Care One At Millbury

should be ample documentation in a residents' medical record if education, including risks, was provided to a resident who refused the use of assistive devices and that the provider should be notified of refusals.

The SDC said that if education is given verbally to a resident, the staff [nursing and rehabilitation] are responsible to write a progress note indicating education was completed.During a telephone interview on 11/19/25 at 4:05 P.M., the Director of Rehabilitation said when Resident #1 was discharged from skilled therapy on 09/20/25 the discharge plan included using two person staff assist with use of the stand aid for transfers, to maintain the safety of both Resident #1 and the staff.

The Director of Rehabilitation said she had not been notified of Resident #1's refusals to use the stand aid prior to his/her fall on 10/04/25, and if she had been notified, the therapists would have re-evaluated him/her because refusing to use the required assistive devices for transfers becomes a safety issue.Review of Resident #1's medical record indicated that prior to the incident on 10/04/25, there was no documentation to support that nurses or rehab staff were made aware of Resident #1's refusals to use the stand aid or that education was provided to him/her regarding the risks of not using the stand aid.

During an interview on 11/19/25 at 4:17 P.M, the Director of Nurses (DON) said when Resident #1 refused to use the stand aid the CNAs should have kept him/her in bed to maintain patient safety and let the supervisor know.

The DON said no one had told her that Resident #1 had refused the stand aid prior to his/her fall on 10/04/25.

The DON said if Resident #1 had been educated about the risks of not using the stand aid it would have been documented in the nursing progress notes.

The DON said she thought the CNAs had brought the stand aid into Resident #1's room to transfer him/her out of bed on 10/04/25, she said she did not realize that was not the case.

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