Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
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 West Rehab And Nursing during CMS and state inspections, most recent first.
A resident who was severely cognitively impaired and fully dependent on staff for bed mobility fell from bed and sustained a head injury requiring hospital treatment after a CNA turned away during incontinence care, leaving the resident unattended and out of reach. The bed was in its highest position at the time, and the incident resulted in a laceration and epidural hematoma.
Improper Dumpster Area Sanitation: Surveyors observed the area around three kitchen dumpsters covered with debris and trash, including food-related waste, broken items, open rubbish, a chair, a rolling walker, two nursing medication carts, and electrical equipment. The District Dietary Manager, FSD, DON, and Maintenance Director all stated the area should have been kept clean and that the accumulated trash was not sanitary and could attract rodents, insects, raccoons, and other wildlife.
Unpasteurized eggs were used in preparing over easy eggs for residents despite the facility policy requiring pasteurized eggs or fully cooked eggs with firm yolks and whites. The FSD was observed with unpasteurized eggs in the walk-in refrigerator, and later eight eggs on the warming table had runny, not set yolks. The DON stated the kitchen staff had been using unpasteurized eggs and that they should not have been used for over-easy eggs.
A resident with PTSD and hearing impairment reported missing hearing aids, but the grievance was not resolved within the facility’s required timeframe. The grievance form was incomplete, the hearing aids were still not located weeks later, and the SW and DON acknowledged the issue had not been resolved promptly.
A resident with multiple medical conditions and moderate cognitive impairment was administered quetiapine, an antipsychotic medication, without written informed consent as required by facility policy. Consent was not obtained until more than a month after the medication was started, and the consent form did not reflect the actual prescribed dosage. The DON confirmed that informed consent should have been obtained prior to administration and that the documentation was missing.
A resident with an above-the-knee amputation and a history of falls required bilateral bedrails for safe mobility, as documented in their care plan and physician orders. When one bedrail became detached, staff were aware but did not ensure timely repair or replacement. The resident subsequently fell while attempting to use the missing bedrail, resulting in a femur fracture and head injury.
A resident with a history of amputation and falls was provided bilateral bedrails without documented assessment or trial of alternatives, as required by facility policy. Staff confirmed the resident used bedrails for mobility, but there was no evidence of risk discussion or annual reassessment, and the DON acknowledged the lack of required documentation.
A resident with bipolar disorder was administered an incorrect dosage of quetiapine for multiple days after nursing staff inaccurately reconciled hospital discharge orders, resulting in the medication being given twice daily instead of once daily. The error was not identified until the resident showed signs of lethargy and unstable vital signs, revealing a failure to properly verify and clarify medication orders as required by facility policy.
Two residents who required total staff assistance for ADLs had incomplete CNA documentation in their medical records, with multiple shifts left blank over several weeks, despite facility policy requiring accurate and complete charting.
A facility failed to maintain complete and accurate medical records for a resident, with incomplete nursing documentation in the MAR and inaccuracies in the Controlled Substance Register. The MAR showed blank spaces for scheduled medications, indicating a lack of documentation for medications like Clonazepam and Oxycodone. The Controlled Substance Register was missing prescription numbers, dates, and accurate dosage directions. The resident had a history of brain disorders and anxiety, requiring medications such as Ativan, Clonazepam, and Oxycodone.
The facility failed to maintain accurate Advance Directives for three residents. Two residents had invalid MOLST forms due to missing signatures from their HCPs and physicians, despite being cognitively impaired. Another resident, deemed capable of making medical decisions, was not offered the opportunity to establish a new Advance Directive after their HCP was deactivated.
The facility failed to notify the physician of significant health changes for two residents. One resident with Diabetes Mellitus Type 2 had blood sugar levels exceeding 400 mg/dL on multiple occasions without physician notification, contrary to facility policy. Another resident experienced a significant weight loss of 10.73% in one month, but the physician was not informed, and a requested re-weight was not obtained. These deficiencies indicate a failure to follow notification protocols for significant health changes.
