Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Agawam South Rehab And Nursing during CMS and state inspections, most recent first.
Laundry infection control failures were observed in the laundry room. Feces was seen in a washer with linens, a washer setting and the chemical programming box did not match, a washer had not been working properly for about a year but was still in use, wet linens were left in the washer overnight, wet mop heads were placed in a bin instead of being hung to dry, and a washed lift sling that smelled of urine was hung with clean slings. Residents also reported clothing that smelled like mildew.
Late completion of Annual MDS assessments was identified for two residents. One resident with COPD, dementia, and chronic respiratory failure had an assessment completed after the required timeframe, and another resident with protein malnutrition, anxiety, mild cognitive impairment, and a history of falls also had an Annual MDS completed late. The MDS Nurse confirmed both assessments were not completed within the required 14-day window.
Late Quarterly MDS Assessments: The facility failed to complete several quarterly MDS assessments within the required 14-day window after the ARD for four residents. The MDS Nurse confirmed the assessments were not completed on time for residents with diagnoses including chronic respiratory failure, CKD, COPD, dementia, depression, diabetes, and protein malnutrition.
MDS coding was inaccurate for two residents. One resident with osteoarthritis and osteoporosis had OT documentation showing left hand and wrist contracture issues and a recommendation for a WHFO/palm guard, yet the MDSs did not code a functional ROM limitation for an upper extremity. Another resident with chronic respiratory failure, CKD, and atherosclerotic heart disease was coded as receiving an anticoagulant during the look-back period even though physician orders did not show an anticoagulant and the MDS nurse confirmed it was entered in error.
The facility failed to implement wound care orders for a resident with right heel and ankle wounds, including delayed and missing treatment orders after Wound Provider recommendations, and also failed to maintain bowel regimen orders and documentation for another resident with constipation complaints. The bowel issue involved a consult recommendation to start a bowel regimen, but no corresponding orders were in place, and a suppository was later given without an order or documentation. The DON and PA both acknowledged gaps in the wound and bowel order process.
Meals were not served at proper temperatures or in a palatable manner on two units. Residents reported bland food, hard rice, untoasted bread, and hot items that were not hot. During test trays, the DON, Administrator, and staff observed casserole bake, oatmeal, and coffee that were below the 135 degrees F goal and described as bland, watery, or not palatable; the FSD acknowledged the temperatures did not meet the goal.
A resident at risk for malnutrition developed a pressure injury and experienced significant weight loss due to the facility's failure to promptly notify the RD and implement nutritional interventions. Staff did not consistently monitor or report weight changes, and the RD was not made aware of the resident's condition until weeks after the issues began, resulting in delayed support for wound healing and nutritional needs.
A resident with wounds, significant weight loss, and ADL needs did not have complete and accurate medical records due to missing weekly wound logs, incomplete skin assessments, and blank entries in both the TAR and CNA flow sheets. Nursing and CNA staff confirmed that required documentation was not consistently completed or reviewed, resulting in gaps in the resident's official care record.
A resident with a history of end-stage renal disease, type II diabetes, and hypertension experienced significant medication errors when Midodrine was administered despite physician orders to hold the medication if systolic blood pressure exceeded 130 mmHg. The medication was given on multiple occasions when the resident's blood pressure was above the specified threshold, as confirmed by the MAR and nursing staff interviews.
The facility failed to adhere to infection control standards, risking the transmission of infections among residents. Staff did not use PPE as required for residents on contact precautions, and wound care supplies were improperly handled. Additionally, enhanced barrier precautions were not maintained for a resident with a feeding tube and colostomy, indicating systemic issues in infection control practices.
A resident's wheelchair was repeatedly observed with dirt, debris, and food particles, indicating a failure to maintain a clean and homelike environment. The Director of Housekeeping admitted to not following the cleaning schedule and lacking a tracking system for wheelchair maintenance.
