Every finding on record at Elmwood Nursing and Rehabilitation Center

Based on clinical record review and staff interview, the facility failed to ensure that residents who are appealing a transfer or discharge notice from the facility, remain in or return to the facility, pending their appeal for 1 of 1 resident reviewed, Resident ID #1.Findings are as follows:Review of a community reported complaint submitted to the Rhode Island Department of Health on 7/2/2026, alleges that the facility issued a 30 day involuntary discharge notice to Resident ID #1 on 6/25/2026. The resident exercised his/her right to appeal the discharge on [DATE] and the ombudsman filed a request for an appeal hearing on the resident's behalf. The involuntary discharge was subject to the appeal process and should have been stayed pending the outcome of the appeal. On 6/29/2026, while the resident was on an approved leave of absence (LOA), s/he sustained a fall and was transported to the hospital for evaluation. During the resident's hospital stay, it was made known that the facility would not be permitting the resident to return to the facility, refusing readmission during the resident's appeal process. The resident was discharged from the hospital to the street, with no money, medications, or a safe place to live.Record review revealed Resident ID #1 was admitted to the facility in January of 2026 with diagnoses including, but not limited to, cerebral infarction (stroke), spondylosis without myelopathy (a degenerative spinal condition where the vertebrae and discs deteriorate without compressing the spinal cord or nerve roots) in the lumbar region, chronic pain syndrome, and osteoarthritis.Further review revealed the resident required a multifaceted pain management plan for treatment of chronic pain which included standing orders for opioid medications, Tylenol, and muscle relaxers.Record review revealed a document titled [NAME] ISLAND DEPARTMENT OF HUMAN SERVICES PRE-TRANSFER OR PRE-DISCHARGE 30 DAY NOTICE dated 6/25/2026, revealed the resident was notified that s/he would be discharged from the facility in 30 days due to consistent violation of the smoking policy and being a danger to the health and safety of other individuals in the facility. Additionally, the document stated the resident had the right to appeal this discharge.Review of a document titled [NAME] ISLAND DEPARTMENT OF HUMAN SERVICES REQUEST FOR A HEARING revealed that on 6/26/2026, the resident was requesting an appeal of the discharge.Record review revealed that while the resident was on a LOA from the facility on 6/29/2026, s/he had a fall and was subsequently transported to a local hospital for evaluation and observation.Record review of a hospital document dated 6/30/2026, revealed that the facility refused to accept the resident back into the facility. Further review revealed that s/he was discharged into the community on the morning of 7/1/2026.Review of the facility's census on 7/1/2026 failed to reveal evidence that that Resident ID #1 returned to the facility while an appeal of his/her discharge was pending.During surveyor interviews with the Administrator on 7/15/2026 at 10:25 AM and 1:15 PM, she revealed that the resident was presented with a 30-day notice of discharge on [DATE] due to several instances of noncompliance with the facility's smoking policy, including keeping his/her smoking materials on him/her, which is a danger to the health and safety of other residents in the facility. Additionally, she acknowledged that the resident submitted an appeal of the discharge. Furthermore, she acknowledged that the resident went to the hospital during a LOA on 6/29/2026 and was not permitted to return to the facility despite there being an active appeal of the discharge.

Based on surveyor observation, clinical record review, and staff interview, it has been determined the facility failed to provide care in accordance with a resident's plan of care to prevent falls for one of three residents reviewed, Resident ID #1, who sustained a fall with injury requiring hospitalization.Findings are as follows: Record review of a facility reported incident that was received by the Rhode Island Department of Health on 3/31/2026, alleged that while a Nursing Assistant (NA) was providing care to Resident ID #1 in bed, the resident rolled towards the NA and out of the bed, causing both the NA and resident to fall to the floor. The resident was assessed and a hematoma (a closed wound involving localized bleeding outside of the blood vessels) was immediately noted to his/her right temple. The resident was emergently transported to the hospital for further evaluation, where s/he was admitted with diagnoses including, fall, right frontal hematoma (localized bleeding to the right forehead region), and subdural hematoma (bleeding between the brain and its outer covering). Record review revealed the resident was admitted to the facility in September of 2022 with a diagnosis that includes, but is not limited to, Alzheimer's disease. Review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident is nonverbal and dependent on staff, Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity, for all activities of daily living including transfers and rolling left to right in bed. Record review of a care plan for falls, initiated on 9/17/2022, revealed the resident was identified as being at risk for falls due to a decline in condition, poor safety awareness, and a lack of trunk control. Further review revealed the care plan was revised on 3/27/2023 to include that, due to poor trunk control, staff were to ensure the resident was positioned in the center of the bed during repositioning to prevent sliding out of bed. Additional review revealed the care plan was further revised on 3/29/2023 to indicate the resident required the use of a mechanical lift and the assistance of two staff members for all transfers. Record review of a progress note dated 3/31/2026 at 10:57 AM, authored by Registered Nurse, Staff A, revealed at 9:15 AM, the resident was receiving care and when s/he was turned to his/her side, s/he fell out of bed, landing on the NA and hitting the right side of his/her head on the floor. The resident sustained a hematoma to his/her right temple. Further review of the progress note revealed that the resident is nonverbal, contracted (a permanent inability to move the joints and muscles through full range) with advanced dementia, and receives a blood thinner twice daily. Record review of a written statement authored by the NA, Staff B, dated 3/31/2026 revealed that she had provided the resident's morning care and then she proceeded to apply the Hoyer pad under the resident by rolling him/her. When she attempted to roll the resident towards her, the resident rolled off the bed and both the NA and the resident fell to the floor. Record review revealed the resident was transferred to the hospital following his/her fall on 3/31/2026 where s/he was admitted with diagnoses including, fall, right frontal hematoma, and subdural hematoma. S/he was hospitalized for 4 days and returned to the facility on 4/3/2026. Record review revealed following the resident's fall with injury, his/her care plan for falls was revised on 3/31/2026 to include an intervention for two staff to assist with all care. During a surveyor interview on 4/15/2026 with Registered Nurse, Staff A, at 11:24 AM, she revealed that NAs are provided with an assignment sheet each shift which indicates the levels of care and assistance each resident requires. She further indicated the assignment sheets are updated as needed and reviewed weekly to reflect the residents' most recent status. Additionally, she revealed that Resident ID #1 required assistance of one staff person for care and to apply the Hoyer pad underneath the resident. She indicated that staff would then get assistance from another staff member to perform the transfer using the Hoyer lift. Further, Staff A indicated that she was unaware that Resident ID #1's care plan was revised on 3/31/2026 to include an intervention for two staff to assist with all care. During a surveyor interview on 4/15/2026 at approximately 11:30 AM with NA, Staff C, she revealed that staff refer to the assignment sheets to accurately inform them of the level of care and assistance that is required for each resident. Additionally, Staff C revealed that she was unaware that Resident ID #1's care plan was revised on 3/31/2026 to include an intervention for two staff to assist with all care. Record review of a document provided to the surveyor on 4/15/2026, titled 7-3, 3-11, 11-7 Assignments revealed the following for Resident ID #1: Hoyer; total care; 1:1 feed . Additional review of the document failed to reveal evidence that Resident ID #1 required two-person assistance with all care as indicated by the resident's care plan. During a surveyor interview on 4/17/2026 at 10:03 AM with the Director of Nursing Services, she revealed that total care includes dressing, bathing, rolling, and transfers. Additionally, she indicated she was unaware that the assignment sheet provided to staff failed to accurately reflect the requirement for two-person assistance with all care following the resident's fall with injury on 3/31/2026.

