Agawam West Rehab And Nursing

received a telephone call from the ADON informing her that Resident #1 had fallen out of bed during care and that he/she was bleeding.The DON said she conducted a re-enactment of the incident with CNA #1 on 09/24/25.

The DON said CNA #1 demonstrated how she rolled Resident #1 onto his/her left side and how she turned away to obtain incontinent supplies from the tray table located diagonally behind her.

The DON said CNA #1 told her she did not leave Resident #1's bedside, that Resident #1 was just out of her reach, and when she turned back to face him/her, he/she had rolled off the bed and onto the floor.On 10/15/25, the Facility was found to be in past Non-Compliance with an effective date of 9/26/25, and provided the surveyor with a plan of correction which addressed the area of concern as evidenced by: A) Upon return from the Hospital, Resident #1's care plan was immediately updated to:- require two staff members be present at all times for personal care and bed mobility.- a perimeter mattress with positioning wedges are always provided while in bed. B) On 09/24/25, the Staff Development Coordinator (SDC) re-educated CNA #1 on Positioning/ADL Care, which included but was not limited to the following:-When providing care to a resident in bed, do not leave them unattended until they are safely positioned - this includes reaching for personal care items such as barrier creams, linens, briefs, etc. followed by a written competency, and demonstration. C) On 09/24/25, the Staff Development Coordinator (SDC) or her designee re-educated all clinical staff (Nursing and CNAs) where Resident #1 resides on Positioning/ADL Care, followed by written competencies, and demonstrations. D) On 09/26/25, the Facility completed a whole house Fall From Bed Audit that encompassed the dates between 07/24/25 and 09/24/25 to determine whether residents who fell were provided with the level of assistance they required during the event, determined the root cause for the fall, and identified any interventions that were added as a result of the fall. E) The Director of Nursing, Staff Development Coordinator or their Designee are conducting weekly audits, followed by random audits to ensure all residents are receiving the necessary level of assistance needed for bed mobility, including turning and repositioning a resident in bed to provide care, as well as ensuring residents' care plans are updated and accurate. F) The deficient practice will be presented at the next monthly Quality Assurance Improvement (QAPI) meeting and will continue to be discussed at monthly QAPI meetings as needed to ensure substantial compliance is achieved and maintained. G) The Director of Nursing and/or their Designee are responsible for overall compliance.

Facility ID: