 6 days after his/her admission, revealed the resident was found to have a facility acquired wound to his/her right buttocks, that measured 3.5 centimeters(cm) by 3.5 cm by 0.1 cm. Record review revealed a physician's order dated 1/23/2025 to cleanse a right buttocks wound with wound cleanser followed by honeygel (a wound gel) and cover the wound with a bordered foam dressing daily. Review of a wound physician's progress note dated 1/28/2025 revealed the resident had a moisture associated wound which measured 2 cm by 3 cm by 0.2 cm. Further review revealed the surrounding area of the wound was normal. During multiple surveyor observations on 1/27, 1/28, 1/29, and 1/30/2025, all days of the survey, the resident was noted to be lying in bed, flat on his/her back. During a surveyor interview on 1/30/2025 at 9:28 AM with Nursing Assistant (NA), Staff J, she indicated that she had been assisting the resident this past week and had not transferred the resident out of bed. She further indicated that she thought that the resident preferred to stay in bed. During a surveyor interview on 1/30/2025 at 9:31 AM with the resident in the presence of Staff J, the resident stated that s/he would love to get out of bed. S/he then stated that the staff have never offered to transfer him/her out of bed. During an interview on 1/30/2025 at 11:04 AM with Registered Nurse (RN), Staff B, she indicated that she was unaware if the resident had been transferred out of bed since admission. During a surveyor observation of the resident's buttocks wound on 1/30/2025 at 9:43 AM, in the presence of Staff B, she removed the soiled dressing from the resident, this dressing was dated 1/28/2025 indicating that it was not changed on 1/29/2025, as ordered. Observation of the wound revealed two dark colored areas around the wound with non-blanchable redness (when you push the skin, and the area stays red, indicating there is little or no blood flow going to that area) to the proximal peri wound (around the wound). Staff B acknowledged these observations. During a surveyor interview on 1/30/2025 at 10:31 AM with the Wound Nurse, Staff K, she indicated that a moisture associated wound is typically blanchable (when the skin loses its color when pressure is applied and quickly returns) where a pressure ulcer (injury to the skin caused by prolonged pressure) is characterized by a non-blanchable area. During a surveyor interview and observation of the resident's buttocks wound on 1/30/2025 at 10:40 AM with Staff K, she indicated that the darkened areas and the non blanchable redness on the resident's buttocks were not present on 1/28/2025, and that these pressure areas were new. She further indicated that the approximate measurements of the two darkened areas were each 0.5 cm by 0.5 cm and that the non-blanchable area was approximately 3 cm by 5 cm. During a surveyor interview on 1/30/2025 at 11:31 AM with the Director of Nursing Services, she indicted that she would expect staff to offer a resident to get out of bed. The facility's failure to transfer the resident out of bed for 15 consecutive days resulted in the resident developing a pressure ulcer, as evidenced by the resident not having a wound to his/her buttocks upon admission. Cross reference F-688

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, resident, and staff interview, it has been determined that the facility failed to ensure a resident with limited range of motion (ROM) received appropriate treatment and services to increase ROM and/or to prevent further decrease in ROM for 2 of 2 residents reviewed with contractures (the shortening of muscles, tendons, skin, and nearby soft tissues that cause the joints to become very stiff, which prevents normal movement), Resident ID #s 67 and 79. Additionally, the facility failed to ensure a resident with limited mobility received appropriate services and equipment for 1 of 1 resident reviewed who was admitted to the facility for respite care, Resident ID #272. Findings are as follows: Review of a facility policy titled admission of A Resident states in part, .obtain sufficient, accurate information that will be required to properly care for the resident .Perform admission Evaluation/Screen .Review with the Interdisciplinary Team: diet orders, rehabilitation orders, and social services concerns . Review of a facility policy titled Screens, last revised January 2012, states in part, .All patients/residents will be screened annually .the purpose of the screen is to determine if the patient/resident would benefit from a therapy evaluation . 