A facility failed to notify the state mental health authority for a resident review after a resident was diagnosed with Bipolar Disorder, despite policy requirements for a Level II PASRR referral. The resident, admitted with Chronic Respiratory Failure and Obstructive Sleep Apnea, was cognitively intact but had not been evaluated by a Level II PASRR. The Social Worker confirmed that a Change of Condition should have been submitted but was not.
The facility failed to create baseline care plans within 48 hours for two residents, one with MRSA and another with ESRD and DM II. This led to delays in implementing necessary precautions and providing care instructions. The Infection Preventionist and Unit Manager acknowledged the lapses in timely care planning.
A resident with a PICC line for antibiotic administration did not have the required measurements of external catheter length and arm circumference documented, as per physician orders and facility policy. This oversight was identified through a survey, which revealed no evidence of these measurements being taken since admission, despite the potential risks of catheter migration and other complications. Nursing staff confirmed the lack of documentation, and the resident could not recall the measurements being obtained.
A resident with multiple health conditions, including dementia and apraxia, did not receive consistent assistance with oral hygiene, leading to plaque buildup and odor. Despite being dependent on staff for daily living activities, the resident's oral care was neglected, with CNAs failing to provide necessary support or setup. The DON confirmed that oral care should be routine, highlighting a lapse in adherence to facility policies.
A facility failed to provide appropriate respiratory care for a resident requiring CPAP therapy due to missing physician orders after a hospital transfer. The resident, who needed assistance with the CPAP machine, did not receive consistent help from staff, leading to infrequent use. Observations showed improper storage of CPAP equipment, and interviews confirmed the omission of CPAP orders during re-admission.
A facility failed to act on a Consultant Pharmacist's recommendation for a resident on Atorvastatin, missing a fasting lipid panel to monitor cholesterol levels. The MRR was marked as agreed but was unsigned and undated, with no follow-up action taken. The DON was responsible for overseeing pharmacy recommendations but could not confirm who marked the MRR.
A medication pass error rate of 5.71% was observed when a resident received two medications late. The resident, with conditions including cerebral infarction and vascular dementia, was administered Gabapentin and Benztropine Mesylate via G-tube one hour and 41 minutes past the scheduled time. Nurse #7 cited a system problem due to workload and scheduling as the cause of the delay.
The facility failed to obtain physician-ordered lab tests for two residents, leading to a deficiency in care. One resident did not have their valproic acid levels monitored as required, while another did not receive routine tests for blood glucose, thyroid hormones, and lipids. The Director of Nursing acknowledged systemic issues and accidental discontinuation of lab orders, highlighting a gap in the facility's processes.
A resident on hospice care with COPD and GERD did not receive the correct food items as per their dietary plan, leading to unmet nutritional needs. Despite protocols for checking meal trays, the resident's meal tickets were not followed, resulting in missing items like an apple cinnamon muffin, potato wedges, and ice cream. Staff interviews revealed a lapse in the process, with the Dietary Aide responsible for ensuring correct tray contents.
Laundry infection control failures
Penalty
Summary
The facility failed to maintain infection control practices in its laundry services for the A Wing, C Wing, and D Wing. The report states that residents reported their clothing washed by the facility smelled of mildew, and that personal laundry for two residents was being processed by the facility. The facility’s laundry policy required soiled linens to be handled appropriately, the washer door lip to be disinfected before use, damp textiles not to remain in machines overnight, and damaged or broken equipment not to be operated. During observation of the main laundry room, a brown solid substance identified by the Housekeeping and Laundry Manager as feces was seen spinning in a washer with linens. The washer machine was set to the heavy soil setting while the chemical programming box was set to the personals setting. The manager stated that the chemical programming box did not work correctly and had to be set to personals all the time, and that the washer settings were programmed based on the type of load being washed. The report also states that washer machine #2 had not been functioning properly for about a year, including not spinning or draining correctly, yet it continued to be used. Additional observations showed wet linens left in a washer overnight, clean mop heads placed wet into a bin instead of being hung to dry, and a washed lift sling that smelled of urine hanging with clean lift slings. The Housekeeping and Laundry Manager stated that mop heads were washed by evening staff and left in a bin while still wet, that the wet linens observed in the washer had been washed the previous evening, and that the sling smelled of urine. The Administrator stated that mop heads should be hung dry, linens should not be left in the washer overnight, lift slings that were still dirty should not be hanging with clean lift slings, and feces should not be in the washer machine.
