Blue Hills Health and Rehabilitation Center LLC

Blue Hills Nursing Home Stoughton MA

Stoughton Elder Abuse and Nursing Home Neglect Attorneys Serving the South Shore

MI Elder Abuse Free Legal ConsultationDid someone you love suffer elder abuse or neglect at Blue Hills Health and Rehabilitation Center LLC? Our lawyers can help.

Abuse of the elderly is not acceptable and we fight hard in these types of cases. If you suspect a nursing home or caregiver has caused harm to your loved one in someone elses’ care, contact our law firm today for a free legal consultation. Talking to us does not obligate you to anything, but we may be able to tell you if you have a claim and the value of your case. If we accept your case, you pay no fee unless we recover for you.

Blue Hills Nursing Home Stoughton MAAbout Blue Hills Health and Rehabilitation Center LLC

Blue Hills Health and Rehabilitation Center LLC is owned by NSL BLUE HILLS LLC, and is a for profit, 92-bed Medicare/Medicaid certified skilled nursing facility.

Service Area:  The facility provides services to the residents of the South Shore area, Norfolk County, and surrounding areas, including Stoughton, Canton, Sharon, Randolph, Brockton, Holbrook, Noorwood, Easton, Walpole, Abington, Foxborough, Braintree, Dedham, Mansfield, Westwood, and Milton.

Blue Hills Health and Rehabilitation Center LLC focuses on 24 hour care, respite care, hospice care and rehabilitation services.

Blue Hills Health and Rehabilitation Center LLC
1044 Park Street
Stoughton, MA 02072
Phone: (781) 344-7300

CMS Star Quality Rating

The Centers for Medicare and Medicaid (CMS) rates all nursing homes that accept medicare or medicaid benefits. CMS created a 5 Star Quality Rating System—1 star is the lowest rating and 5 stars is the highest—that look at three areas.  As of 2017, Blue Hills Health and Rehabilitation Center LLC in Stoughton Massachusetts received an overall rating of 1 out of 5 stars (much below average.)

Performance Area Rating
Overall Rating 1 out of 5 (Much Below Average)
State Health Inspections 1 out of 5 (Much Below Average)
Staffing 3 out of 5 (Average)
Quality Measures 4 out of 5 (Above Average)

Fines and Penalties

The Federal Government fined Blue Hills Health and Rehabilitation Center LLC:

  • $27,073 on 08/13/2014;
  • $145,373 on 07/30/2015; and
  • $29,673 on 07/08/2015 for health and safety violations.

Offenses and Complaints Against Blue Hills Health and Rehabilitation Center LLC (NSL BLUE HILLS LLC)

Government records indicate that the nursing home had committed the following offenses:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

The nursing home failed to keep each resident's personal and medical records private and confidential.

Based on observation and interview the Facility staff failed to secure protected health
information for 17 current and past Residents of the Facility.

Findings include:

On 03/03/17 at 8:20 A.M. the Surveyor observed a binder next to the nurses station labeled 2016 DPH Survey Results. The binder contained the statement of deficiency from the Department of Public Health dated 09/13/16. The statement of deficiency contained confidential identifiers to protect the identity of each Resident. A list containing the identity of all 17 Residents, with corresponding identifiers was observed behind the statement of deficiency.

The Administrator was interviewed on 03/03/17 at 1:00 P.M. and confirmed the confidential identity of the Residents should not be part of the binder.

The nursing home failed to provide care for residents in a way that keeps or builds each resident's dignity and respect of individuality.

Based on observation, record review, and staff interview, the Facility failed to ensure that for 1 Resident (#1), of a total sample of 17 Residents, that the Resident was provided care and treatment in a dignified manner that recognized the Resident’s individual needs.

Findings include:

Resident #1 was admitted with [DIAGNOSES REDACTED].

According to the most recent MDS (minimum data set), signed as being completed 1/6/17, the resident experienced short and long-term memory impairment with severely impaired cognitive skills for daily decision making, required extensive to total dependence with all ADLs (activities of daily living), and was incontinent of bowel and bladder. The MDS indicated that the Resident had clear speech, was rarely understood, could rarely understand, had trouble concentrating, and exhibited inattention and disorganized thinking.

Record review and observation of the Resident on 3/1/17, revealed the Resident displayed additional behaviors of wandering about the Facility, including entering other resident’s rooms, and was physically (kicking, striking) and verbally abusive to staff and other residents.