The facility failed to complete and transmit MDS assessments within required timeframes for four residents. Delays included a quarterly assessment transmitted 28 days late and an admission assessment completed 17 days after the ARD. MDS nurses indicated that corporate staff handle transmissions, and they lack access to do so themselves.
A facility failed to notify the State Mental Health Authority for a resident review after a significant change in mental condition. The resident, with diagnoses including Bipolar Disorder and Major Depression, experienced suicidal ideation and was transferred to the hospital twice. Despite these changes, the facility did not request a PASRR Level II evaluation. The Social Worker acknowledged the oversight during an interview.
A resident with a diagnosis of hearing loss did not receive audiology services despite a request from their representative and a physician's order for ancillary care. The resident's hearing ability declined, and they were not provided with hearing aids, leading to communication difficulties. The DON confirmed that the resident should have been referred to an audiologist, indicating a failure in care coordination.
A resident, solely reliant on tube feeding, did not receive the prescribed volume of enteral nutrition due to a nurse administering only 240 ml instead of the ordered 356 ml. This discrepancy was acknowledged by the nurse, highlighting a failure to adhere to Physician's orders and placing the resident at risk for altered nutritional status.
A facility failed to maintain an oxygen concentrator filter in a clean and functional manner for a resident with asthma and acute respiratory failure. Despite physician orders for weekly cleaning, observations showed a thick coating of dust on the filter, indicating non-compliance. The Unit Manager confirmed the discrepancy between documented cleaning and the filter's condition, posing a risk to the resident's respiratory care.
A resident with quadriplegia and a signed consent for dental services was not referred for necessary dental care, despite a physician's order and facility policy requiring such services. The resident, who was cognitively intact, reported never being seen by a dentist and relied on their brother for oral hygiene assistance. The DON confirmed the oversight, acknowledging the resident should have received dental services.
The facility failed to maintain sanitary conditions in three unit kitchenettes, with observations of sticky substances in refrigerators and food debris in a microwave. Staff were unclear about cleaning responsibilities, and the A Wing kitchenette had unlabeled and undated food. The Food Service Director confirmed the lack of a cleaning schedule for these appliances.
A facility failed to document social service supportive visits for a resident with a history of suicidal ideation, despite multiple hospital evaluations. The resident, diagnosed with bipolar disorder and major depression, expressed suicidal thoughts on several occasions. Facility policies require documentation of such visits, but the social worker admitted to not recording them, leading to incomplete medical records.
A facility failed to implement proper infection control measures for a COVID-19 positive resident. Despite clear signage and available PPE, a CNA entered the resident's room without wearing the required N95 respirator, eye protection, gown, and gloves. The Infection Preventionist confirmed the need for isolation precautions, which were not followed.
Resident Fall Due to Inadequate Supervision During Bedside Care
Penalty
Summary
A deficiency occurred when a resident who was severely cognitively impaired and dependent on staff for all activities of daily living, including bed mobility, was not adequately supervised during personal care. The resident, who had diagnoses including dementia, dysphagia, and glaucoma, required extensive assistance and was unable to move independently. During the provision of incontinence care, a CNA positioned the resident on their side in bed and then turned away to retrieve a wet cloth from a table located diagonally behind her, leaving the resident unattended and out of her immediate reach. While the CNA's back was turned, the resident rolled off the bed and fell to the floor, sustaining a laceration to the back of the head. The bed was noted to be in its highest position at the time of the incident. The resident was found on their back, actively bleeding from the head wound. Immediate assistance was called, and the resident was transferred to the hospital emergency department for evaluation and treatment. Medical evaluation revealed that the resident required staples to close the head wound and was diagnosed with a left lateral epidural hematoma. Interviews with staff and family confirmed that the resident was completely dependent on staff for mobility and could not reposition themselves. The incident was attributed to the CNA turning away from the resident during care, resulting in a lack of adequate supervision and failure to ensure the resident's safety during a vulnerable moment.