Late Completion of Annual MDS Assessments
Penalty
Summary
The facility failed to complete comprehensive assessments within the required 14 days of the Assessment Reference Date for two residents. Resident #36, admitted in November 2023 with diagnoses including COPD, major depressive disorder, dementia, and chronic respiratory failure with hypoxia, had an Annual MDS Assessment with an ARD of 10/23/25 that was completed on 11/11/25, five days after the required due date of 11/6/25. Resident #95, admitted in August 2019 with diagnoses including protein malnutrition, anxiety disorder, mild cognitive impairment, and a history of falling, had an Annual MDS Assessment with an ARD of 1/27/26 that was completed on 2/23/26, 13 days after the required due date of 2/1/26. During interview, the MDS Nurse confirmed both assessments were not completed within the required timeframe.
Late Quarterly MDS Assessments
Penalty
Summary
The facility failed to complete quarterly MDS assessments within the required timeframe for four residents out of a sample of 19. The report states that quarterly assessments were not completed no later than 14 days after the ARD for Resident #6 on two occasions, Resident #36 on one occasion, Resident #70 on two occasions, and Resident #95 on one occasion. The late assessments included Resident #6’s quarterly MDS with ARDs of 9/22/25 and 12/4/25, Resident #36’s quarterly MDS with ARD of 1/22/26, Resident #70’s quarterly MDS with ARDs of 10/28/25 and 1/27/26, and Resident #95’s quarterly MDS with ARD of 10/28/25. Resident #6 was admitted in June 2025 with diagnoses including chronic respiratory failure, stage 3 kidney disease, and atherosclerosis heart disease. Resident #36 was admitted in November 2023 with diagnoses including COPD, major depressive disorder, dementia, and chronic respiratory failure with hypoxia. Resident #70 was admitted in July 2025 with diagnoses including cerebral infarction, Type II diabetes, depression, and chronic kidney disease. Resident #95 was admitted in August 2019 with diagnoses including protein malnutrition, anxiety disorder, mild cognitive impairment, and a history of falling. During interview, the MDS Nurse reviewed the quarterly assessments and stated that the listed MDS assessments were not completed within the required 14 days.
MDS Coding Errors for ROM and Anticoagulant Use
Penalty
Summary
The facility failed to accurately code MDS assessments for two residents out of a sample of 19. For one resident admitted with osteoarthritis and osteoporosis, the OT discharge summary showed therapy services were provided for increased flexion and contracture of the left hand and wrist, with a goal related to a left hand WHFO and later recommendation for a left-hand palm guard. However, the resident’s MDS assessments dated 12/9/25, 9/9/25, and 6/10/25 were coded as not having a functional limitation in ROM to the upper extremities, even though OT and MDS staff stated the resident should have been coded for a functional limitation in ROM for one upper extremity. For another resident admitted with chronic respiratory failure, stage 3 kidney disease, and atherosclerosis heart disease, the most recent MDS indicated the resident was receiving an anticoagulant during the 7-day look-back period. Review of January 2026 physician orders did not show an anticoagulant prescription, and the MDS nurse confirmed the resident was not on an anticoagulant during the assessment period and that the item had been marked in error.
