Agawam North Rehab and Nursing

Inspectors wroteBased on observations, interviews and record review, the facility failed to maintain a clean and sanitary facility kitchen and on two units (A-Wing and F-Wing) out of four units observed. Specifically, the facility failed to: -ensure Dietary Staff adhered to the hair restraint policy to minimize the potential for physical contamination during food preparation and meal service in the main facility kitchen. -label, date and store foods in the facility kitchen to decrease potential for food contamination and food-borne illnesses. -ensure that outside windows to the facility kitchen had screens to prevent pests/rodents from entering. -maintain and store food service equipment in a clean and sanitary manner in the main facility kitchen and on A-Wing and F-Wing units.

Inspectors wroteBased on interviews, and record reviews, the facility failed to ensure that six Residents (#2, #45, #48, #108, #3 and #9) and/or their Resident Representatives were afforded the right to participate in the scheduled interdisciplinary (IDT) care plan meetings, out of a total sample of 23 residents. Specifically, the facility failed to: -For Resident #2, Resident #45, and Resident #108, ensure quarterly IDT care plan meetings occurred and that the Resident was invited to participate in the meetings. -For Resident #48, ensure quarterly IDT care plan meetings occurred and the Resident and/or Resident Representative were invited to participate in the meetings. -For Resident #3, and Resident #9, ensure IDT care plan meetings occurred and the Resident and/or Resident Representative were invited to participate in the meetings.

Inspectors wroteBased on interviews, and record review, the facility failed to ensure that four Resident's (#12, #6, #45 and #84), out of a total sample of 23 residents, had the right to privacy when receiving letters, packages and other materials delivered to the facility via postal services. Specifically, for Resident's #12, #6, #45 and #84, the facility failed to ensure that mail addressed to the Residents' was delivered unopened.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that there was sufficient nursing staff to assist residents in attaining and maintaining the highest practicable physical, mental, and psycho-social well-being on four units (A-Wing, C-Wing, D-Wing, and F-Wing), out of a total of four units, and for three Residents (#51, #45, and #13), out of a total sample of 23 residents. Specifically, 1. The facility failed to ensure that staffing levels on the A-Wing, C-Wing, D-Wing and F-Wing were provided to meet the residents needs of each unit safely. 2. For Resident #51, the facility failed to ensure toileting assistance was provided promptly when the Resident was indisposed and had the call light on for over 20 minutes. 3. [...]

Inspectors wrote2. Resident #23 was admitted to the facility in October 2023 with diagnoses including Dementia and Type 2 Diabetes. Review of the Resident's clinical record indicated the Consultant Pharmacist had recommendations for the following dates and noted to refer to the report for details on: -9/19/24 -11/20/24 -12/18/24 -1/23/25 Further review of the Resident's clinical record failed to indicate documented evidence on what the Consultant Pharmacist recommendations were or that the recommendations were addressed by the facility and/or the Physician. On 4/9/25 at 2:21 P.M., the surveyor requested the Consultant Pharmacy Recommendations for Resident #23 from the DON. [...]

Inspectors wroteBased on observations, interviews and records reviewed, the facility failed to provide a dignified existence for two Resident's (#9 and #17), out of a total sample of 23 residents. Specifically, the facility failed to: 1. ensure that Resident #9 had appropriate clothing to wear while out of his/her room. 2. For Resident #17, ensure dressing assistance was provided in accordance with the Resident's preference to be washed and fully dressed by 6:00 A.M., when the Resident required assistance from staff with dressing needs.

Inspectors wroteBased on interview, and record review, the facility failed to uphold resident rights for one Resident (#13), out of a total sample of 23 residents, relative to rights exercised by the Resident's Representative (RR #1). Specifically, the facility failed to provide Resident #13's Representative with a copy of the Resident's medical record when RR #1 was exercising the Resident's right to review a copy of the medical records, and the medical records were requested through the appropriate process from the facility by RR #1.

Inspectors wroteBased on interview, and record review, the facility failed to act upon, provide timely responses, and document written responses and rationale to grievances of resident care and services brought to facility administration by the Resident Council. Specifically, the facility failed to promptly respond to resident grievances relative to laundry delays, loss and errors.