Based on clinical record review and staff interview, the facility failed to inform the resident's appointed representative, in advance, of the care to be furnished by the physician or other provider, of the risks and benefits of proposed care or treatment alternatives relative to the ordering and administration of an antipsychotic medication for 1 of 1 resident reviewed, for the use of Zyprexa (an atypical antipsychotic medication), Resident ID #2.Findings are as follows:Review of the facility policy titled, Medication Administration Safety, Psychotropic Medications and New Medication Orders dated 4/28/2025 states in part, .Any and all psychotropic medications require resident or representative consent. Consent must include their awareness of the medication(s) ordered, the side effects to include black box warnings when applicable, and the risk/benefit.consent is necessary prior to administration of these medications medications.If/When a new medication is ordered, this signals a change in resident condition and the.Representative must be notified of that change.The progress notes (or other form being used in the medical record) must show evidence of this notification .Record review revealed the resident was readmitted to the facility in October of 2025 with a diagnosis including, but not limited to, encephalopathy (a term used to describe any disorder or disease that affects the brain leading to dysfunction. Brain dysfunction can appear as confusion, memory loss and personality changes).Review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score was not conducted as the resident is rarely/never understood.Review of a progress note dated 10/27/2025, authored by the Physician, revealed that the resident has been pulling out his/her catheter (a thin flexible tube that is inserted through the urethra to help drain urine from the bladder), wound vac (is a medical treatment that uses a vacuum device to apply controlled suction to wounds. This therapy helps to promote healing by reducing swelling, increasing blood flow, and creating a moist environment conducive to tissue regeneration) and refusing care. Additional review revealed an order for Zyprexa 5 milligrams (mg) for agitation.Further record review failed to reveal evidence that resident's representative was informed regarding the order for Zyprexa or of the risks, benefits, and alternatives to the medication.Review of the October, November and December 2025 Medication Administration Records (MAR) revealed that the resident received Zyprexa 5 mg daily from 10/27/2025 through 12/31/2025. Further review of the January 2026 MAR revealed that the resident received Zyprexa 5 mg daily from 1/1/2026 to 1/13/2026. During a surveyor interview on 1/14/2026 at approximately 2:00 PM with the Director of Nursing Services, she was unable to provide evidence that the order for Zyprexa was reviewed with the resident's representative prior to the initiation of the medication on 10/28/2025.

Based on clinical record review and staff interview, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice relative to following physician's orders for a neurology consult and psychiatric services for 1 of 1 resident reviewed, Resident ID #2.Findings are as follows:According to Mosby's 4th Edition, Fundamentals of Nursing page 314, states in part, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients.Record review revealed the resident was readmitted to the facility in October of 2025 with diagnoses including, but not limited to, encephalopathy (a term used to describe any disorder or disease that affects the brain leading to dysfunction. Brain dysfunction can appear as confusion, memory loss and personality changes) and cardiac arrest (heart attack).1a. Record review revealed a physician's order dated 10/6/2025, for a neurology consult related to recent shock (an acute medical condition associated with a fall in blood pressure.)Additional record review failed to reveal evidence that the neurology consult appointment was scheduled or completed after it was ordered 10/6/2025.1b. Record review revealed of a physician's order dated 10/16/2025, to obtain a psychiatric and psychological health evaluation.Record review of a psychiatric evaluation and consultation form dated 10/28/2025, revealed the current assessment plan included a follow up in 30-45 days.Further record review failed to reveal evidence that the resident was seen for a psychiatric follow up after the above-mentioned assessment.During a surveyor interview on 1/13/2026 at 4:04 PM with the Physician, he indicated he would have expected that the facility to schedule the neurology consultation for the resident. Additionally, he indicated it would be his expectation for the resident to have been seen for psychiatric follow up.During a surveyor interview on 1/13/2026 at 4:16 PM, with the Director of Nursing Services, she was unable to provide evidence that the resident was seen by psychiatric services for follow up. Additionally, she was unable to provide evidence that the neurology consultation was scheduled or completed for the resident.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide the mandatory effective communication training for 7 of 7 direct care staff members, Staff K, L, M, N, O, P, and Q regarding Resident ID #63 who only speaks Cantonese (a traditional variety of Chinese language originating from the city of [NAME]). Findings are as follows:During a surveyor interview on 9/2/2025 at approximately 10:20 AM with Resident ID #63, s/he was unable to communicate in English.Review of a Quarterly Minimum Data Set assessment dated [DATE] revealed that his/her preferred language is Chinese.Record review of his/her care plan revealed that s/he does not speak the dominant language of the facility and speaks Cantonese.Record review of the employee education records failed to reveal evidence that effective communication trainings were completed for the following staff members in order to successfully communicate with Resident ID #63:-Staff K, Licensed Practical Nurse-Staff L, Certified Medication Technician-Staff M, Nursing Assistant-Staff N, Registered Nurse-Staff O, Nursing Assistant-Staff P, Dietary Aide-Staff Q, Nursing AssistantDuring a surveyor interview on 9/5/2025 at 9:25 AM with the Director of Nursing Services, she indicated that she would expect the facility to provide communication education to staff members. During a surveyor interview on 9/5/2025 at 9:34 AM with the Administrator, she acknowledged that the facility does not include effective communications as mandatory training for any facility staff members, as required.Cross reference F-675