The Resident was observed throughout the day on 3/15/17 and 3/16/17 as noted:

On 3/15/17 at 10:10 A.M., the Resident was observed wandering aimlessly on the North and East Units, gazing into other residents’ rooms as he/she wandered about the units. The Resident mumbled unintelligibly (German is his/her native language) as he/she wandered about. The AD (Activity Director) passed the Resident but did not try to engage or redirect the Resident toward the MDR (Main Dining Room) where activities were underway.

The Resident’s hair was observed to be long and greasy in appearance. He/she was observed to be wearing a form-fitting green shirt that was tucked into a loose fitting pair of blue denim pants. The Resident was observed to have no bra for support underneath their shirt. The Resident was observed to be wearing slipper socks as footwear. Observation of the back of the Resident’s pants revealed a large bulging area from the incontinent brief that the Resident was wearing.

At 12:07 P.M., the Resident was observed wandering without purpose in the North Unit corridor holding a white facecloth in his/her hand. The Resident was dressed in the same manner as at 10:10 A.M., with no bra in place, and the large bulging outline of the incontinent brief at the buttocks area.

At 1:35 P.M., the Resident was observed standing just inside of the Serenity Room on the East Unit, a room identified to be used for residents requiring staff supervision. The Resident was wearing the same clothing observed at 12:07 P.M. There was still no bra in place and the large bulging area at the back of her pants from the incontinent brief had shifted to the left side. Two female staff and several family members were observed in the room at that time.

At 3:30 P.M., the Resident was observed lying in a male resident’s bed on the East Unit (Resident #1 resides on the North Unit). Two female nursing staff members walked by the room and did not notice the Resident lying in the male resident’s bed.

At 4:10 P.M., the Resident was observed lying flat in the male resident’s bed on the East Unit and appeared to be asleep.

At 4:28 P.M., the Resident remained lying flat in the male resident’s bed on the East Unit and appeared to be asleep.

On 3/16/17 at 8:00 A.M. the Resident was observed wandering without purpose on the North and South units. The Resident was dressed in purple sweat pants that had multiple bleached areas scattered over the front and sides. The Resident’s hair remained greasy and unkept. From the back, a large, bulky incontinent brief was visible at the buttocks area as observed throughout the day on 3/15/17. The Resident continued to wear slipper socks as footwear.

At 9:40 A.M., the Resident was observed wandering without purpose, near the North/South Unit nurses station wearing the same clothing as observed at 8:00 A.M. The Resident was now wearing a navy blue button up sweater over the Polo-type shirt with the buttons unevenly fastened. The Surveyor asked a female CNA to assist with buttoning the sweater up evenly.

At 10:00 A.M. the DON (Director of Nursing) and AD (Activity Director) were interviewed regarding the Facility’s failure to provide the Resident with a dignified appearance, meaningful social interaction, or individualized attention/diversion by staff.

Both, the DON and AD stated that the Resident was a challenge to care for and to engage in socialization or activities. However, the DON was unaware of the undignified manner in which the Resident was dressed on 3/15/17 and 3/16/17, to include not wearing a bra the entire day on 3/15/17, the greasy hair, the bulging incontinent brief, the lack of appropriate footwear, or the Resident sleeping in another resident’s bed without staff awareness. The DON said that she would address the Resident’s manner of dress, to include the incontinent briefs (to order pullups), and would find out what happened to the Resident’s sneakers, and replace them if necessary.

Failed to ensure that nurse aides show they have the skills and techniques to be able to care for residents' needs.

Based on interview and review of employee training documentation, the Facility staff failed to ensure that all staff received the required initial and annual dementia care training and evaluation.

Findings include:

Review of the Facility’s tracking list of relevant staff indicated that 2 staff members were not documented as having completed the initial eight hours of required dementia training and 21 staff members were not documented as having completed the annual 4 hour required dementia training.

On 03/02/17 at 11:30 A.M., during an interview, the Admission Coordinator stated she was responsible for the dementia training and tracking of the training in the Facility. The Admission’s Coordinator stated that she had not obtained documentation that two new employees completed the initial eight hours of dementia training prior to release from orientation. She also stated that she was under the impression that staff needed to complete 4 hours of training within a rolling 12 month period and not a calendar year. The last documented dementia training held by the Facility was on 08/24/16.

The nursing home failed to provide activities to meet the interests and needs of each resident.