Failure to Implement Wound and Bowel Treatment Orders
Penalty
Summary
The facility failed to ensure physician orders and wound treatment recommendations were implemented for a resident with multiple right foot and ankle wounds. The resident was admitted with diagnoses including osteomyelitis of the right ankle/foot, type II diabetes, peripheral vascular disease, and a non-pressure chronic ulcer of the right heel and mid-foot. The resident was cognitively intact and had dressings to the feet on the MDS assessment. The facility policy required weekly assessment and documentation of skin impairments and monitoring of wound care through the Risk Management Committee. For the resident’s right heel wound, the Wound Provider recommended treatment in January 2026, including cleansing with 0.125% Dakin’s solution, collagen particles, alginate with silver, and a dry clean dressing daily and PRN. The TAR showed the treatment was not initiated until eight days after the recommendation, and the Dakin’s solution was not added until 15 days after the recommendation. In February 2026, the Wound Provider updated the right heel treatment to Dakin’s solution, honey hydrogel, and a dry clean dressing daily and PRN, and also recommended treatment for a right superior ankle stage 3 pressure ulcer. The TAR showed the right heel treatment was only provided for four days and then stopped, and there was no scheduled treatment after discontinuation. The updated recommendations from late February were not initiated for either the right heel or the right superior ankle wound. The March physician orders included treatment for the right superior ankle but did not include any order for the right heel. The facility also failed to ensure bowel regimen orders and documentation were in place for another resident with constipation complaints. The resident was admitted with diagnoses including morbid obesity, mild intellectual disability, muscle weakness, unsteadiness on feet, diverticulosis, and aftercare following surgery for neoplasm. The resident reported constipation and rectal pain, and the bowel monitoring flow sheet showed no bowel movement for four consecutive days. A consulting physician note documented constipation and recommended initiating a bowel regimen, but no bowel regimen medications appeared in the physician orders or MARs, and nursing notes did not document bowel regimen interventions. The DON later stated the nurse administered a suppository without a physician order and did not follow the facility bowel protocol, which was described as using lactulose or MiraLAX before a suppository. The DON also stated there was no documentation showing what medication had been administered or how the resident responded.
Meals Not Served at Proper Temperature or Palatable
Penalty
Summary
The facility failed to ensure resident meals were palatable, attractive, and served at safe and appetizing temperatures on Units A and C. The facility policy titled Food Preparation stated the Dining Services Director/Cook(s) were responsible for food preparation techniques that minimized the time food items were exposed to temperatures greater than 41 degrees F and/or less than 135 degrees F, and the meal assessment form listed 135 degrees F as the minimum serving temperature for entrees, starches, and hot beverages. During the initial pool process, residents reported that food was awful, rice was too hard, bread was not toasted, hot items were not hot, preferences were not honored, and alternate meals such as grilled cheese sandwiches were not always properly prepared. On Unit C, the surveyor observed the breakfast cart arrive and later completed a test tray with the UM, DON, and Administrator. The square casserole bake measured 108 degrees F and was not palatable, coffee measured 102 degrees F and was not palatable, and the untoasted white bread was not palatable in appearance or taste. On Unit A, the surveyor observed the breakfast cart arrive and later completed a test tray with Nurse #5 and the Administrator. Oatmeal measured 124.2 degrees F and was described as very bland and watery, coffee measured 110.0 degrees F and was not hot, and the square casserole bake measured 125 degrees F and was bland and not identifiable by appearance or taste. During interviews, staff and the Administrator described the casserole bake and oatmeal as bland, and the FSD acknowledged that the hot food and beverage temperatures did not meet the 135 degrees F goal.