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, relative to the utilization of a heel offloading device for 1 of 2 residents reviewed, Resident ID #3.Findings are as follows:According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients.Record review revealed the resident was readmitted to the facility in January of 2025 with diagnoses including, but not limited to, cerebral palsy and contractures of the right and left lower legs.Record review revealed a physician's order dated 8/26/2024 to offload the resident's right heel and ankle when in bed, as tolerated, with an ankle offloading device.Surveyor observations revealed that the resident's right heel was not offloaded, and his/her heel was lying directly on the mattress on the following dates and times:- 9/3/2025 at 12:44 PM- 9/5/2025 at 8:46 AM, 10:25 AM, and 12:19 PMRecord review failed to reveal evidence that the resident could not tolerate his/her right heel being offloaded with the offloading device while in bed.During surveyor interviews on 9/5/2025 at 8:46 AM and 12:19 PM with Registered Nurse, Staff A, she acknowledged that the resident's right heel was directly on the mattress, and the offloading device was placed on the resident's left ankle instead of the right ankle. She further revealed that the resident's heels did not need to be offloaded because the resident was using an air mattress. The physician's order was reviewed with Staff A, and she acknowledged that the order for the offloading device was to be placed on the resident's right heel and ankle.During a surveyor interview on 9/5/2025 at 10:25 AM with Nursing Assistant, Staff B, she acknowledged that the resident's right heel was not offloaded and indicated the offloading device has not been placed on the resident's right ankle but rather on his/her left ankle.During a surveyor interview on 9/5/2025 at 12:25 PM with the Director of Nursing Services, she revealed it is her expectation for the resident to have the right heel and ankle offloading device in place, as ordered.

Based on surveyor observation, record review, representative and staff interview, it has been determined that the facility failed to ensure that the care and services provided are person-centered, and honor and support each resident's preferences, choices, values and beliefs for 1 of 1 resident reviewed who is unable to speak or understand the English language, Resident ID #63.Findings are as follows:Record review revealed the resident was admitted to the facility in February of 2005 with diagnoses including, but not limited to, Alzheimer's disease.During a surveyor interview on 9/2/2025 at approximately 10:20 AM with the resident, s/he was unable to communicate in English.Review of a Quarterly Minimum Data Set assessment dated [DATE] revealed that his/her preferred language is Chinese.Record review of his/her care plan revealed that s/he does not speak the dominant language of the facility and speaks Cantonese (a traditional variety of Chinese language originating from the city of [NAME]) with an intervention to encourage him/her to use flash cards when expressing him/herself, and to provide him/her with visual cueing, interpreter services, and a foreign language dictionary to enhance communication.Record review of the flash cards labeled Communication Cards English and/or Chinese traditional failed to reveal evidence of content in the Cantonese language. This is a concern, as the resident is known to understand Cantonese. The absence of Cantonese-specific materials may limit effective communication with the resident.Further record review of the care plan revealed that the resident's cultural preferences will be respected and observed as s/he is of Chinese descent. The interventions include identifying coping strategies per the resident's preferences and to provide support in processing life events were identified. However, the facility staff failed to provide evidence that they can communicate effectively with the resident to provide the above-mentioned interventions.During surveyor observations on the following dates and times the resident was observed lying in bed without translation cards or a Cantonese language dictionary:- 9/2/2025 at 10:20 AM- 9/3/2025 at 9:49 AM and 12:57 PM- 9/4/2025 at 7:55 AMDuring a surveyor interview on 9/3/2025 at 1:05 PM with Registered Nurse, Staff C, she was unable to identify what type of Chinese language the resident was speaking and was unaware of an interpreter service to utilize for communicating with the resident. She added that she calls the resident's family member to assist with translating and communicating the resident's concerns.During a surveyor interview on 9/4/2025 at 11:29 AM with the Activity Director and the Activity Aide, Staff D, revealed that they did not know what type of Chinese language the resident spoke. Additionally, they revealed that they were not aware of any available interpreter service they can utilize to communicate with the resident.During a surveyor interview on 9/4/2025 at 11:42 AM with the resident's assigned Nursing Assistant, Staff E, she revealed that she was unaware of what language the resident spoke and did not know about the utilization of a translating card to communicate to the resident.During a surveyor interview on 9/4/2025 at 11:45 AM with Nursing Assistant, Staff F and Medication Technician, Staff G, they revealed that they were unaware of what type of Chinese language the resident spoke and acknowledged that they have never utilized an interpreter service to communicate with the resident.During a surveyor interview on 9/5/2025 at 10:53 AM with the resident's family member, s/he revealed that the resident is unable to understand or speak English as the resident only speaks a specific dialect of Cantonese.During a surveyor interview on 9/4/2025 at 11:55 AM with the Director of Nursing Services, she revealed that the facility did not have interpreter services available for the residents. Additionally, she was unable to provide evidence of person-centered care that honors and supports the resident's preferences, choices, values and beliefs for Resident ID #63.Cross reference F 941

Based on record review and staff interview, it has been determined that the facility failed to develop, implement, and maintain an effective training program for all newly hired employees and annual training for existing employees consistent with their expected roles, relative to education involving abuse, infection control, dementia behavioral health management, trauma informed care and Quality Assurance and Performance Improvement (QAPI) per the facility assessment, for 5 of 7 staff members reviewed, Staff K, L, M, N, and O.Findings are as follows: Review of the Facility Assessment, last updated 1/5/2025, states in part, Education.Training/Competencies related to resident specific service.Yearly and as needed .In person in-services are used for our annual education and new hire through our Annual Education Binder.1. Record review revealed Licensed Practical Nurse, Staff K, was hired on 3/23/2018. Review of her training records failed to reveal evidence that she received or completed annual education regarding Trauma Informed Care.2. Record review revealed Certified Medication Technician, Staff L, was hired on 10/12/2023. Review of her training records failed to reveal evidence that she received or completed annual education regarding Trauma Informed Care or QAPI.3. Record review revealed Nursing Assistant (NA), Staff M, was hired on 4/12/2024. Review of her training records failed to reveal evidence that she received or completed annual education regarding Trauma Informed Care or QAPI.4. Record review revealed Registered Nurse, Staff N, was hired on 6/25/2024. Review of her training records failed to reveal evidence that she received or completed annual education regarding Trauma Informed Care or QAPI.5. Record review revealed NA, Staff O, was hired on 8/2/2024. Review of her training records failed to reveal evidence that she received or completed annual education regarding, Infection Control, Abuse, Dementia behavioral health management, Trauma Informed Care or QAPI.During a surveyor interview on 9/5/2025 at 9:34 AM with the Administrator, she could not provide evidence of the above-mentioned required trainings for Staff K, L, M, N, and O.

Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident receives treatment and care in accordance with professional standards of practice for 1 of 1 resident reviewed with recommendations from a urologist (a medical practitioner that specializes in the diagnosis and treatment of disorders of the urinary system), Resident ID #40.Findings are as follows:Record review revealed the resident was admitted to the facility in January of 2021 with a diagnosis including, but limited to, malignant neoplasm (a cancerous tumor) of the prostate.Record review of the After Visit Summary dated 8/4/2025 from the urologist revealed a recommendation to obtain a Prostate-Specific Antigen (PSA- a test that is used to measure the amount of protein produced by prostate cells and is utilized to monitor for prostate cancer).Review of the resident laboratory results failed to reveal evidence that the PSA was completed on or after 8/4/2025 or that the physician at the facility was contacted to write an order for the lab work.During a surveyor interview on 9/3/2025 at 1:06 PM with Registered Nurse, Staff A, she revealed that it is facility's procedure to contact the primary care physician when a specialist treatment recommendation is received. Additionally, she was unable to provide evidence of the above-mentioned laboratory results.During a surveyor interview on 9/3/2025 at 1:31 PM with the Director of Nursing Services, she revealed that the above-mentioned recommendation should have been reviewed by the facility nurse upon receipt and a physician's order should have been obtained. Additionally, she indicated that the PSA recommendation was reviewed and approved with the provider and has been implemented as a physician's order after it was brought to the facilities attention by the surveyor.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure each residents' medication regimen is free from a medication error rate of 5% or greater. Based on 28 opportunities for errors observed during the medication administration task, there were 2 errors resulting in an error rate of 7.14%, affecting Resident ID #s 2 and 64.Findings are as follows:Review of a facility policy titled, Medication Administration Safety Program (MASP)- Safety Guidelines last reviewed 1/2/2025, states in part, .It is the policy of this facility that resident[s] shall receive medications in a safe and timely manner and in accordance with established regulations and guidelines.1. Record review revealed Resident ID #64 has a physician's order dated 5/13/2025 to administer two doses of polyethylene glycol 3355 powder (MiraLAX - a medication prescribed for constipation) 17 grams (g) for a total dose of 34g once daily. Surveyor observation during the medication administration task on 9/4/2025 at 8:57 AM with Certified Medication Technician (CMT), Staff H, she was observed to administer 17g of MiraLAX instead for a total of 34g, as ordered. During a surveyor interview on 9/4/2025 at 3:35 PM with Staff H, she acknowledged that she administered 17g of MiraLAX instead of the 34g to Resident ID #64. 2. Record review revealed Resident ID #2 has a physician's order dated 8/20/2025 for MiraLAX 17g with special instructions to mix the medication in 4 to 6 ounces (oz) of fluids. Surveyor observation during the medication administration task on 9/4/2025 at approximately 9:51 AM with CMT, Staff G, she was observed to mix the MiraLAX powder in approximately 2 oz of fluids instead of the 4 to 6 oz, as ordered.During a surveyor interview on 9/4/2025 at approximately 10:00 AM with Staff G, she acknowledged that she mixed the MiraLAX powder in approximately 2 oz of fluid. Additionally, she indicated that she was unaware that the order indicated to mix the medication in a particular amount of fluid. During a surveyor interview on 9/4/2025 at 3:07 PM with the Director of Nursing Services, she indicated that she would expect the physician's orders to be followed.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections, relative to staff wearing the appropriate personal protective equipment (PPE) while handling soiled linen, for 1 of 1 staff member observed, Staff I.Findings are as follows:Review of the facility policy titled, Infection Control Guidelines for Housekeeping/Laundry, states in part, .All laundry will be handled as if it is potentially infectious and/or capable of transmitting infectious disease.Laundry workers will wear appropriate personal protective equipment when handling contaminated laundry to include at a minimum.gown or apron and face mask protection is to be available and used when there is a possibility of splashing body fluids into the mouth, nose, or eyes. During a surveyor observation on 9/5/2025 at approximately 11:40 AM, Laundry Aide, Staff I, was observed handling soiled personal clothing and linens in the soiled linen room, wearing only procedure gloves, and without wearing a gown or apron. During a surveyor interview with Staff I during the above observation, she indicated that she usually only wears gloves when handling soiled linens. Additionally, she indicated that she only wears a gown if she is told that a resident is on precautions, or if the linen is in a red bag, indicating there is blood on the linens. During a surveyor interview on 9/5/2025 at approximately 11:45 AM with Laundry Aide, Staff J, she indicated that she had not been made aware that a gown or apron should be worn when handling soiled linens. During a surveyor interview on 9/4/2025 at 2:20 PM with the Infection Preventionist, she indicated that staff only wear PPE for handling soiled laundry for residents on precautions and not for handling all residents' soiled laundry.

Based on record review and staff interview, it has been determined that the facility failed to ensure that nursing staff have the appropriate competencies and skill sets to provide nursing and related services to assure resident safety to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment as required for 1 of 1 staff reviewed, Registered Nurse, Staff A . Findings are as follows: Record review of the facility assessment states that the resident population diagnoses include, but are not limited to, chronic obstructive pulmonary disease (a lung condition caused by damage to the lungs) and acute respiratory failure with hypoxia (low levels of oxygen in your body tissues). Further review revealed nurse competencies should be completed upon hire and annually, and as dictated by the care needs of residents. Record review failed to reveal evidence of competencies and skill sets for acute respiratory failure with hypoxia on orientation relative to the use of oxygen therapy for Staff A, with a hire date of 6/25/2024. During a surveyor interview on 12/16/2024 at 2:12 PM with the Director of Nursing Services, she indicated that the facility does not complete education, or competencies specifically related to administering oxygen for any of their nursing staff. Cross reference F-658.