Improper Dumpster Area Sanitation
Penalty
Summary
The facility failed to ensure that garbage was disposed of properly. Review of the facility policy for Food Related Garbage and Rubbish Disposal, last revised 11/5/24, indicated that garbage and rubbish containing food waste were to be kept in containers, stored in a manner inaccessible to vermin, and that storage areas would be kept clean at all times. The policy also stated that outside dumpsters provided by garbage pickup services would be kept closed and free of surrounding litter. On 9/11/25, the surveyor and the District Dietary Manager observed the area around three kitchen dumpsters outside the facility building and found the ground covered with debris and trash. Items observed included gloves, broken debris, decomposing flat cardboard boxes, plastic containers and bags, wet and decomposing papers, condiment containers, small milk cartons, potato chip bags, cereal bowls, bottle caps, drink covers, plastic cutlery, a free-standing open rubbish bin, a chair, a rolling walker, two nursing medication carts, and electrical equipment. During interviews, the District Dietary Manager, FSD, DON, and Maintenance Director all stated that the dumpster area should have been clean and that the accumulated trash was not sanitary and could attract rodents, insects, raccoons, and other wildlife.
Unpasteurized Eggs Used for Over Easy Eggs
Penalty
Summary
The facility failed to follow professional standards of practice for food safety by using unpasteurized eggs in the preparation of over easy eggs for residents. The facility policy titled Raw Eggs, last revised 11/5/24, stated that eggs must be thoroughly cooked until the yolks and whites are firm, served immediately, and that unless eggs are pasteurized, soft cooked, undercooked, sunny side up, poached, and over easy eggs will not be served. Review of invoices from the facility vendor dated 7/23/25, 7/30/25, 8/13/25, 8/20/25, 8/27/25, 9/3/25, and 9/10/25 showed that the eggs purchased for over easy eggs were not pasteurized. On 9/10/25 at 7:04 A.M., the surveyor and the FSD observed unpasteurized eggs in the walk-in refrigerator. The FSD stated at that time that the eggs were being provided fully cooked with a firm and set yolk. Later that morning, the surveyor observed eight eggs on the warming table in the main kitchen for the breakfast meal with runny, not set, orange yolks. During an interview on 9/10/25 at 11:51 A.M., the DON stated that the kitchen staff had been using unpasteurized eggs and that the eggs should not have been unpasteurized for use as over-easy eggs.
Delayed Resolution of Missing Hearing Aids Grievance
Penalty
Summary
The facility failed to resolve a grievance in a timely manner for a resident with PTSD and right ear hearing impairment who reported missing hearing aids. The facility policy required follow-up within 72 hours and reasonable efforts to resolve grievances within 30 calendar days, but the grievance form for the missing hearing aids left the sections for confirming the grievance and corrective action blank. The form indicated the hearing aids were not found after a complete search and that staff would continue to look for them, with the resolution date assigned on the same day the grievance was filed. Record review showed that more than a month later, an audiology consultation documented that the facility was still unable to locate the hearing aids. Nursing notes stated the resident had recently been transferred to the wing and many items were missing, and that staff contacted social services to work on finding the devices. During interviews, the social worker stated the grievance had been filed in December 2024 regarding the missing hearing aids and had been resolved by the Administrator, but also acknowledged the hearing aids had not been located and no attempt had been made to obtain a new pair through the consulting audiologist. The DON stated the grievance should have been resolved within three days and had not been, and that the missing hearing aids were not addressed until the surveyor brought it to the facility's attention.
Failure to Obtain Timely and Accurate Informed Consent for Psychotropic Medication
Penalty
Summary
A deficiency occurred when the facility failed to obtain written informed consent for the administration of a psychotropic medication to one resident prior to starting the medication. The facility's policy required that psychotropic medications be administered only after obtaining informed consent from the resident or their responsible party. The resident, who was admitted with diagnoses including bipolar disorder, anemia, osteoarthritis, diabetes mellitus, hypertension, and atrial fibrillation, was assessed as having moderate cognitive impairment but was still able to make their own decisions, as their Health Care Proxy was not activated. Despite this, the resident was administered quetiapine fumerate, an antipsychotic medication, starting in early February, without any documentation of written informed consent in the medical record. Written consent was not obtained until over a month after the medication had been initiated. Furthermore, the consent form that was eventually signed did not match the resident's current medication order, as the dosage range on the consent form was lower than the actual prescribed dose. The DON confirmed that no documentation of informed consent prior to administration could be found and acknowledged that consent should have been obtained before starting the medication.
Failure to Timely Repair Bedrail Results in Resident Fall and Injury
Penalty
Summary
A resident with a history of left above-the-knee amputation, repeated falls, and other medical conditions required bilateral bedrails for safe transfers, turning, and positioning, as documented in the physician's orders and care plan. The resident's left bedrail became detached from the bed, and although staff were aware of the issue, the bedrail was not repaired or replaced in a timely manner. The maintenance work order for the repair was not submitted until after the resident experienced a fall. On the night of the incident, the resident attempted to sit up on the edge of the bed and reached for the missing left bedrail, lost balance, and fell forward onto the floor, resulting in a right femur fracture and head injury. Staff interviews confirmed that the resident frequently self-transferred without assistance and that the left bedrail had been broken prior to the fall. The CNA and nurse on duty were aware of the broken bedrail but did not ensure that the maintenance request was promptly entered or that the resident's environment was made safe in the interim. The facility's fall reduction policy required identification of residents at risk for falls and implementation of appropriate interventions, including assistive devices. Despite this, the necessary assistive equipment was not provided as required, and the lack of timely repair or replacement of the bedrail directly contributed to the resident's fall and subsequent injury.
Failure to Assess and Document Bedrail Use and Alternatives
Penalty
Summary
The facility failed to ensure that a resident, who was cognitively intact and made independent medical decisions, was properly assessed for the use of bedrails and that alternatives were trialed prior to their installation. The facility's policy required that the appropriateness of bedrails be evaluated in relation to the resident's condition, with documentation of alternatives explored, rationale for use, and the resident's cognitive ability. However, there was no documentation in the resident's medical record to support that an assessment for bedrail use was conducted, that alternatives were attempted, or that the continued use of bedrails was reassessed annually as required by policy. The resident, who had a history of left leg above the knee amputation, insomnia, generalized anxiety disorder, and repeated falls, was observed using bilateral quarter length bedrails. Staff interviews confirmed that the resident used bedrails for mobility and transfers, but the resident did not recall any discussion about the risks associated with bedrail use. A physical therapy screen noted the appropriateness of the bed setup but did not document any evaluation of alternatives or their outcomes. The Director of Nurses confirmed that no documentation existed to show compliance with assessment and policy requirements regarding bedrail use.
Significant Medication Error Due to Incorrect Reconciliation of Antipsychotic Order
Penalty
Summary
A deficiency occurred when a resident with bipolar disorder was admitted to the facility and experienced significant medication errors due to inaccurate medication reconciliation. Upon admission, nursing staff transcribed the resident's hospital discharge orders for quetiapine incorrectly, resulting in the resident receiving 900 mg of quetiapine twice daily instead of the intended 900 mg once daily at bedtime. The error persisted for 25 days, during which the resident was administered a total daily dose that exceeded the usual recommended range. Nursing staff relied on the hospital discharge summary and medication list but failed to clarify the frequency of administration, despite noting that the dosage seemed excessive. The nurse did not consult further with the provider to confirm the correct order. The error was discovered when the resident became lethargic and exhibited unstable blood pressure and heart rate. Upon review, it was found that the quetiapine order had been duplicated and administered twice daily in error. The facility's policy required verification of medication orders and clarification with the provider if a dosage appeared excessive or unrelated to the resident's condition, but this process was not followed. The Director of Nursing stated that staff should have reviewed the psychiatric and provider notes to identify the discrepancy in the medication order.
Incomplete ADL Documentation for Dependent Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents who were dependent on staff for all activities of daily living (ADLs). For one resident with diagnoses including cerebral infarction, diabetes mellitus, and osteomyelitis, review of ADL flow sheets over multiple weeks revealed numerous shifts where all ADL care areas were left blank, indicating incomplete documentation. Specifically, there were missing entries across all three shifts on several days, despite the resident's total dependence on staff for care. Similarly, another resident with multiple diagnoses such as anemia, osteoarthritis, diabetes mellitus, bipolar disorder, hypertension, and atrial fibrillation also had incomplete ADL documentation. Over a period of nearly a month, there were multiple days where entire shifts lacked any documentation of ADL care. The facility's policy requires that each resident have an active medical record with accurately documented information, and the unit manager confirmed that CNAs are responsible for completing this documentation by the end of their shift.
Incomplete Medication Documentation and Inaccurate Controlled Substance Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, as evidenced by incomplete nursing documentation in the Medication Administration Record (MAR) and inaccuracies in the Controlled Substance Register. The MAR for the resident showed blank spaces for scheduled medications, indicating that the nurse did not document the administration of medications such as Clonazepam and Oxycodone on multiple occasions across January, February, and March 2025. Interviews with nursing staff confirmed that blank spaces on the MAR suggest that the medications were not documented as administered, which is against the facility's policy. Additionally, the Controlled Substance Register for the resident contained several inaccuracies and incomplete entries. The register was missing prescription numbers, prescription dates, and accurate dosage directions for medications like Ativan, Clonazepam, and Oxycodone. The register also included incorrect dosage directions for Clonazepam and failed to document scheduled and PRN doses for Oxycodone. Interviews with nursing staff and management confirmed these discrepancies, highlighting a failure to maintain accurate records as required by the facility's policies. The resident involved had a history of brain disorders, malformations of cerebral vessels, and anxiety disorder, requiring medications such as Ativan, Clonazepam, and Oxycodone. The deficiencies in documentation and record-keeping could potentially impact the resident's care, as accurate records are essential for ensuring proper medication administration and monitoring. The facility's policies clearly outline the requirements for medication administration and documentation, which were not adhered to in this case.
Failure to Ensure Accurate Advance Directives
Penalty
Summary
The facility failed to ensure that Advance Directives were accurate for three residents, leading to deficiencies in the management of their medical care preferences. For two residents, the Massachusetts Medical Order for Life-Sustaining Treatment (MOLST) forms were not valid as they lacked the necessary signatures from the residents' Health Care Proxies (HCP) and physicians. Resident #3, who was severely cognitively impaired, had a MOLST form that was unsigned by both the HCP and the physician, despite the HCP being invoked. Similarly, Resident #62, who was cognitively impaired, had a MOLST form that was also unsigned by the HCP and physician, even though the HCP had been invoked. The social worker acknowledged that these forms were invalid and should have been updated. Additionally, the facility did not offer Resident #39 the opportunity to formulate a new Advance Directive after the resident's HCP was deactivated by the physician, as the resident was deemed capable of making their own medical decisions. Despite the resident being cognitively intact, there was no evidence in the clinical record that the resident was provided with the opportunity to establish a new MOLST. The social worker confirmed that a new MOLST should have been established once the resident was determined to have the capacity for informed medical decision-making.
Failure to Notify Physician of Significant Health Changes
Penalty
Summary
The facility failed to notify the Physician or Non-Physician Practitioner of significant changes in the condition of two residents, leading to deficiencies in care. For one resident with a diagnosis of Diabetes Mellitus Type 2, the facility staff did not inform the physician when the resident's blood sugar levels exceeded 400 mg/dL on multiple occasions. Despite the facility's policy requiring immediate notification of the physician for blood sugar levels above 400 mg/dL, there was no documentation of such notifications in the resident's progress notes. The Unit Manager confirmed that the physician should have been notified and that the lack of documentation was an oversight. Another resident, who was severely cognitively impaired and receiving nutrition via tube feeding, experienced a significant unplanned weight loss of 10.73% in one month. The facility's policy mandates notifying the physician and dietician of significant weight changes, but there was no evidence that the physician was informed of this resident's weight loss. Additionally, a re-weight was requested to confirm the accuracy of the recorded weight, but it was not obtained. The Unit Manager and a nurse were unaware of the re-weight request, indicating a communication breakdown within the facility. These deficiencies highlight the facility's failure to adhere to its own policies regarding the notification of significant changes in residents' conditions. The lack of communication and documentation regarding these critical health changes could potentially impact the residents' health outcomes, as timely medical intervention is crucial in managing such conditions.
Failure to Timely Complete and Transmit MDS Assessments
Penalty
Summary
The facility failed to ensure the timely completion and transmission of the Minimum Data Set (MDS) Assessments for four residents, as required by the CMS Resident Assessment Instrument (RAI) guidelines. Specifically, the facility did not adhere to the required timeframes for setting the Assessment Reference Date (ARD), completing the MDS assessments, and transmitting the data to the state. For one resident, the quarterly MDS assessment was transmitted 28 days after the completion date, while another resident's admission MDS assessment was completed 17 days after the ARD. Additionally, two residents had their MDS assessments completed but not transmitted within the required timeframe. During an interview, MDS Nurse #1 acknowledged the delays in completing and transmitting the MDS assessments, citing that the facility's Corporate MDS staff is responsible for the transmission process, and the nurses do not have access to transmit the assessments themselves. The nurse confirmed that the completion date for the MDS assessment should be 14 days from the ARD, but this was not met for several residents. The deficiencies were identified through a review of clinical records and interviews with the facility's MDS nurses.
Failure to Notify State Mental Health Authority After 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 a resident. The resident, admitted in May 2024, had diagnoses including Bipolar Disorder, Major Depression, and Suicidal Ideation. Initially, the resident's PASRR Level I form indicated no need for a Level II evaluation as there were no treatments due to mental illness, no history of emergency mental health interventions, and no functional life impairments due to mental illness. However, subsequent events indicated a significant change in the resident's mental condition. On May 13, 2024, the resident reported intermittent suicidal ideation and was evaluated by a Nurse Practitioner, who determined the resident was not actively suicidal at that time. The following day, the resident was transferred to the hospital for suicidal ideation and returned after a crisis evaluation. On June 17, 2024, the resident expressed a desire to die rather than eat and had not eaten in two days, leading to another hospital transfer. Despite these significant changes, the facility did not request a PASRR Level II evaluation. During an interview, the Social Worker acknowledged that the resident's suicidal ideation should have triggered a Level II request, but it was not submitted.
Failure to Provide Audiology Services for Resident with Hearing Loss
Penalty
Summary
The facility failed to provide necessary care and services to address a hearing problem for a resident, leading to a deficiency. The resident, who was admitted with a diagnosis of hearing loss, had a physician's order for ancillary and specialty care as needed. Despite a request for audiology services being made by the resident's representative, the facility did not provide these services. The resident's Minimum Data Set (MDS) assessments indicated a decline in hearing ability, yet no hearing aids were provided, and the resident was only sometimes able to understand others. During an interview, the resident expressed significant difficulty in hearing and understanding, stating they were very deaf and unable to read lips. The clinical record review confirmed that the resident had not been referred to an audiologist, despite the family's consent for such services. The Director of Nursing acknowledged that the resident should have been referred to an audiologist, highlighting a lapse in the facility's coordination and provision of necessary care for the resident's hearing deficit.
Failure to Administer Correct Enteral Nutrition Volume
Penalty
Summary
The facility failed to administer the correct volume of enteral nutrition as per the Physician's orders for a resident who relied solely on tube feeding for nutrition. The resident, who was admitted with diagnoses including Subarachnoid Hemorrhage and Respiratory Failure, was severely cognitively impaired and received nutrition via a feeding tube. The facility's policy required that enteral feeding orders be followed to ensure consistent volume infusion, but this was not adhered to in the case of the resident. During an observation, a nurse administered only 240 ml of Osmolite 1.5 CAL tube feeds instead of the prescribed 356 ml, resulting in a deficit of 119 ml. The nurse acknowledged the error and the importance of providing the correct volume, as the resident's sole source of nutrition was through the enteral feeds. This failure to follow the Physician's orders placed the resident at risk for altered nutritional status.
Failure to Maintain Oxygen Concentrator Filter
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident by not maintaining the oxygen concentrator filter in a clean, safe, and functional manner as per physician orders. The resident, who was admitted with diagnoses including asthma and acute respiratory failure, had a physician's order for continuous oxygen delivery at one liter per minute via nasal cannula. The order also specified that the oxygen concentrator filter should be cleaned weekly during the night shift every Friday. However, observations on multiple dates revealed a thick coating of gray dust on the filter, indicating that the cleaning had not been performed as required. The Unit Manager confirmed during an interview that the filter cleaning was documented as completed on the specified dates, but the physical condition of the filter suggested otherwise. The failure to clean the filter as ordered placed the resident at risk for impaired oxygen delivery and potential equipment malfunction. The Unit Manager acknowledged the importance of maintaining clean filters to prevent equipment issues and protect residents with respiratory conditions from allergens and germs.
Failure to Provide Dental Services to Resident
Penalty
Summary
The facility failed to provide necessary dental services for a resident who had been admitted with quadriplegia and was dependent on staff for oral hygiene. Despite having a signed consent for dental services dated December 3, 2019, and a physician's order for a dental consult from December 8, 2020, the resident had not been referred for dental care. The resident, who was cognitively intact, expressed during an interview that they had never been seen by a dentist and relied on their brother for assistance with oral hygiene. The facility's policy required coordination with ancillary services, including dental care, based on individual needs. However, a review of the resident's medical records showed no indication of any dental consultation or treatment. The Director of Nursing confirmed that the resident had not been seen by a dentist, acknowledging that the resident should have received dental services as consent had been provided by the resident's representative.
Failure to Maintain Sanitary Conditions in Unit Kitchenettes
Penalty
Summary
The facility failed to maintain safe and sanitary conditions in three unit kitchenettes, specifically on the F Wing, C Wing, and A Wing. Observations revealed that the refrigerators in these kitchenettes had sticky red and brown substances splattered on the inside of the doors and shelves. Additionally, the microwave in the F Wing kitchenette had food debris splattered inside. Interviews with staff, including a Unit Manager, a Certified Nurses Aide, and a Nurse, indicated a lack of clarity regarding responsibility for cleaning these appliances. The staff acknowledged the unsanitary conditions and expressed uncertainty about who should be notified for cleaning. Further investigation revealed that the refrigerator in the A Wing kitchenette contained three plastic containers of food that were unlabeled and undated, contrary to the facility's policy requiring food to be dated and tightly sealed. The Food Service Director confirmed that the Dietary department was responsible for maintaining and cleaning the appliances in the unit kitchenettes. However, there was no routine maintenance and cleaning schedule in place for these appliances, which contributed to the unsanitary conditions observed by the surveyor.
Failure to Document Social Service Support for Resident with Suicidal Ideation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who required support services after multiple hospital evaluations for suicidal ideation. The facility's policies on responding to self-harm and behavior management require thorough documentation of behaviors, interventions, and social service visits. However, the facility did not document social service supportive visits for the resident after incidents of suicidal ideation, despite the resident's history of mental health issues, including bipolar disorder and major depression. The resident, who was cognitively intact, expressed suicidal ideation on several occasions, leading to hospital evaluations. Despite the facility's policy requirements, there was no documentation of social service visits following these incidents. The social worker acknowledged the lack of documentation and admitted to not recording supportive visits, which should have been documented according to the facility's policies.
Inadequate PPE Use for COVID-19 Positive Resident
Penalty
Summary
The facility failed to implement appropriate infection control measures for a resident who tested positive for COVID-19. According to the facility's Infection Prevention and Control Program, healthcare providers are required to wear an N95 respirator, eye protection, gown, and gloves when caring for residents with confirmed COVID-19 infections. Despite these guidelines, a Certified Nurses Aide (CNA) entered the room of the infected resident without donning the necessary personal protective equipment (PPE), including a gown, N95 respirator, eye protection, and gloves. The incident was observed by a surveyor, who noted the presence of a clear plastic bin containing PPE and an isolation sign outside the resident's room, indicating the required precautions. The CNA admitted to not paying attention to the isolation sign and failing to wear the required PPE. The Infection Preventionist confirmed that the resident was on isolation precautions due to a positive COVID-19 test and stated that all staff should have adhered to the posted instructions for PPE use when entering the room.
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What surveyors actually found near you
We read the 484 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
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Illustrative
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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 South Rehab And Nursing | 0 mi | ★★★★★ | 8 | 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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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.