Based on observations, interviews and record review, the Facility staff failed to provide an ongoing program of activities designed to meet the needs of individual residents in accordance with the comprehensive assessment and interests for 7 of 17 sampled Residents (#1, #3, #4, #5, #9, #11, and #14) and 1 Non Sampled Residents (NS #2). In addition, the overall systems for the provision of meaningful activities was lacking for all Residents.

The Dementia Specialty Care Unit (DSCU) encompasses the entire Facility. The Facility utilized the Main Dining Room for scheduled Activities. There were smaller rooms on each of the 3 units; North Unit-Drop In Center, East Unit- Serenity Room, South Unit- Sunshine Cafe.

Findings include:

1. Resident #1 was admitted in ,[DATE] with [DIAGNOSES REDACTED].

The most recent MDS (Minimum Data Set), signed as being completed [DATE], the Resident experienced short and long-term memory impairment with severely impaired cognitive skills for daily decision making. The Preferences for Customary Routine and Activities section indicated it was completed with the Resident’s family and activity preferences that were either very important or important included books, newspaper, and magazines to read, listening to music, being around animals, keeping up with the news, doing things with groups, doing favorite activities, going outside when the weather was good and participation in religious practices.

Review of the medical record for Resident #1 indicated that the Resident was married, his/her life’s work was in the home, the Resident was of the Catholic faith, and his/her preferred activity times were in the morning and afternoon.

The initial Activity Assessment completed [DATE] indicated that the Resident would benefit from 1:1, small or large group activities in the General Activities Program. The assessment also indicated that passive activities such as sitting outside, watching TV, watching movies, listening to music, and pet interaction would be pursued. Past creative activities listed on the assessment included culinary-past.

The most recent Activity Progress Note, dated [DATE], indicated that the Resident ambulated in and out of activities as desired, enjoyed dining in the MDR (Main Dining Room) at lunch, enjoyed music and pet visits. The progress note also indicated that he/she only lingers a short time in programs.

The Resident was observed throughout the day on [DATE] and [DATE] as noted below. At no time was the Resident engaged in, or offered, encouragement to participate in the Facilities’ activities.

On [DATE] at 10:10 A.M., the Resident was observed wandering seemingly without purpose on the North and East Units, gazing into other residents’ rooms as he/she wandered about the units. The Resident mumbled unintelligibly (German was his/her native language) as he/she wandered about.  The AD (Activity Director) passed the Resident but did not try to engage or redirect the Resident toward the MDR where activities were underway.

At 12:07 P.M., the Resident was observed wandering without purpose in the North Unit corridor holding a white facecloth in his/her hand. Multiple staff members passed the Resident but none attempted to engage the Resident.

At 1:35 P.M., the Resident was observed standing just inside of the Serenity Room on the East Unit, a room identified to be used for residents who required staff supervision. Two staff and several family members were observed in the room at that time. Neither staff member tried to engage the Resident or invite him/her into the Serenity Room.

At 3:30 P.M., the Resident was observed lying in a male/female resident’s bed on the East Unit (Resident #1 resides on the North Unit).

At 4:10 P.M., the Resident was observed lying flat in the male/female resident’s bed on the East Unit and appeared to be asleep.

At 4:28 P.M., the Resident remained lying flat in the male/female resident’s bed on the East Unit and appeared to be asleep.

On [DATE] at 8:00 A.M. the Resident was observed wandering seemingly without purpose on the North and South units. Multiple staff passed the Resident, however none of the staff members attempted to engage the Resident.

At 9:40, the Resident was observed wandering without purpose near the North/South Unit nurses station. The Surveyor approached a CNA who walked by the Resident without trying to engage the Resident.

At 10:00 A.M. the DON (Director of Nursing) and AD (Activity Director) were interviewed regarding the Facility’s failure to provide consistent and meaningful activities to the Resident. The AD said that the Resident’s spouse died recently and that he/she used to visit regularly and bring in fabric for the Resident to handle, as he/she worked as a seamstress in her younger years. The AD did not say what interventions, if any, had been used to address the Resident’s significant loss or why activities were not provided the Resident. The AD said that it was hard to get the Resident to sit down, but that he/she would sit down for food and drink. The AD also said that the Resident could be physical with staff but gave no specifics. The AD said I haven’t had time to do 1:1 visits with the Resident. The AD also said that the Resident would benefit from 1:1 activities if the Facility had more staff.