Based on record review and staff interview it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, relative to oxygen administration during an acute medical event for 1 of 2 residents reviewed, Resident ID #1. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health on 12/13/2024, alleged that the resident was on oxygen and when emergency medical service (EMS) arrived to the facility, the oxygen was not on. The complaint further alleged that the resident was brought to the hospital with hypoxia (low levels of oxygen in your body tissues). According to [NAME] 9th Edition, Nursing Procedures page 621, which states in part, Oxygen administration helps relieve hypoxemia and maintain adequate oxygenation of tissues and vital organs .Indications for oxygen administration include .oxygen saturation .less than 90% on room air .Monitor the patient's oxygen saturation level using pulse oximetry [a noninvasive method for monitoring blood oxygen saturation] to assess the response to oxygen therapy . Record review revealed that the resident was readmitted to the facility in August of 2024 with diagnoses including, but not limited to, dementia and chronic obstructive pulmonary disease (a lung condition caused by damage to the lungs). Record review of a Nurse Practitioner (NP) encounter note dated 12/12/2024 at 4:00 PM, revealed the resident was assessed to be having acute respiratory failure with hypoxia and presented with signs of mild respiratory distress, tachypnea (increased respiratory rate), tachycardia (increased heart rate), and slight expiratory wheezing. Further review revealed oxygen therapy was initiated for oxygen saturation less that 91%, with a goal of 90 to 97%. Additional review revealed the nursing staff was informed of the plan of care. Record review of a late entry nursing progress note, authored by Registered Nurse (RN), Staff A revealed that on 12/12/2024 at approximately 7:00 PM the resident appeared lethargic with increased weakness, a delayed response and an oxygen saturation of 85% on room air. Further review indicated the nurse put the resident on 2 liters (L) of oxygen via nasal canula (tubing that delivers oxygen through the nose) to improve the resident's breathing. Additional review revealed the resident's family member requested that resident be sent to the hospital for an evaluation, at which time the NP was contacted, and the resident was sent to the hospital via 911. Review of the EMS Patient Care Report dated 12/12/2024 at 7:28 PM revealed that upon arrival to the facility, the resident's oxygen was turned off and his/her oxygen saturation was 84% on room air. Further review revealed the resident's oxygen saturation improved to 95% on 6 L of oxygen and the resident became alert to verbal stimuli. Record review of hospital documentation dated 12/13/2024 revealed the resident was admitted to the hospital on 12/12/2024 with hypoxia and was being evaluated for sepsis (an infection in the blood stream). During a surveyor interview on 12/16/2024 at 10:57 AM with Nursing Assistant (NA), Staff B, she indicated that she was working on the resident's unit on 12/12/2024, 3:00 PM -11:00 PM shift, and saw that the resident was sick and put on oxygen. She further indicated that the concentrator started beeping so she informed the nurse who went into the resident's room to turn the concentrator off and on again. Additionally, she indicated that the concentrator continued beeping and the nurse was aware that it was not working appropriately. Staff B indicated that RN, Staff A stated to her it's okay [s/he] is going to the hospital anyway. During a surveyor interview on 12/16/2024 at 12:26 PM with RN, Staff A, she indicated that she was the resident's nurse on 12/12/2024 and had been made aware of the resident's condition by the resident's family member. She further indicated that she obtained the resident's vital signs including oxygen saturation which was 85% on room air. Additionally, she indicated that she placed the resident on 2 L of oxygen via a concentrator which started beeping but then stopped. Furthermore, she acknowledged that she did not reevaluate the resident after placing the resident on oxygen. During a surveyor interview on 12/16/2024 at 1:44 PM with the Director of Nursing Services, she indicated that she would expect the resident to be placed on oxygen and that the nurse would assess the resident's oxygen saturation after applying the oxygen. Cross reference F-726.

Based on record review and staff interview, it has been determined that the facility failed to ensure residents are free from abuse related to involuntary seclusion for 1 of 3 residents reviewed, Resident ID #1. Findings are as follows: Record review of a facility reported incident received by the Rhode Island Department of Health on 12/6/2023 states in part, Upon initial investigation of the incident, it appears a nurse [Licensed Practical Nurse, Staff C] involuntarily restrained a resident in [his/her] room . Record review of the facility policy titled Abuse prohibition revealed in part, .Involuntary seclusion = separation of the resident from others or confinement to a room when it is against the resident's wishes . Record review revealed Resident ID #1 was admitted to the facility in August of 2023 with diagnoses including, but not limited to, Alzheimer's disease, and unspecified signs and symptoms involving cognitive functions and awareness. Record review of a Minimum Data Set assessment dated [DATE] revealed that the resident was unable to complete a Brief Interview for Mental Status. Record review of a statement written on 12/6/2023 by the scheduler, Staff A, states in part, I walked up on the floor to talk to [Staff B] about scheduling, heard banging on the door behind me. I saw there was a towel on the door handle that appeared to be holding the resident in the room. I asked [Staff B] what was going on. She said the nurse put it there to keep the resident in room .I reported to DNS [Director of Nursing Services] immediately. During a surveyor interview with Staff A on 12/7/2023 at 10:00 AM, she confirmed the above statement and further indicated that the resident was not able to get out by his/herself. Record review of a statement written on 12/6/2023 by the Nursing Assistant (NA), Staff B, states in part, My nurse [Staff C] asked me for towel on this date, she did not tell me what it was for. I got her a towel. I called [Staff A] as I had to talk to her about an appointment, we heard banging behind us. We both noticed a towel was around a door handle- [NA] from agency walked over immediately and removed the towel . During a surveyor interview with Staff B on 12/7/2023 at 12:45 PM, she confirmed the above statement that she heard Resident ID #1 banging on the door until the agency NA let him/her out of the room. During a surveyor interview with Staff C, on 12/7/2023 at 12:25 PM, she acknowlegded that she held the door closed, preventing the resident from exiting his/her room. Additionally, Staff C, acknowledged that it was not acceptable to prevent residents from leaving their room without their consent. During a surveyor interview with the Administrator, in the presence of the DNS and Assistant DNS on 12/7/2023 at approximately 1:30 PM, they were unable to provide evidence that the resident was kept free from abuse relative to involuntary seclusion.