Failure to Timely Notify Dietitian and Implement Nutritional Interventions for Resident with Weight Loss and Pressure Injury
Penalty
Summary
A resident with diagnoses including Parkinson's disease and bacteremia was admitted to the facility and assessed by the Registered Dietitian (RD) as being at risk for malnutrition. Despite this, the resident developed a pressure injury and experienced a significant, unplanned weight loss over a short period. The facility's policies required prompt notification of the RD and initiation of nutritional interventions for residents at risk of skin breakdown or with significant weight changes, but these steps were not taken in a timely manner. Family members reported that the resident did not receive adequate assistance with eating, leading to further weight loss. Documentation showed that the resident's weight dropped from 168 lbs. to 145.6 lbs. in just over a month, representing a 13.3% loss. Although the resident's diet was modified by therapy staff and the resident was able to eat independently, there was no evidence that the RD was notified of the severe weight loss or the development of the pressure injury until several weeks after these issues were identified. Nursing staff and unit managers confirmed that weight monitoring and reporting processes were not consistently followed, and the RD relied on nursing staff for notifications rather than proactively reviewing weight reports. Interviews with facility staff revealed that significant weight changes were not promptly communicated to the RD, and the required progress notes and notifications were not completed. The RD only became aware of the resident's condition and initiated appropriate nutritional interventions weeks after the onset of the pressure injury and significant weight loss. This delay in notification and intervention contributed to the resident not receiving timely nutritional support to address their health needs.
Incomplete Medical Record Documentation for Wound Care and ADLs
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident who required wound treatments, had significant weight loss, and needed assistance with activities of daily living (ADLs). Nursing staff did not consistently complete required weekly wound logs and weekly nursing skin review assessments in the electronic health record (EHR) as mandated by facility policy. Specifically, there were missing entries for the weekly nursing skin review and several weekly wound logs, with staff interviews confirming that these assessments were not documented in the EHR, even though some information was recorded on paper forms that were not considered part of the official medical record. Further deficiencies were identified in the documentation of wound care treatments on the Treatment Administration Record (TAR). Several wound treatments were left unsigned on multiple dates and shifts, resulting in blank spaces on the TAR. Nursing progress notes indicated that some treatments were not administered because the resident was out of bed, but the documentation was vague and did not clarify whether treatments were re-attempted or if education was provided to the resident. Staff interviews confirmed that the lack of documentation meant it was unclear if the treatments were performed as required. Additionally, the Certified Nurse Aide (CNA) ADL flow sheets for several months contained numerous blank entries for essential care tasks such as oral hygiene, nutrition (fluid intake), and nutrition (amount eaten). CNAs and nursing staff acknowledged that documentation was expected to be completed by the end of each shift and that blank spaces indicated the required documentation was not done. The expectation was for floor nurses to review CNA documentation at the end of each shift, but this oversight did not occur, resulting in incomplete records for the resident's daily care.
Failure to Adhere to Physician's Orders for Midodrine Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of Midodrine, a medication used to treat orthostatic hypotension. The physician's orders clearly stated that the medication should be held if the resident's systolic blood pressure (SBP) was above 130 mmHg. However, the Medication Administration Record (MAR) for November 2024 indicated that the medication was administered on five occasions when the resident's SBP exceeded the specified threshold. The resident involved had a medical history that included end-stage renal disease, type II diabetes mellitus, and hypertension, and was dependent on renal dialysis. Despite the clear physician's orders, the medication was not held on the dates when the SBP was recorded as 141, 138, 145, 134, and 143 mmHg. Interviews with the nursing staff confirmed that the medication should have been withheld according to the physician's parameters, but it was not, leading to a significant medication error.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to infection control standards, leading to potential transmission of communicable diseases and infections among residents. Specifically, the facility did not ensure that wound care supplies used inside a resident's room were not removed and stored in the clean utility room, which could lead to contamination. During wound care for a resident with MRSA, a nurse used contaminated scissors to cut clean dressing materials without disinfecting them, risking cross-contamination of the wound. Staff also failed to wear necessary PPE to maintain contact isolation precautions for residents with communicable infections. For instance, a rehabilitation staff member and maintenance staff entered a resident's room, who was on contact precautions, without donning a gown and gloves. Similarly, a nurse entered the same resident's room without PPE, allowing her clothing to come into contact with potentially contaminated surfaces. Additionally, the facility did not maintain enhanced barrier precautions for a resident with a feeding tube and colostomy. Staff members entered the resident's room and provided care without wearing gowns, despite the requirement for PPE during high-contact activities. This lack of adherence to infection control protocols was observed across multiple staff members and residents, indicating a systemic issue within the facility.