2. Resident #4 was admitted to the Facility in ,[DATE] with [DIAGNOSES REDACTED].

The most recent comprehensive MDS with a reference date of [DATE] indicated Resident #4 had a moderately impaired cognitive status. The Preferences for Customary Routine and Activities was conducted by Facility staff and indicated the Resident prefers reading books, newspaper, or magazines, listening to music, doing things with groups of people, and participating in favorite activities.

Review of the medical record for Resident #4 indicated the Resident was Vietnamese speaking, unable to communicate via telephonic translator and preferred not to utilize communication cards. Review of the initial Recreation/Leisure Patterns Summary completed [DATE] indicated Resident #4 was comfortable in a setting of small groups (,[DATE] people), sometimes preferred quiet areas, and enjoyed watching others rather than actively participating in activities.

Review of the Individualized Care Plan for Activities updated on [DATE] indicated Resident #4 prefers small groups and one to one activities of music or videos. A progress note written by the activities department on [DATE] indicated Resident #4 enjoyed socials, group dining, some music, some movies, sensory items and nature videos.

The Resident was observed on [DATE] at 1:20 P.M. in his/her room sitting in a recliner chair, an over bed table in front of him/her with a lunch tray, the radio on the window-sill was not on, the TV was placed behind the recliner chair so that the Resident could not face it while sitting in the chair and was not on. On [DATE] at 3:45 PM the Resident was observed to be in bed, with a blanket pulled over his/her head. On [DATE] at 2:25 P.M. the Resident was observed to be laying in bed and alert, the Resident waved to the Surveyor and smiled, the scheduled activity to start at 2:30 P.M was Glee Club Sings. The Activity Director (AD) was interviewed on [DATE] at 2:00 P.M., she stated the Resident had a radio in his/her room and preferred afternoon activities. Resident #4 was not observed to attend any activities on ,[DATE], ,[DATE], ,[DATE] or [DATE]. The Activity Director stated it could be difficult to get the Resident to attend activities.

3. For Resident #3 the Facility failed to provide identified and individualized activities to address the Resident’s needs.

Resident #3 was admitted in, [DATE] with [DIAGNOSES REDACTED].

The MDS (Minimum Data Set), signed as being completed [DATE], the Resident was assessed to have moderately impaired cognitive skills for daily decision making, could sometimes understand/could sometimes be understood, displayed disorganized thinking.

An Initial Activity Assessment was signed as being completed on [DATE]. The assessment indicated that the Resident’s Preferred Activity Times were morning, afternoon, and evening.

The Activity Assessment indicated that the Resident was independently capable of participating in activities without facility intervention and was independently capable of choosing and attending activities. The assessment indicated that the Resident preferred small and large group activities in the General Activities Program and would benefit from participating in the Resident Council. Passive activities assessed for the Resident included sitting outside, watching TV, watching movies, listening to music, and pet interaction. The Resident’s favorite activities, listed on the Activity Assessment, included Loves history, politics, music, socials, ambulation, sports, and movies.

The Resident’s Care Plan for Activities indicated that the Resident would participate in activities of choice.

  • The goals for the Resident included:
  • Invite to groups 2 x/daily
  • Music and entertainment as offered
  • Discussion groups and history talk as offered
  • Pet visits
  • May need redirection when ambulating wheelchair in busy space

The Resident was observed on multiple occasions on [DATE] and [DATE]. During this two-day observation period, the Resident was not offered, or engaged in, any of the activities that were outlined in the Initial Activity Assessment or in the Resident’s Care Plan for Activities.

On [DATE] at 11:02 A.M., the Resident was observed fully dressed, lying in bed with large bolsters alongside the sides of the edge of the bed-lengthwise. The Resident was awake at that time. No TV, music, reading material, or any sort of meaningful activity or stimulation noted.

On [DATE] at 12:12 P.M., the Resident was observed lying in bed quietly with the head of the bed at approximately 30 degrees. The privacy curtain was pulled blocking the full view of the Resident. The Resident could be seen behind the curtain. He/She was awake and was observed eating a container of ice cream and drinking what appeared to be a nutritional supplement. There was no TV, music, or diversionary activities in or around the Resident’s bedside.

On [DATE] at 12:17, a CNA pulled the privacy curtain in the presence of Surveyor #1. The Resident was observed lying in bed quietly and was fully dressed.

On [DATE] at 12:30 P.M., the Resident was observed lying quietly in bed and remained fully dressed. The Resident had a blue bib in his hand that he used to wipe his mouth. The Resident had finished all of the ice cream and supplement that was observed on his overbed table earlier.