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents who are trauma survivors receive trauma informed care in accordance with professional standards of practice and accounting for residents' experiences for 1 of 1 resident reviewed who was re-traumatized relative to water on his/her face, Resident ID #4. Additionally, the facility failed to assess 6 of 17 residents reviewed for Trauma Informed Care, Resident ID #s 1, 2, 4, 25, 28, and 29. Findings are as follows: Record review of a facility policy titled, Trauma Informed Care states in part, .It is the policy of this facility to avoid or minimize re-traumatization of the residents we care for who may have been traumatized in the past .It is through identification and understanding of past traumas that we will be able to plan care in a sensitive manner that eliminates or minimizes these effects .Procedure: 1. A trauma screening assessment will be done on each resident by the social worker as part of the admission social history .4. The trauma assessment tool may be utilized anytime throughout the course of care if indicated. 1. Record review revealed Resident ID #4 was admitted to the facility in March of 2023 with diagnoses including, but not limited to, Alzheimer's disease and mood disorder due to a known physiological condition with depressive features. Record review of a Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 4 out of 15, indicating severely impaired cognition. Record review of a progress note dated 9/18/2023 at 5:42 PM authored by Licensed Practical Nurse (LPN), Staff E, revealed in part, that Resident ID #4 put him/herself on the floor because s/he didn't want to be showered. The resident verbalized to the staff that s/he does not take showers. The note further reveals that the resident's son was notified that the resident had placed themselves on the floor because s/he did not want to be showered and he informed the staff that the resident had a near drowning when s/he was a child and since has a fear of water, especially on his/her face. As a result of this incident the nurse indicated in the progress note that the resident would have a full bed bath to prevent a fall. Record review of the resident's careplan revealed it was updated on 9/19/2023 to include that the resident's preference to not be showered and to only receive bed baths. Record review failed to reveal evidence that a social history assessment and assessment for trauma was completed for the resident. Further record review failed to reveal evidence that a trauma informed care plan was developed for the resident prior to the above-mentioned incident. During a surveyor interview on 9/22/2023 at 10:41 AM with LPN, Staff F, she revealed that the resident often refuses showers and exhibits combative behaviors. Additionally, she revealed that she was unaware of the resident's past childhood trauma until the above-mentioned incident occurred. Furthermore, she revealed if there was any past trauma identified, it would be included in the resident's care plan. During a surveyor interview on 9/22/2023 at 9:11 AM and again at 9:19 AM with Nursing Assistant (NA), Staff G, she indicated that the resident refuses showers sometimes and she doesn't know why. She further revealed she is unaware that the resident does not like showers due to a childhood near drowning experience, despite the care plan having been updated on 9/19/2023 to reflect this information. During a surveyor interview on 9/22/2023 at 9:14 AM with NA, Staff C, she indicated that she continues to offer the resident showers and s/he refused sometimes and she's not sure why, but stated, probably because [s/he] is confused. Additionally when asked by the surveyor if she was aware of the resident's childhood trauma, she acknowledged that she was aware of the resident's fear of water on his/her face. When she was asked by the surveyor why she continues to offer showers to the resident, she was unable to provide an explanation. During a surveyor interview on 9/22/2023 at 9:27 AM with the Social Worker, she revealed she remembers speaking with the resident towards the end of March and one of the first questions she asks about is trauma. She further revealed that the Social History Assessment that includes a screening to identify past trauma, is completed upon admission and should be finalized within the first two weeks. Additionally, she indicated if past trauma was identified, she would include the information in the resident's care plan and notify the nurses and nursing assistants. She was unable to provide evidence that the resident was assessed for past trauma prior to the above-mentioned incident. During a follow up interview on 9/22/2023 at 11:35 AM with the Social Worker, she acknowledged that the Social History Assessment was completed with the resident who was identified as severely cognitively impaired and not with the resident's son, who is actively involved with his/her care. She further revealed that the resident did not identify any past trauma, and if s/he did, it would've been included in the care plan. During a surveyor interview on 9/22/2023 at 11:45 AM with the Director of Nursing Services (DNS), she revealed that she would expect the Social Worker to have completed the Social History Assessment upon admission with the resident's son due to the resident's impaired cognition to obtain an accurate assessment. She further revealed she would expect that all staff involved in providing care to the resident should be made aware of his/her past trauma. Additionally she indicated that she would expect the resident's care plan to be followed. 2. Review of the facility's policy titled, Substance Abuse and Mental Health Services Administration, Trauma Informed Approach, states in part, .without screening, clients' trauma histories and related symptoms often go undetected .screening, early identification, and intervention serves as a prevention strategy .the first two steps in screening are to determine whether the person has a history of trauma and whether he/she has trauma-related symptoms .trauma-informed screening is an essential part of the evaluation and planning process .an assessment determines the nature and extent of the problem and presenting struggles to develop an appropriate treatment plan . 2a. Record review revealed Resident ID #1 was readmitted to the facility in March of 2023 with diagnoses including, but not limited to, post-traumatic stress disorder (PTSD), and depression. Record review of a care plan dated 7/26/2023 revealed the resident .has a history of traumatic experience .was abused as a child both sexually and verbally . Record review failed to reveal evidence that a trauma screening assessment was completed. 2b. Record review revealed Resident ID #2 was admitted to the facility in February of 2013 with diagnosis including, but not limited to, anxiety. Record review failed to reveal evidence that a trauma screening assessment was completed. 2c. Record review revealed Resident ID #4 was admitted to the facility in March of 2023 with diagnoses including, but not limited to, Alzheimer's disease and mood disorder due to a known physiological condition with depressive features. Record review failed to reveal evidence that a trauma screening assessment was completed. 2d. Record review revealed Resident ID #25 was admitted to the facility in July of 2017 with diagnoses including, but not limited to, psychotic disorder with hallucinations, depression and anxiety. Record review failed to reveal evidence that a trauma screening assessment was completed. 2e. Record review revealed Resident ID #28 was readmitted to the facility in July of 2023 with diagnoses including, but not limited to, schizophrenia and anxiety disorder. Record review failed to reveal evidence that a trauma screening assessment was completed. 2f. Record review revealed Resident ID #29 was admitted to the facility in April of 2022 with diagnoses including, but not limited to, major depressive disorder and anxiety disorder. Record review failed to reveal evidence that a trauma screening assessment was completed. During a surveyor interview with the Social Worker on 9/22/2023 at approximately 9:20 AM, she indicated that she completes a trauma screening assessment within two weeks of a resident's admission. She further revealed that for long term residents who have been living at the facility prior to the Trauma Informed Care Assessment regulatory requirement enforced in November 2019, a trauma screening assessment is completed with the next Minimum Data Set (MDS) Assessment. Additionally, she was unable to explain why the trauma screening assessments had not been completed for the above-mentioned residents. During a surveyor interview on 9/22/2023 at 11:45 AM with the DNS, she revealed that she would expect the Social Worker to have completed the required trauma screenings and social histories for all of the above-mentioned residents. She further revealed that she would expect that all staff involved with resident care to be made aware of the residents' past traumas and would expect that the residents' care plans be developed and followed to reflect their past history. 47279 47808