Inspectors wroteBased on interview and record review, the facility failed to ensure that advanced directives were honored for one Resident (#2), out of a total sample of 23 residents. Specifically, for Resident #2, the facility failed to ensure that the Medical Orders for Life-Sustaining Treatment (MOLST: legal document that allows individuals to communicate their preferences for life-sustaining treatment to healthcare providers) form and Physician's orders accurately reflected the Resident/Resident Representative's wishes putting the Resident at risk for being resuscitated (perform full measures including cardiopulmonary resuscitation and intubation) when the advanced directive wishes were for no resuscitation (do not resuscitate [DNR] and intubate [DNI]).

Inspectors wroteBased on record review, and interview, the facility failed to notify the Office of the State Long-Term Care Ombudsman in writing, of a transfer or discharge for three Residents (#58, #13 and #47), out of a total sample of 23 residents. Specifically, the facility failed to provide written notification to the Office of the State Long-Term Care Ombudsman: 1. For Resident #58, when the Resident was transferred out of the facility to the hospital on 3/11/25. 2. For Resident #13, when the Resident was transferred out of the facility to the hospital on 3/27/25. 3. For Resident #47, when the Resident was transferred out of the facility to the hospital on 3/8/25.

Inspectors wroteBased on record reviews, and interviews, the facility failed to ensure a comprehensive care plan was initiated for the care and services of one Resident (#9), out of a total sample of 23 residents. Specifically, the facility failed to develop a comprehensive care plan for Resident #9 relative to Suicidal Ideations (SI) that the Resident experienced in the hospital, prior to his/her admission to the facility, which continued after his/her admission to the facility.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that three Residents (#2, #17, and #88), were provided activity of daily living (ADL) care in accordance with their needs/preferences, out of a total sample of 23 residents. Specifically, the facility failed to: 1. For Resident #2, ensure grooming assistance relative to facial hair removal was provided when the Resident was dependent on staff for personal hygiene needs. 2. For Resident #17, ensure dressing assistance was provided in accordance with his/her preferences when the Resident required assistance from staff with dressing needs. 3. For Resident #88, provide grooming assistance when the Resident required extensive physical assistance with grooming and had a preference for facial hair removal daily.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure treatment and care in accordance with professional standards of practice relative to monitoring and assessing skin conditions for two Residents (#30 and #45), out of a total of 23 sampled residents. Specifically, the facility failed to: 1. For Resident #30, identify, assess and implement interventions timely when skin areas developed on his/her inner and outer left lower leg. 2. For Resident #45, perform weekly skin assessments as per the comprehensive plan of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one Resident (#45) out of a total sample of 23 residents, was provided assistance as required to prevent falls. Specifically, for Resident #45, the facility failed to provide assistance of two staff with transferring resulting in the Resident sustaining a fall with assistance of one staff for a transfer from wheelchair to bed.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that competency in skills and techniques necessary to provide resident care were demonstrated for four staff members (#7, #8, #9 and #10) out of a total of five staff reviewed. Specifically, for Staff Member's #7, #8, #9, and #10, the facility failed to ensure that the staff members completed the necessary competencies as indicated in the Facility Assessment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to adhere to infection control standards to prevent the transmission of communicable diseases and infections for two Residents (#272 and #30), out of a total sample of 23 residents. Specifically, 1. For Resident #272, the facility failed to ensure infection control practices were maintained in donning (putting on)Personal Protective Equipment (PPE: items worn to protect from the spread of infection such as a gown or gloves) before administering medication through a [NAME] Catheter (a type of central intravenous line that is inserted through the chest into a larger vein near the heart) placing the Resident at risk for contamination and infection of the [NAME] Catheter. 2. [...]

Inspectors wroteBased on records reviewed and interviews, for one of four sampled residents (Resident #1), who required post-surgical care, including antibiotic therapy, wound monitoring and dressing changes, the facility failed to ensure Resident #1 was provided with nursing care and treatment that met professional standards for quality when 1) antibiotic therapy was not started upon admission despite the medication being available within the facility emergency supply, and 2) wound assessments upon admission, daily monitoring, and documentation related to treatment orders were not completed by Nursing

Inspectors wroteBased on observations, interviews, records and policies reviewed, the facility failed to ensure the staff adhered to infection control standards for transmission based precautions for four Residents (#144, #59, #56 and # 187), out of a total sample of 18 residents, on three out of four units observed. Specifically, the facility failed to ensure: 1. For Resident #144 and #59, that staff wore the required personal protective equipment (PPE) when caring for an Influenza positive resident, to mitigate the spread of infection during an Influenza outbreak in the facility. 2. For Residents #56 and #187, that staff wore the required PPE when caring for COVID-19 positive residents, to mitigate the spread of infection during a COVID-19 outbreak in the facility.

Inspectors wroteBased on observation, interview, record and policy review, the facility failed to implement a care plan intervention for one Resident (#20) out of a total sample of 18 Residents. Specifically, the facility failed to implement an intervention for servings of double protein for Resident #20 who had experienced severe weight loss.

Inspectors wroteBased on interview, record and policy review, the facility failed to provide appropriate indwelling urinary catheter (also referred to as Foley catheter- a flexible tube inserted through the urethra to the bladder allowing urine to flow from the bladder to a drainage bag outside the body) care and services for one Resident (#29) out of a total sample of 18 residents. Specifically, the facility staff failed to obtain Physician orders relative to the size and care of the indwelling urinary catheter utilized for Resident #29.

Inspectors wroteBased on observations, interviews, record and policy review, the facility failed to ensure that medication for one Resident (#137) was appropriately managed by staff prior to administration. Specifically, for Resident #137, the facility staff left antibiotic medication that was not stored or secured in the Resident's room prior to the medication being administered for wound treatment.

Inspectors wroteBased on record review and interview, the facility failed to ensure that Quarterly Minimum Data Set (MDS) Assessments were completed timely, as required, for ten Residents (#32, #7, #39, #3, #28, #55, #47, #50, #2 and #56) out of 11 applicable residents, in a total sample of 18 residents. Specifically, the facility failed to ensure the components of the Quarterly MDS Assessments were completed within the required timeframes as designated by the Centers for Medicare and Medicaid Services (CMS).

Inspectors wroteBased on interview and record review, the facility failed to ensure timely completion of the Comprehensive Minimum Data Set (MDS) Assessments for four Residents (#137, #139, #140 and #78), out of a total sample of 18 residents. Specifically, the facility failed to ensure the components of the Comprehensive MDS Assessments were completed within the required timeframes as designated by the Centers for Medicare and Medicaid Services (CMS).

Inspectors wroteBased on interview, record and policy review, the facility failed to accurately code the Minimum Data Set (MDS) Assessment for three Residents (#20, #2, #43) out of a total sample of 18 residents. Specifically, the facility failed to: 1. Accurately code that Resident's #2 and #20 received an antipsychotic (medication used to treat psychosis for symptoms of delusions, hallucinations, paranoia, and disordered thoughts) medication during the assessment period and mistakenly coded that anti-depressant (medication used to treat clinical Depression) medications were administered. 2. Complete Section GG (pertaining to Functional Ability and Goals) of the MDS Assessment for Resident #43.

Inspectors wroteBased on record review and interview, the facility failed to ensure that its staff documented in the medical record that the recommendations from the Pharmacist medication regimen review had been reviewed by the Physician and what, if any, action had been taken to address them for five Residents (#35, #51, #6, #14, #18) out of a total of 18 sampled residents.

Inspectors wroteBased on record review and interview the facility failed to ensure its staff appropriately monitor the potential adverse effects due to psychotropic medication use for three Residents (#51, #6, and #18) out of a total of 18 sampled residents.

Inspectors wroteBased on interview and record review the facility failed to ensure its staff maintained complete and accurately documented medical records for: 1) Medication administration documentation for Resident (#6), and 2) Advanced directive documentation and documentation related to the use of an assistive hearing device for Resident (#21) out of a total of 18 sampled residents. Findings Include: 1. For Resident #6 the facility failed to document that medication had been administered as ordered. Resident #6 was admitted to the facility in May 2018 with diagnoses including Atrial Fibrillation (AFib) and Parkinson's Disease. Review of the facility policy titled Medication: Administration: General, revised 6/1/21 indicated the following: [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure that its staff followed infection control standards during a medication pass on one unit out of four units observed.