On [DATE] at 1:32 P.M., the Resident was observed lying in bed with his/her eyes closed and appeared to be resting quietly with the the head of the bed at approximately 30 degrees.

On [DATE] at 2:50 P.M., the Resident was observed in the MDR with a large group of Residents with multiple activities occurring simultaneously. The room was extremely loud and chaotic with a trivia game being conducted by the AD, two female residents near the TV, yelling loudly, a Bingo game being conducted across from the trivia game with numbers being called out loudly, and multiple Residents at the Satellite Table engaged in various sensory activities.

At that time, Resident #3 was observed at a table with two other male residents. The three residents at the table were not involved in any activity at that time.

On [DATE] at 3:12 P.M., the Activities Director was observed wheeling the Resident out of the MDR (Main Dining Room) in a wheelchair. The AD said to another staff member that He’s getting slouchy. The Resident was observed by Surveyor #1 sliding forward in the wheelchair. The CNA wheeled the Resident back to his/her room and began getting the Resident ready to go back to bed.

On [DATE] at 4:10 P.M., the Resident was observed lying back in bed with his/her eyes closed. The Resident was wearing a white t-shirt and appeared to be resting comfortably.

On [DATE] at 7:30 A.M., the Resident was observed lying in bed, eyes closed, and appeared to be asleep.

On [DATE] at 12:55 P.M., the Resident was observed lying in bed with the head of the bed at approximately ,[DATE] degrees. The Resident’s eyes were closed and he/she appeared to be asleep. Interview with UM #1 confirmed that the Resident had gotten up to the wheelchair for lunch, had consumed his entire meal, and was put back to bed following the noon meal.

The AD was interviewed on [DATE] at 9:45 A.M., in regards to the lack of engagement in activities for the Resident, in accordance with the Initial Activity Assessment and Activities Plan of Care, reviewed on [DATE]. The AD said that the Resident sits with some of the quieter male/female residents. She said that he/she likes music, dog visits, reading the paper, coming to lunch, and watching TV. The AD did not know why the Resident ate lunch in his bed on [DATE]. She said he/she is a napper and that she doesn’t always know what happens to each Resident each day.

The AD acknowledged Surveyor #1’s multiple observations on [DATE] and [DATE], of Resident #3 not participating in any scheduled group, or individual activities according to the Resident’s Care Plan for Activities. The AD also said I haven’t had time to do 1:1 visits with the Residents and indicated that the Facility was down one full-time and one half-time position in the Activities Department. The AD also said that the Residents would benefit from 1:1 activities if the Facility had more staff.

4. For Resident #9 the Facility staff failed to provide identified and individualized activities to address the Resident’s needs.

Resident #9 was admitted to the Facility in ,[DATE] with [DIAGNOSES REDACTED].

The most recent comprehensive MDS with a reference date of [DATE] indicated Resident #6 had a moderately impaired cognitive status. The Preferences for Customary Routine and Activities section indicated it was completed with the Resident and the Resident stated Activity Preferences that were either very important or important included books, newspaper, and magazines to read, listening to music, being around animals, keeping up with the news, doing things with groups, doing favorite activities, going outside when the weather was good and participation in religious practices.

Review of the initial Activity assessment dated as completed on [DATE] indicated Resident #9 required assistance with activity pursuit, that he/she ambulated, but could be agitated in crowds, enjoyed sports, reading the news paper and music. The Individualized Care Plan for Activities, updated on [DATE], indicated the Resident ambulated, but required orientation to walk to activities.

The Resident was observed on [DATE] at 1:35 P.M. to be lying in bed, on top of the blanket with eyes open, looking at his/her hands, the light in the room was off, the Resident waved to the Surveyor. On [DATE] at 4:15 P.M. the Resident was observed to be lying in bed, the light in the room was off and the Resident had his/her eyes open, looking at the ceiling.

The AD was interviewed on [DATE] at 9:45 A.M. She stated Resident #9 enjoyed reading in his/her room and does not function well in large groups as he/she was quiet and reserved.

The AD stated the Resident was not offered one to one room visits or small groups as there was not enough staff to do this.

Resident #9 was observed on [DATE] at 2:05 P.M. being brought to the Main Dining Room for activities. When the Surveyor asked Activity Aide #1 about the Resident, she stated she was unsure of his/her name because he/she did not come to activities.

5. For Resident #11 the Facility failed to provide identified and individualized activities to address the Resident’s needs.