1. Record review revealed Resident ID #67 was admitted to the facility in November of 2023 with diagnoses including, but not limited to, anoxic brain damage (caused by a lack of oxygen to the brain) and muscle wasting. Record review of a Minimum Data Set Assessment (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating severe cognitive impairment. Further review revealed the resident had impaired range of motion of one side of his/her upper extremities. Additional review revealed the resident is dependent on staff for activities of daily living (ADLs). Record review of a Rehab Screen dated 5/17/2024 failed to reveal documentation of any contractures. During surveyor observations on the following dates and times, the resident was noted to have a contracted left hand, without any intervention in place: - 1/27/2025 at 11:45 AM - 1/28/2025 at 9:52 AM -1/30/2025 at approximately 1:15 PM - 1/31/2025 at 9:41 AM Review of a care plan dated 11/28/2023 revealed the resident has pain related to impaired mobility with interventions including, but not limited to, offer non-pharmacological interventions to reduce pain. Further review revealed the resident is at risk for skin breakdown. Additional review of the care plan failed to reveal evidence the resident had a left-hand contracture, limited range of motion, or that there were interventions implemented to prevent a further decrease in his/her range of motion. Record review of the physician's orders failed to reveal evidence of any orders to prevent a further decrease in range of motion for the resident. During a surveyor interview on 1/30/2025 at 1:20 PM with Licensed Practical Nurse, Staff M, he acknowledged that the resident's left hand was contracted and indicated that the resident is not currently working with physical (PT) or occupational therapy (OT). Additionally, he acknowledged that there were no interventions in place to prevent a further decrease in the resident's range of motion. During a surveyor interview on 1/31/2025 at 9:08 AM with Physical Therapist, Staff N, she acknowledged that when the resident was screened by rehab on 5/17/2024, it was not documented that s/he had a left hand contracture. Additionally, she could not provide evidence that any interventions have been put in place to prevent a further decrease in the resident's range of motion. During a surveyor interview on 1/31/2025 at 9:41 AM with Resident ID #67, s/he indicated that his/her left hand was painful and that s/he could not move it. The resident further indicated that s/he does not work with therapy but would wear a splint if it would help with the pain his/her hand. During a surveyor interview on 1/31/2025 at 9:44 AM with Registered Nurse (RN), Staff F, she indicated that the resident does complain of pain to his/her left hand when staff are providing care. During a surveyor interview on 1/31/2025 at 9:49 AM with the Director of Nursing Service (DNS), she indicated that the resident has impaired cognition however, s/he knows information about him/herself. She further indicated that she was aware that the resident had a left hand contracture and would expect the contracture and limited range of motion to be addressed in the care plan and to have interventions should be in place to prevent a further decrease in the resident's range of motion. 2. Record review revealed Resident ID #79 was admitted to the facility in September of 2024 with diagnoses including, but not limited to, spinal stenosis (spinal narrowing which compresses the spinal cord) and peripheral autonomic neuropathy (nerve damage). Review of a MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15, indicating intact cognition. Further review revealed the resident was documented as not having any range of motion impairments to his/her upper extremities. Record review of a Rehab Screen dated 11/11/2024 failed to reveal documentation of any contractures. During a surveyor interview and observation on 1/27/2025 at 11:44 AM, with Resident ID #79, s/he indicated that s/he is not receiving therapy services. The resident was observed to have a limited range of motion and his/her hands were contracted. Review of the care plan dated 9/18/2024 revealed the resident has an ADL deficit related to weakness. Further review failed to reveal evidence that the resident has limited range of motion, or that there were interventions in place to prevent a further decrease in the resident's range of motion. Record review revealed the following physician's orders: -OT evaluation and treatment as indicated dated 11/30/2024 -PT evaluation and treatment as indicated dated 12/30/2024 During a surveyor interview on 1/29/2025 at approximately 10:00 AM with the Interim Director of Rehab, Staff O, she indicated that rehab