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain medical records that are accurately documented in accordance with professional standards and practices for 1 of 4 residents reviewed for elopement, Resident ID #516. Findings are as follows: Record review revealed the resident was admitted to the facility in September of 2023 with diagnosis including, but not limited to, schizophrenia (a disease which causes people to interpret reality abnormally). Record review of the Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating severely impaired cognition. Additionally, s/he was assessed for wandering behavior and was coded as utilizing a wander/elopement alarm daily. Record review revealed a physician's order with a start date of 9/12/2023 to monitor placement of the wanderguard (elopement alarm) to his/her left wrist every shift. Surveyor observations on the following dates and times failed to reveal evidence that the resident was wearing his/her wanderguard as ordered: - 9/19/2023 at 12:16 PM - 9/20/2023 at 9:09 AM - 9/20/2023 at 11:05 AM - 9/20/2023 at 3:55 PM Record review of the September 2023 Treatment Administration Record revealed that the order to monitor placement of the wanderguard was signed off as completed despite it not being observed on the resident. During a surveyor interview with the Nursing Assistant, Staff C, on 9/21/2023 at 10:51 AM, she acknowledged that the resident is an elopement risk and did not have his/her wanderguard on as ordered. During a surveyor interview with the Director of Nursing Services on 9/21/2023 at 1:36 PM, she revealed that she would expect the staff to follow the physician's order to ensure the placement of wanderguard and document accordingly.

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that services provided meet professional standards of quality for 1 of 5 residents reviewed relative to positioning, Resident ID #25. Findings are as follows: Mosby's 4th Edition, Fundamentals of Nursing, page 314 states, The physician is responsible for directing medical treatment. Nurses are obligated to follow physicians' orders unless they believe the orders are in error or would harm the clients. Record review for the resident revealed s/he was admitted to the facility in August of 2017 with diagnoses including, but not limited to dysphasia (difficulty swallowing foods or liquids), Alzheimer's disease with early onset, and Gastro-esophageal reflux disease (a condition where acid from the stomach leaks up into the esophagus). Review of a physician's order dated 7/10/2022, which states, keep the HOB [head of bed] elevated at 45 degrees at all times. Review of a Minimum Data Set (MDS) assessment dated [DATE], revealed the resident is totally dependent on staff for eating and drinking and requires a one person assist with eating and drinking. Review of a care plan dated 8/4/2023, states in part, .potential nutrition risk for aspiration R/T [related to] mechanically altered diet .ensure proper positioning during all PO [oral] intake. Monitor for s/s [signs and symptoms] of aspiration or difficulty chewing or swallowing. During a surveyor observation on 9/21/2023 at 1:50 PM, revealed the head of the resident's bed was not was not elevated at 45 degrees per the physician's order, and s/he was lying flat on his/her back. Additionally, the resident's lips were quivering, and his/her lunch tray was on the bedside table, which had been eaten as evidenced by having minimal food left on the plate. During a surveyor interview on 9/21/2023 immediately following the above observation, with Certified Medication Technician, Staff A, she acknowledged that the resident had eaten lunch and should not be lying flat in bed as observed due to his/her requiring the head of the bed to be elevated as per a physician order. During a surveyor interview on 9/21/2023 at approximately 1:55 PM, with Registered Nurse, (RN), Staff B, she acknowledged the resident's bed was not elevated at 45 degrees as ordered by the physician. Additionally, the RN acknowledged that the resident requires the head of the bed to be elevated at all times due to a diagnoses of dysphasia and a history of aspiration. During a surveyor interview on 9/22/2023 at approximately 10:57 AM, with the Director of Nursing Services, she acknowledged that the resident has a physician's order for the head of the bed to be elevated at 45 degrees at all times.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents identified as an elopement risk received adequate supervision for 1 of 4 residents reviewed, Resident ID #516. Findings are as follows: Record review of a facility policy titled Elopement Assessments states in part, .5. If the resident is at risk for elopement, then the necessary and appropriate intervention must be put in place immediately to keep the resident safe, ( .wanderguard bracelet .) . Record review revealed the resident was admitted to the facility in September of 2023 with diagnosis including, but not limited to, schizophrenia (a disease which causes people to interpret reality abnormally). Further record review revealed the resident resides on an unsecured unit. Record review of the Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating severely impaired cognition. Additionally, s/he was assessed for wandering behavior and was coded as utilizing a wander/elopement alarm daily. Record review of the document titled Elopement/Wander Risk Scale completed on 9/12/2023 revealed a score of 14, which indicates that the resident is at risk for elopement. Record review revealed a physician's order with a start date of 9/12/2023 to monitor placement of wanderguard (elopement alarm) to left wrist every shift. Surveyor observations on the following dates and times revealed the resident was not wearing his/her wanderguard: - 9/19/2023 at 12:16 PM - 9/20/2023 at 9:09 AM - 9/20/2023 at 11:05 AM - 9/20/2023 at 3:55 PM - 9/21/2023 at 10:14 AM - 9/21/2023 at 10:51 AM During a surveyor interview with the Nursing Assistant, Staff C, on 9/21/2023 at 10:51 AM, she acknowledged that the resident is an elopement risk and did not have his/her wanderguard on. During a surveyor interview with the Director of Nursing Services on 9/21/2023 at 1:36 PM, she acknowledged that the resident needs to have the wanderguard on. Additionally, she revealed that she would expect the staff to follow the physician's order and ensure the placement of the wanderguard.

Based on surveyor observation, record review, and staff interview it has been determined that the facility failed to meet professional standards of practice relative to a peripherally inserted central catheter (PICC) for 1 of 1 resident observed for intravenous (IV) antibiotic administration via a PICC line, Resident ID #520. Findings are as follows: According to an article in the Journal of Infusion Nursing dated 2021, states in part, .1. During the initial flush, slowly aspirate the VAD [Vascular Access Device] for free-flowing blood return that is the color and consistency of whole blood, an important component of assessing catheter function prior to administration of medications and solutions . Record review revealed that the resident was admitted to the facility in September of 2023 with diagnoses including, but not limited to, subacute osteomyelitis (bone infection) of the right ankle and foot, and type 2 diabetes mellitus. Record review revealed the following physician orders: - 9/6/2023 PICC single lumen right arm. - 9/5/2023 ceftriaxone (antibiotic) to be given intravenously once a day between 11:00 AM and 1:00 PM for 35 days. During a surveyor observation on 9/21/2023 at 11:13 AM of Registered Nurse, Staff D, she was observed flushing the resident's PICC line with 10 milliliters of normal saline and failed to assess for blood return prior to administering the above-mentioned antibiotic medication intravenously. During a surveyor interview on 9/21/2023 at approximately 11:15 AM with Staff D immediately following the above observation, she acknowledged that she did not assess for blood return prior to administering the IV antibiotic medication to the resident. She revealed that the resident's PICC line is a single lumen catheter, and believed it was not necessary. During a surveyor interview with the Director of Nursing Services on 9/21/2023 at 1:55 PM, she revealed she would expect staff to assess the patency of the PICC line by flushing the catheter with normal saline and checking for a blood return. Additionally, she was unable to provide evidence that the facility fully assessed the PICC line function prior to the IV antibiotic medication administration.

Based on record review and staff interview it has been determined that the facility failed to have a tracking mechanism that identified each staff's role, assigned work area, and how they interact with residents for individuals who provide care, treatment, or other services for the facility and/or its residents, under contract or by other arrangement. Findings are as follows: Review of the facility's Staff COVID-19 vaccination tracking document revealed tracking for direct hire staff. The document failed to reveal evidence of tracking for individuals who provide care, treatment, or other services for the facility and/or its residents, under contract or by other arrangement. Additional record review failed to reveal evidence of a COVID-19 vaccination tracking document for individuals who provide care, treatment, or other services for the facility and/or its residents, under contract or by other arrangement, including, but not limited to the following individuals or contracted companies: 1. Continuum Hospice Registered Nurse 2. Wound Physician 3. Attending Physician 4. Podiatrist 5. Any names of staff members from Preventative Diagnostic ( x-ray company) 6. Any names of staff members from East Side Clinical Laboratory During a surveyor interview on 8/4/2022 at approximately 1:00 PM with the Director of Nursing Services (DNS) and the Infection Preventionist, they revealed the facility does not track any contracted staff or vendors COVID-19 vaccination information. During a surveyor interview with the DNS and the Administrator on 8/4/2022 at approximately 2:40 PM they were unable to provide evidence of a COVID-19 vaccination tracking document for individuals who provide care, treatment, or other services for the facility and/or its residents, under contract or by other arrangement.

Based on 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 prevent new pressure ulcers from developing for 1 of 4 sample residents reviewed who is at risk for developing pressure ulcers, Resident ID #1. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health, dated 6/6/2022 revealed this resident has a sacral wound which is almost completely down to the bone. Review of a facility policy titled Skin Care Protocol states in part, .For those residents identified as at risk, interventions must be carried out in a timely manner .The physician and the resident's representative shall be made aware of any pressure ulcers and significant changes in the resident's condition . Record review revealed this resident was admitted to the facility in May of 2017 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of an annual Minimum Data Set assessment (MDS, an assessment of each resident's functional capabilities) dated 4/15/2022 indicating s/he is totally dependent on two staff for bed mobility. Additionally, a Brief Interview for Mental Status assessment revealed s/he has severe cognitive impairment. Record review of a Braden Assessment (an assessment used to predict the risk for developing pressure ulcer) dated 4/13/2022 revealed the resident had a score of 12. This score indicates s/he is at a high risk for developing a pressure ulcer. Record review of a care plan initiated on 6/22/2020 and edited on 6/1/2022 revealed the resident is at risk for impaired skin integrity secondary to lower extremity impairment and s/he is unable to move and reposition him/herself. Further review of the care plan indicates the resident has a pressure ulcer to his/her coccyx and left buttocks. Record review revealed the following: -4/9/2022: .New Non-Blanchable area, complete wound documentation per policy . - 4/10/2022: .slit to coccyx: size: 2cm [centimeter] x 0.5cm no depth . - 4/13/2022: Resident noted with a slit to coccyx .Resident at risk for skin break down .Resident referred to wound doctor . - 4/14/2022: .slit to coccyx: size: 2cm x 0.5cm no depth . - 4/17/2022: .Slit to coccyx worsen and changed to pressure . Record review of the facility's document titled [NAME] Wound Care Initial Evaluation dated 4/18/2022 revealed the resident had an unstageable (Full thickness tissue loss in which actual depth of the ulcer is completely obscured by dead tissue) wound to his/her coccyx. Further record review of this evaluation revealed the wound measured 5 cm x 7 cm x not measurable (length x width x depth). Additional record review of the facility document titled Wound evaluation Management Summary revealed the following: -4/27: .Unstageable due to necrosis [death of cells or tissue through disease or injury] to coccyx: wound size: 5 x 4.5 cm x not measurable . - 5/11: .Stage 3 Pressure wound coccyx full thickness: wound size: 3.4 x 5.2 cm x not measurable . - 5/18: .Stage 3 Pressure wound coccyx full thickness: wound size: 4.2 x 4 cm x not measurable . - 5/25: .Stage 3 Pressure wound coccyx full thickness: wound size: 5.5 x 5 cm x not measurable .wound progress: Deteriorated . - 6/1: Stage 4 Pressure wound [ the most severe form of bedsores/deep wound that reaches the muscles, ligaments, or even bone], coccyx full thickness: wound size: 8.2 x 8.5 x 1.6 cm .wound progress: Deteriorated .wound has deteriorated significantly this past week .severe worsening of the wound and plan moving forward with IV [intravenous] [MEDICATION(S)] [a medication used to treat infection] . Record review revealed this resident was transferred and admitted to the hospital on 6/4/2022 with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of a hospital document dated 6/6/2022 states in part, .concern for infection, most likely source being deep sacral wound that appears to extend to bone .obtain CT to evaluate for any deeper extension of infection . Record review failed to reveal evidence that the physician was made aware of the change in condition when the skin impairment was identified. Additionally, the resident's wound was not assessed by a physician until 4/18/2022 which is 9 days after the skin impairment was identified by the staff. During a surveyor interview with a Registered Nurse, Staff A, on 6/8/2022 at 2:29 PM, she acknowledged she observed the skin condition change on 4/9/2022. During a surveyor interview with the Director of Nursing Services (DNS) on 6/8/2022 at 1:45 PM and 3:15 PM, she indicated that she would expect the staff to notify the physician of any changes in the resident's condition when identified by the staff. Additionally, she could not provide evidence as to why the staff did not notify the physician until 4 days after the change was identified. During a surveyor interview with the Nurse Practitioner, Staff B, on 6/8/2022 at 3:18 PM, he indicated the facility did not inform him of the resident's change in skin condition on 4/9/2022. Additionally, he acknowledged that the resident's wound did deteriorate from the date it was identified. He further indicated that the resident was receiving IV antibiotics due to infection in the wound.