Resident #11 was admitted to the Facility in ,[DATE] with a [DIAGNOSES REDACTED]. The Resident was readmitted to the Facility in ,[DATE] with a feeding tube.

The most recent comprehensive MDS with a reference date of [DATE] indicated Resident #11 had a severely impaired cognitive status. The Preferences for Customary Routine and Activities was conducted by Facility staff and indicated the Resident prefers listening to music, being around animals, doing things with groups, participating in favorite activities, spending time outdoors and participating in religious activities.

Review of the initial Activity assessment dated as completed on [DATE] indicated Resident #11 required assistance with activity pursuit, that he/she would prefer one to one activities, small group activities, large group activities and the general activities program. The Individualized Care Plan for Activities, updated on [DATE], indicated the Resident required physical assistance to and from activities. The progress note written by the activities department on [DATE] indicated the Resident enjoyed music and sensory stimulation.

On [DATE] at 11:15 A.M. Resident #11 was observed to be brought to the Main Dining Room from his/her bedroom. The Resident was placed three feet from the main door, was not placed with other Residents and was not placed at a table. There was no scheduled activity at this time. The Main Dining Room was observed to have a large group of Residents, 2 Residents were observed to be reading, staff were assisting other Residents to their designated eating locations. At 12:00 PM. Resident #11 was placed in the hallway across from the nurses station during lunch. At 2:00 P.M. Resident #11 was observed to be in his/her bed, the scheduled activity at this time was an Ice Cream Social at 2:30 P.M. and Musical Journey at 3:30 P.M. Based on observation, Resident #11 did not participate in activities on [DATE].

On [DATE] at 10:20 A.M. Resident #11 was brought to the Serenity Room. There was one other Resident and one CNA, sitting at a table at this time. The Resident was not placed at the table, but was placed away from the table, facing the television. The scheduled activity at this time in the Main Dining Room was Mornings in Motion. From 12:45 P.M. to 1:30 P.M., Resident #11 was observed to be alert and seated across from the nurses station. At 1:35 P.M. the Resident was brought to the Serenity Room, the TV was playing the same movie that was playing that morning. At 3:00 P.M. the Resident was observed to be in bed, the Speech Therapist was working with the Resident. At 4:00 P.M. the Resident was observed in bed, to be alert and staring straight ahead, there was no music and no television on. The scheduled activities for the afternoon were Comedy Club at 2:00 P.M. and Wordpower at 2:30 P.M. Based on observation, Resident #11 did not participate in activities on [DATE].

6. For Resident #14 the Facility failed to provide identified and individualized activities to address the Resident’s needs.

Resident #14 was admitted to the Facility in ,[DATE] with a [DIAGNOSES REDACTED].

A review of the most recent comprehensive MDS with a reference date of [DATE] indicated Resident #14 had a moderately impaired cognitive status. The Preferences for Customary Routine and Activities was conducted by Facility staff and indicated the Resident prefers reading books, newspaper, or magazines, listening to music, being around pets, doing things with groups of people, participating in favorite activities, spending time outdoors, and participating in religious activities.

Review of the initial Activity Assessment completed upon admission, indicated Resident #14 required assistance with activity pursuit, that he/she would prefer small group activities, large group activities and the general activities program. The Individualized Care Plan for Activities, updated on [DATE], indicated the Resident required physical assistance to and from activities. The progress note written by the activities department on [DATE] indicated the Resident’s spouse visited almost daily, the Resident loved music and attended daily groups in the Main Dining Room.

On [DATE] at 10:30 A.M. Resident #14 was observed to be in bed, getting morning care. The scheduled activity at this time was Mornings in Motion. From 11:05 through 11:25 A.M., the Resident was observed to be in the Main Dining Room at a table with 4 other males. There were books on the table, the Resident was not looking at the books. Staff did not attempt to engage with the Resident during this time. At 2:45 P.M., the Resident was observed to be in the Main Dining Room, where there was classical music playing, at a table with 6 other Residents. There were no activities on the table, the Resident had his/her eyes closed and head down. The scheduled activity at this time was Wordpower.

On [DATE] at 10:55 A.M. Resident #14 was observed to be in bed, getting morning care. The scheduled activity at this time was Mornings in Motion.

7. Resident #5 was admitted in ,[DATE] with [DIAGNOSES REDACTED].

The MDS, signed as being completed [DATE], the resident experienced short and long-term memory impairment with severely impaired cognitive skills for daily decision making.