screens are completed quarterly and that due to the resident being bed bound (if someone is bedbound, it means they are not able to move around safely or comfortably. They may need to help to get to and from the toilet, to sit up in bed or to move from the bed to a chair, and help to change their position in bed), s/he does not require therapy services. Additionally, she was unable to provide evidence of a therapy screen upon Resident ID #79's admission in September 2024. During a surveyor interview and observation on 1/31/2025 at 8:58 AM with RN, Staff B, she acknowledged that both of the resident's hands were contracted. During a surveyor interview on 1/31/2025 at 11:14 AM with Staff O, she indicated that she was unaware that the resident had a limited range of motion to his/her bilateral hands. Additionally, she could not provide evidence that a PT or OT evaluation had been completed as ordered, or that interventions were put into place to prevent a further decrease in the resident's range of motion. During a surveyor interview on 1/31/2025 at 11:16 AM, with the DNS, she was unaware that the resident had limited range of motion in his/her upper extremities. She further indicated that she would have expected the limited range of motion to have been identified by therapy and that a care plan would be implemented to prevent a further decrease in the resident's range of motion. 3. Record review revealed Resident ID #272 was admitted to the facility in January of 2025 with diagnoses including, but not limited to, reduced mobility and a history of poliomyelitis (a viral infection that causes nerve injury which leads to partial or full paralysis.) Record review revealed a BIMS dated 1/17/2025 with a score of 14 out of 15, indicating the resident's cognition was intact. During a surveyor interview on 1/27/2025 at approximately 10:00 AM with the resident, s/he indicated that s/he had not been out of bed since his/her admission. Additionally, the resident revealed that s/he enjoyed sitting in his/her recliner at home. Furthermore s/he indicated that s/he had an uncomfortable area on his/her buttocks. Review of a hospital continuity of care form dated 1/16/2025 revealed activity instructions including, but not limited to, Bed and wheel chair bound. Review of the .admission Screening Tool dated 1/16/2025 revealed the resident was admitted to the facility for a 2-3 month respite stay, due to his/her caregiver having surgery. Further review revealed the resident requires the assistance of two people for transfers. Review of a care plan dated 1/27/2025 revealed the resident has a self-care deficit related to impaired mobility with interventions including, but not limited to, encourage the resident to get out of bed with all meals. Record review failed to reveal evidence that the resident had been screened by Physical or Occupational therapy since his/her admission to the facility. During multiple surveyor observations on 1/27, 1/28, 1/29, and 1/30/2025, all the days of the survey, the resident was lying in bed, flat on his/her back. Further observations failed to reveal that the resident had a wheelchair in his/her room. During a surveyor interview on 1/30/2025 at 9:28 AM with Nursing Assistant (NA), Staff J, she indicated that she had been assisting the resident with care this past week and had not transferred the resident out of bed. She further indicated that she thought that the resident preferred to stay in bed. During a surveyor interview on 1/30/2025 at 9:31 AM with the resident in the presence of Staff J, the resident stated that s/he would love to get out of bed. S/he then stated that the staff have never offered to transfer him/her out of bed. During an interview on 1/30/2025 at 11:04 AM with Registered Nurse (RN), Staff B, she indicated that she was unaware if the resident had been transferred out of bed since his/her admission. She further indicated that the resident did not have a wheelchair and would need to be screened by therapy to receive a wheelchair from the facility. During a surveyor interview on 1/30/2025 at 11:07 AM with the Regional Therapy Director, she indicated that she would expect a therapist to screen each resident within 24 to 48 hours of admission to establish a baseline and to provide the resident with any adaptive equipment needed, including a wheelchair. Additionally, she could not provide evidence that a therapy screen had been completed for the resident since his/her admission. During a surveyor interview on 1/30/2025 at 11:31 AM with the DNS, she indicated that she would expect a therapy screen to be completed to establish safe transfer status for the resident, and to