Failure to Maintain Clean Wheelchair for Resident
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for a resident, specifically regarding the cleanliness of the resident's wheelchair. The resident was observed multiple times over several days with a wheelchair that had dirt, debris, and food particles on the chair cushion, frame, brakes, and wheels. These observations were made on three separate occasions, indicating a persistent issue with the cleanliness of the wheelchair. During an interview, the Director of Housekeeping acknowledged the failure to adhere to the wheelchair cleaning schedule, which was supposed to occur twice a month. The Director admitted that there was no tracking system in place to verify which wheelchairs had been cleaned. Despite the schedule indicating that the wheelchairs on the resident's unit were due for cleaning, the resident's wheelchair remained unclean. The Director of Housekeeping confirmed that the wheelchair should not have been in such a condition and needed cleaning, but could not specify when it was last cleaned.
Failure to Notify State Mental Health Authority After Resident's Significant Change in Condition
Penalty
Summary
The facility failed to notify the state mental health authority for a resident review after a significant change in mental condition occurred for one resident. Specifically, the facility did not request a Preadmission Screening and Resident Review Level II screen (PASRR) after the resident was diagnosed with Bipolar Disorder and experienced limitations in major life activities due to mental illness. The facility's policy required prompt referral to the state mental health or intellectual authority for a Level II resident review when a resident exhibits a newly evident or possible serious mental disorder. The resident was admitted with diagnoses including Chronic Respiratory Failure and Obstructive Sleep Apnea. The Minimum Data Set assessment indicated the resident was cognitively intact and had not been evaluated by a Level II PASRR, despite having active diagnoses of Depression and Bipolar Disorder. The resident's PASRR Level I screen showed no diagnosis of mental illness or treatment history, and a negative SMI screen. A Behavioral Health Group Note later confirmed the diagnosis of Bipolar Disorder and a history of Depression and Anxiety. The Social Worker acknowledged that a Change of Condition should have been submitted through the Massachusetts Executive Office of Health and Human Services portal, but it was not done.
Failure to Create Timely Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to create a baseline care plan within 48 hours of admission for two residents, leading to deficiencies in their care. One resident, who was admitted with a diagnosis of Methicillin-Resistant Staphylococcus Aureus (MRSA) in a wound, did not have a baseline care plan created until eight days after admission. This delay resulted in the absence of necessary contact precautions for six days, despite the resident's condition requiring such measures to prevent the spread of infection. The Infection Preventionist confirmed that a baseline care plan should have been established within 72 hours, and a physician's order for contact precautions should have been in place upon admission. Another resident, admitted with End Stage Renal Disease and Type 2 Diabetes, also did not have a baseline care plan completed within the required 48-hour timeframe. The plan was completed four days after admission, and a copy was not provided to the resident. The Unit Manager acknowledged that the baseline care plan should be completed within 48 hours and reviewed with the resident, although a copy was not given. These oversights indicate a failure to meet the immediate care needs of the residents upon their admission to the facility.
Failure to Measure and Document PICC Line Measurements
Penalty
Summary
The facility failed to provide care in accordance with professional standards of practice for a resident with a Peripherally Inserted Central Catheter (PICC) line. The deficiency was identified through observation, interview, and record review, revealing that the facility did not measure the external catheter length and arm circumference as ordered by the physician. This oversight increased the potential risk of complications such as infiltration, migration, and deep vein thrombosis. The resident was admitted with diagnoses including cellulitis and Methicillin-Resistant Staphylococcus Aureus (MRSA) and had a PICC line inserted for intravenous administration of antibiotics. The facility's policy required measuring the length of the lumen and the circumference of the upper arm upon admission, with each dressing change, and as needed. However, there was no documented evidence of these measurements being taken since the resident's admission, despite physician orders specifying these requirements. During the survey, it was observed that the PICC line dressing was in place, but the necessary measurements had not been recorded. Interviews with nursing staff confirmed the lack of documentation and the importance of these measurements to ensure the PICC line had not migrated. The resident also could not recall staff obtaining these measurements since admission, highlighting the facility's failure to adhere to its own policies and physician orders.