An Activities Reassessment was conducted on [DATE]. At that time, the Resident required assistance with activity pursuit, preferred small and large groups, in-room activities and the General Activities Program. Passive activities included sitting outside, watching TV, watching movies, listening to music, and pet interaction ?. Creative activities listed on the assessment included gardening.

A [DATE] Activities Progress Note indicated that the Resident continues to participate enthusiastically in Satellite and general programs. The Resident loves to manipulate stringy cloth or towel (terry materials). He/She enjoys the dog visits, music, all socials. And, his/her family visits often and are proactive in her care.

The Resident was observed multiple times on [DATE] and [DATE] as noted below:

On [DATE] at 10:35 A.M., the Resident was observed seated at the Satellite Group with 6 other residents present. The resident was being supervised by a female CNA while the resident was holding a ball of yarn in her hands. The CNA was observed trying to engage one resident to play with a number of large playing cards, but no other resident at the Satellite Group table were engaged. The MDR, where the Satellite Group was held, was loud and chaotic with a music video playing loudly on the widescreen TV. A female resident was yelling out intermittently.

On [DATE] at 1:46 P.M., the Resident was observed in the Drop-in Center on the North Unit, which was a room used for residents to socialize while being supervised by staff. Resident #5 was observed sitting in a wheelchair with his/her eyes closed. The TV was on at that time and a large group of residents were observed in the room. One female resident was screaming loudly. The CNA in the room at that time interpreted that she was saying, There are too many people in my house.

On [DATE] at 2:50 P.M., the Resident was observed seated in a wheelchair in the MDR at the Satellite Group table. The Resident was holding a ball of white yarn in her hand.

On [DATE] at 4:15 P.M., the Resident was seated in the MDR at the Satellite Group table. A CNA was observed showing pictures to Resident #5 and the other residents at the table.

On [DATE] at 8:50 A.M., the Resident was observed seated in a wheelchair in his/her room. A CNA was grooming the Resident’s hair and putting a blue bib on the Resident in preparation for breakfast.

On [DATE] at 10:45 A.M., the Resident was observed seated in a wheelchair in the MDR at the Satellite Group table. A CNA was discussing large playing cards with the Resident. A male Resident had large dominos in front of him but was not playing with them. Two female residents were looking at pictures in a book. The CNA was not observed trying to engage the other residents at the Satellite Group table.

The AD was interviewed on [DATE], regarding the lack of variety of activities for Resident #5 and the other residents who attended the Satellite Group. Surveyor #1 also discussed the lack of engagement of the residents by the CNAs assigned to supervise the group. The AD said that ideally, the group would be held in a quiet environment away from the MDR. However, she said that it was impossible to provide that type of environment due to the lack of adequate activity staff.

8. Non-Sampled Resident (NS) #2 was admitted to the Facility in ,[DATE] with [DIAGNOSES
REDACTED].

A review of the most recent comprehensive MDS with a reference date of [DATE] indicated NS #2 had a severely impaired cognitive status. The Preferences for Customary Routine and Activities was conducted by Facility staff and indicated the Resident prefers listening to music, being around pets, doing things with groups of people, participating in favorite activities, spending time outdoors, and participating in religious activities.

Review of the activity documentation record for NS #2 indicated the Resident was Portuguese speaking. Review of the Individualized Care Plan for Activities updated on [DATE] indicated NS #2 was often thirsty and to offer beverages and can be redirected by holding hands with some dance-like motion.

On [DATE] at 10:45 A.M., NS #2 was observed to be in the main dining room, sitting in the far right corner and yelling out and staff made no attempts to engage with the Resident. At 4:15 P.M., NS #2 was observed over to the right side of the MDR near the window, screaming almost non-stop, with no staff member approaching or intervening.

On [DATE] at 9:45 A.M. the Activity Director was interviewed regarding NS #2. She said the Resident use to love to dance and sing and that the plan for NS #2 was to provide the resident with a doll or some other soft sensory item. She said the Resident likes you to talk to her and likes hand massages with a little lotion. The AD was informed that NS #2 was not provided a doll or soft sensory item throughout the day on [DATE]. The AD stated she has not been able to provide hand massages to Residents and it had been hard to schedule them.

On [DATE] at 10:45 A.M. NS #2 was observed at this time seated in a wheelchair at the far right hand corner of the MDR by herself. NS #2 was observed holding a doll in her arms and yelling intermittently. No staff approached the resident to investigate why he/she was yelling, or to provide any meaningful interaction with the resident.