identify if a resident needs a wheelchair. During a surveyor interview on 1/31/2025 at 1:09 PM with Physician, Staff L, he indicated that he would expect an elderly resident who is admitted to the facility for more than a few days, to be screened by therapy for safety. Record review revealed a Rehab Screen was conducted for this resident on 1/30/2025, after the above concerns were brought to the facility's attention by the surveyor, 15 days after the resident's admission. Additional review of the Rehab Screen revealed that the resident required the assistance of one staff for transfers to a wheelchair. Further review revealed that the resident was provided with a wheelchair. Cross reference F-686

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide necessary treatment and services consistent with professional standards of practice, to promote healing and prevent new pressure ulcers from developing for 1 of 6 residents reviewed who is at risk for developing pressure ulcers or who have actual pressure ulcers, Resident ID #56. Findings are as follows: Record review revealed the resident was admitted to the facility in June of 2017 and readmitted in September of 2022 with diagnoses which include, but are not limited to, vascular dementia and muscle weakness. Record review of a quarterly Minimum Data Set (MDS, used to assess a resident's cognitive and functional status) assessment dated [DATE] revealed the resident requires extensive assistance of two staff with bed mobility. Record review of a care plan initiated on 5/22/2019 and revised on 2/17/2022 states in part, .at risk for skin breakdown due to [his/her] advanced age, limited mobility, and incontinence .Interventions .Treatment as ordered . Record review of a pressure injury evaluation dated 11/10/2022 states in part, .current stage: Suspected deep tissue injury [localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure] .left great toe .type: pressure .length: 0.25 cm [centimeter] width:0.25 cm .comments: dark red/black discoloration noted to left great toe .Eschar [a collection of dry, dead tissue within a wound] 75% . Record review of a nursing progress note dated 11/10/2022 states in part, Resident noted with a dark reddish-black circular area to [his/her] left great toe. Area measures approximately 0.25 cm x [by] 0.25 cm .Facility DON [Director of Nursing] along with NP [Nurse Practitioner] is made aware, NO [new order]: 1. Apply skin prep to wound bed qshift [each shift] 2. Place a foot cradle [a device placed at the foot of the bed that is used to relieve the weight of the bedding from the feet] . Record review of the resident's physician's orders failed to reveal evidence of an order for a foot cradle from 11/10/2022 through 11/30/2022 when it was brought to the facility's attention by the surveyor. During surveyor observations on the following dates and times, the resident was observed lying in bed without the foot cradle in place: -11/27/2022 at 11:00 AM -11/28/2022 at 12:00 PM - 11/30/2022 at 8:09 AM and 9:45 AM. Additional record review of a physician's order with a revision date of 11/16/2022 states in part, Measure area to left great toe weekly and complete pressure evaluation everyday shift Tuesday . Record review of the resident's weekly skin evaluation failed to reveal evidence of a skin assessment of the left great toe on 11/17/2022 and 11/24/2022 as ordered. During an additional surveyor observation on 11/30/2022 at 10:15 AM in the presence of a License Practical Nurse, Staff C, reveal the resident lying in bed without a foot cradle. Additionally, the resident left great toe was measured by Staff C which revealed a measurement of 1.5 cm x 0.7 cm. During a surveyor interview immediately following this observation with Staff C, he acknowledged that the foot cradle was not in place as ordered. Additionally, Staff C acknowledged that the resident's area on his/her left great toe had increased in size from the initial measurement on 11/10/2022. During a surveyor interview on 11/30/2022 at 1:19 PM with the Director of Nursing Services, she could not provide evidence as to why the order for the foot cradle was not implemented when it was ordered on 11/10/2022. Additionally, she indicated that she would expect the staff to assess and document the resident's left great toe wound weekly as ordered. During a surveyor interview on 12/1/2022 at 12:01 PM with the Nurse Practitioner, Staff E, she indicated that she would expect the order for the foot cradle to have been implemented as ordered on 11/10/2022. Additionally, she indicated that she would expect the staff to do a weekly assessment of the resident's left great toe as ordered.