Failure to Provide Adequate Oral Hygiene Assistance
Penalty
Summary
The facility failed to provide necessary assistance for a resident, identified as Resident #45, in performing activities of daily living, specifically oral hygiene. Resident #45, who was admitted in November 2019, has multiple diagnoses including epilepsy, dementia, adult failure to thrive, apraxia, aphasia, and weakness, which render them dependent on assistance for daily activities. The facility's policy mandates that residents unable to perform ADLs independently should receive appropriate care to maintain personal hygiene, including oral care. However, the review of the resident's care plan and task flow sheets indicated inconsistencies in providing oral hygiene care, with several instances where the resident did not participate in oral hygiene care or was not assisted as required. Observations and interviews conducted by the surveyor revealed that Resident #45 had a significant buildup of plaque and debris on their teeth, and a strong odor was noted from their mouth, indicating a lack of regular oral hygiene. During an observation, a CNA was unable to locate a toothbrush and toothpaste in the resident's room, suggesting a lack of preparedness and oversight in ensuring the resident's oral hygiene needs were met. The CNA eventually provided the necessary items, and the resident was able to brush their teeth independently, demonstrating that with proper setup, the resident could participate in their oral care. Further interviews with CNAs revealed a lack of consistent oral care provision, with one CNA admitting to not providing morning mouth care due to concerns about the resident's bleeding gums. This CNA opted to use a toothette instead of a toothbrush, which was not in line with the facility's standard practice as stated by the Director of Nursing. The DON confirmed that mouth care should be provided every morning and night, and was unaware of any specific dental issues with the resident that would necessitate deviation from standard care practices.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident who required the use of a Continuous Positive Airway Pressure (CPAP) machine. The deficiency was identified when it was discovered that there was no physician's order for the CPAP machine, which is necessary for residents with conditions such as chronic respiratory failure and obstructive sleep apnea. The resident, who was cognitively intact, expressed a need for assistance in using the CPAP machine at night but reported that the staff did not consistently offer help, leading to infrequent use of the device. The resident had been admitted to the facility with a care plan that included the use of continuous oxygen and CPAP therapy. However, after a hospital transfer, the CPAP orders were not re-entered into the electronic medical record upon the resident's return. This oversight resulted in the resident not receiving the prescribed CPAP therapy, as there was no documentation of its use in the Medication Administration Record or Treatment Administration Record for several months. Observations by the surveyor revealed that the CPAP machine and its components were not stored properly, with the mask and tubing left undated and unbagged, increasing the risk of contamination. Interviews with the nursing staff and unit manager confirmed that the omission of the CPAP orders was an error during the re-admission process, and the resident had not been offered the CPAP therapy as required since returning from the hospital.
Failure to Address Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure timely action on a Medication Regimen Review (MRR) recommendation for a resident who was receiving Atorvastatin, a cholesterol-lowering medication. The Consultant Pharmacist recommended a fasting lipid panel to monitor the resident's cholesterol levels, but there was no documented evidence that this test was conducted. The MRR, dated 4/18/24, was found to be unsigned and undated, with only a handwritten 'x' indicating agreement, but no follow-up action was taken. The resident involved had a medical history including hypertension and hemiparesis due to a cerebrovascular accident. The Director of Nursing (DON) was responsible for overseeing pharmacy recommendations and acknowledged the lack of follow-through on the MRR. The process involved sending recommendations to the DON's email, printing them, and giving them to the provider for review. However, the lipid panel was not drawn, and the DON was unsure who marked the MRR as agreed, suspecting it might have been the Nurse Practitioner.