At [DATE] at 2:05 P.M., NS #2, along with multiple other non-sampled residents, were observed in the Drop-in Center on the North Unit. A CNA was observed in the room at that time occupied with filling out documentation regarding residents. The CNA was seated at a table adjacent to NS #2, looking down, writing in a book and not paying any attention to the residents gathered in the room. She did not engage NS #2 or any of the other residents gathered in the room at that time.

9. A group interview was conducted with Resident’s who were determined to be able to participate and answer questions, by the Director of Activities, on [DATE] at 2:30 P.M.

The Resident Council President (Non Sampled Resident-NS #1) stated the activities were the same old, same old and new ideas were needed. The Residents stated it would be nice to have activities after dinner time, even in the small rooms (sitting areas off of each unit). NS Resident #1 stated the scheduled Dinner and a movie activity on [DATE] at 5:00 P.M. did not occur and stated that’s when we eat. The Residents stated they had not had an entertainer come to perform in a long time.

Review of the Activity Calendar for the month of March indicated the following:

  • Monday through Friday at 10:00 A.M. Mornings in Motion
  • Mondays at 2:30 P.M. Bingo; 3:30 P.M. Wordpower
  • Tuesdays at 2:30 P.M. Glee Club; 3:00 P.M. Dance Floor open
  • Wednesdays at 2:00 P.M. Comedy Club and Trivia; 2:30 P.M. Wordpower
  • Thursdays 2:30 P.M. Glee Club; 3:00 P.M. Home and Hearth
  • Fridays 2:30 P.M. Ice Cream Social; 3:30 P.M. Musical Journey
  • Monday through Sunday at 5:00 P.M. Dinner and a Movie

10. The following observations of the general activities program were made:

The main dining room was observed for activities during the survey process. On [DATE] at 2:10 P.M. there were 20 Residents in the room at different tables. There were various games, puzzles and magazines on each table. There was one Activity Aide in the room and one Certified Nursing Aide (CNA). Activity Aide #1 was talking to one resident. The CNA was assigned to a table, identified as the Satellite Group, in the far right corner of the room which had 6 Residents. The room was loud, with Residents talked over each other. The scheduled activity at the time was Comedy club/Trivia, neither were observed.

On [DATE] at 10:00 A.M. there were 35 Residents in the room at different tables. The Director of Activities turned on an exercise video which played music loudly, as she yelled out the instructions, in the far left corner of the room. There were 7 Residents observed at the Satellite Group table in the far right corner of the room. The Residents were each given a small plastic bowling pin, two Residents were observed to be banging them on the table, there was no bowling ball provided, the assigned CNA was motioning the exercises from the exercise video on the other side of the room. The CNA was not observed engaging the Residents in the Satellite Group in the bowling activity.

The small rooms on each unit (Serenity Room, Sunshine Cafe, and Drop-in room) were observed on [DATE] at 10:15 A.M. to all be empty.

An interview was conducted on [DATE] at 1:00 P.M. with the Administrator and the AD (Activity Director). The AD stated the times on the calendar were the scheduled times the main dining room was available for large groups. She stated the main dining room was cleaned after lunch and there was a group held on a unit. The AD stated she did not have enough staff in her department to have small groups in the other available rooms while large groups are held in the main dining room. She stated the Serenity Room was utilized for Residents who had increased behaviors and unable to attend the large group activities and a CNA was assigned to monitor this room, there was a TV in this room, there were not scheduled activities in this room. The Activity Director stated the Residents in the far right corner of the main dining room were part of a Satellite Group of eight residents who needed more tactile activities. The AD confirmed the Residents in this group would benefit from a quieter environment, but stated she did not have the staff to separate the Residents to another room. She stated some Residents enjoy small groups and she wished she
had more staff.

The Activity Director was interviewed on [DATE] at 8:50 A.M. The Activity Director stated she was unable to provide participation records for Residents preceding [DATE]. She was able to provide one from [DATE] which was not individualized per Resident, but was a census of all the Residents with a check mark indicating if they attended morning or afternoon activities. She was unable to provide information on which specific activities
any Resident attended.

The Activity Director said that all activities are held in the main dining room. The Satellite Group had been held in the main dining room due to a decrease in activity staff. She stated the CNA’s take turns every half hour to engage Residents.

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Page Last Updated:  November 14, 2017