Medication Pass Error Rate Exceeds Limit
Penalty
Summary
The facility failed to maintain a medication pass error rate of less than five percent, resulting in a medication error rate of 5.71%. This deficiency was observed when a resident was administered two scheduled medications later than the allowed timeframe. The resident, who was admitted to the facility with diagnoses including cerebral infarction, vascular dementia, and gastrostomy, was supposed to receive Gabapentin and Benztropine Mesylate via G-tube at specific times. However, these medications were administered one hour and 41 minutes past the scheduled time. The error occurred during a medication pass on the D-Wing unit, where Nurse #7 was responsible for administering medications. Nurse #7 acknowledged the late administration and attributed it to a system problem, explaining that she was scheduled to work on a different wing earlier in the day and had to manage medications for 17 residents before moving to the D-Wing. The Director of Nursing confirmed that the resident should not have received the medications late, indicating a lapse in the facility's medication administration process.
Failure to Obtain Physician-Ordered Lab Tests
Penalty
Summary
The facility failed to obtain laboratory tests as ordered by the physician for two residents, leading to a deficiency in care. Resident #28, who was admitted with diagnoses including Vascular Dementia, Bipolar Disorder, and Major Depressive Disorder, had a physician's order for routine monitoring of valproic acid levels, a medication used for managing seizures and behaviors. Despite the order being in place since June 2023, the facility did not document any evidence of the valproic acid level being drawn since December 2023. This oversight was confirmed by the Unit Manager and the Director of Nursing, who acknowledged a systemic issue in obtaining routine lab work. Resident #52, diagnosed with Type 2 Diabetes, Hyperlipidemia, and Hypothyroidism, also experienced a lapse in routine lab work. The resident's physician had ordered regular monitoring of blood glucose levels, thyroid hormone levels, and lipid panels. However, there was no documented evidence of these tests being conducted since February 2024. The resident, who was cognitively intact, was unaware of the specific lab work being monitored. The Director of Nursing identified that the routine lab work had been accidentally discontinued and not renewed, resulting in the deficiency. The facility's policy on diagnostic services, revised in October 2024, mandates that diagnostic tests be provided and reported as required by the physician. However, the failure to adhere to this policy for Residents #28 and #52 highlights a significant gap in the facility's processes for managing and executing physician-ordered lab work. The Director of Nursing acknowledged the need for education among the nursing staff regarding the review and renewal of monthly laboratory sheets to prevent such deficiencies in the future.
Failure to Follow Dietary Plan for Resident
Penalty
Summary
The facility failed to follow the dietary plan as recommended by the Registered Dietitian (RD) for a resident, leading to unmet nutritional needs and preferences. The resident, who was on hospice care and had conditions such as Chronic Obstructive Pulmonary Disease (COPD) and Gastro-Esophageal Reflux Disease (GERD), was supposed to receive a regular diet with specific items for comfort and pleasure, including ice cream. However, during multiple meal observations, the resident did not receive the items listed on their meal tickets, such as an apple cinnamon muffin, potato wedges, and ice cream. The resident expressed dissatisfaction with the missing items and noted that complaints to the kitchen had not resulted in changes. Interviews with staff revealed that a nurse was responsible for checking meal trays to ensure they matched the meal tickets before distribution. Despite this protocol, discrepancies were observed, and the Food Service Director acknowledged that the resident should have received the items listed on the meal tickets. The Dietary Aide responsible for loading the meal trays was identified as the person accountable for ensuring the correct items were included, indicating a lapse in the facility's process for meal preparation and delivery.
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 486 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Agawam
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Agawam West Rehab And Nursing | 0 mi | ★★★★★ | 10 | 0 |
| Agawam North Rehab And Nursing | 0.1 mi | ★★★★★ | 0 | 0 |
| Agawam East Rehab And Nursing | 0.3 mi | ★★★★★ | 3 | 0 |
| Julian J Levitt Family Nursing Home | 3.7 mi | ★★★★★ | 0 | 0 |
| East Longmeadow Skilled Nursing Center | 4.6 mi | ★★★★★ | 0 | 0 |
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