Agawam South Rehab and Nursing

Inspectors wroteBased on observations, interviews, and records reviewed, the facility failed to maintain infection control practices relative to laundry services for three units (A Wing, C Wing and D Wing) out of three total units, placing all facility residents at risk for exposure to unsanitary linens, contamination and the spread of infections. Specifically, the facility failed to maintain infection control practices relative to laundry services when: -Resident #93 and Resident #32 indicated during a resident council meeting that their clothing washed by facility laundry smelled of mildew.-Feces were observed in the washer machine with a load of linens being washed. -the chemical programming box was not set to the correct program to ensure proper sanitization of resident's linens. [...]

Inspectors wroteBased on record review and interview, the facility failed to complete comprehensive assessments timely, according to the required Resident Assessment Instrument (RAI) process, for two Residents (#36 and #95) out of a total sample of 19 residents. Specifically, the facility failed to complete comprehensive assessments for Resident #36 and Resident #95 within the required 14 days of the Assessment Reference Date (ARD) date.

Inspectors wroteBased on record review and interview, the facility failed to complete quarterly Minimum Data Set (MDS) assessments timely, according to the required Resident Assessment Instrument (RAI) process, for four Residents (#6, #36, #70 and #95) out of a total sample of 19 residents. Specifically, the facility failed to ensure the following quarterly MDS assessments were completed no later than 14 days after the Assessment Reference Date (ARD): for Resident #6 on two occasions, (ARD 9/22/25 and ARD 12/4/25)for Resident #36, on one occasion, (ARD 1/22/26)for Resident #70, on two occasions, (ARD 10/28/25) and ARD 1/27/26) andfor Resident #95, on one occasion (ARD 10/28/25).

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately code Minimum Data Set (MDS) Assessments for two Residents (#21 and #6), out of a total sample of 19 Residents. Specifically, the facility failed to: 1) For Resident #21, accurately code functional limitation in Range of Motion (ROM- the extent to which a body part can be moved around) when the Resident had an impairment in ROM to one upper extremity. 2) For Resident #6, accurately code the use of an anticoagulant medication (medicine that increases the time it takes for blood to clot).

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that Physician's orders were implemented in accordance with professional standards of practice for two Residents (#17 and #28), out of a total sample of 19 residents. Specifically, 1. For Resident #17, the facility failed to ensure the Wound Provider recommendations from January 2026 were implemented timely for the Resident's right heel and right superior ankle wounds, that new treatment recommendations were implemented in February 2026 for both right heel and right superior ankle wounds, and Physician orders were obtained for the Resident's right heel wound in March 2026, putting him/her at risk of decline in status of the wound and delayed wound healing.2. For Resident #28, the facility failed to ensure: [...]

Inspectors wroteBased on observations, interviews and record reviewed, the facility failed to ensure resident meals were palatable and at appetizing temperatures on two (Units A and C), out of two units observed. Specifically, the facility failed to ensure that food served to the residents on Unit A and Unit C was attractive, palatable and hot foods were maintained at/above 135 degrees Fahrenheit (F) when served.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1) who had an actual area of skin breakdown and was assessed upon admission by the Registered Dietitian (RD) to be at risk for nutritional decline, the Facility failed to ensure that Resident #1 was adequately monitored by the RD, and nutritional interventions were put in place in a timely manner in an effort to prevent significant weight loss and promote wound healing.

Inspectors wroteBased on records reviewed and interviews for one of three sampled Residents (Resident #1), who required wound treatments, had significant weight loss, and required assistance with his/her Activities of Daily Living (ADLs), the facility failed to ensure they maintained a complete and accurate medical record when, 1) Weekly Wound Logs and a Weekly Nursing Skin Review User Defined Assessments (UDA) were not consistently completed by nursing staff, 2) nursing documentation in the Treatment Administration Record (TAR) related to wound care was incomplete with blank spaces, and 3) Certified Nurse Aide (CNA) ADL Flow Sheets for August, September, and October 2023 were incomplete with blank spaces.

Inspectors wroteBased on record review, and interview, the facility failed to ensure that one Resident (#10) out of a total sample of 22 residents, was free from significant medication errors. Specifically, the facility staff failed to adhere to the Physician's orders to hold (not administer) the dose of Midodrine (medication used to treat orthostatic [standing up] hypotension [low blood pressure]) when the blood pressure measured above 130 millimeters of mercury (mmHg) for a Systolic [the pressure in the arteries when the heart contracts] Blood Pressure (SBP).

Inspectors wroteBased on observation, interview, and record review, the facility failed to adhere to infection control standards to prevent the potential transmission of communicable diseases and infections for three Residents (#346, #47 and #6) out of a total sample of 20 residents, and on three units (A Wing, C Wing, and D Wing) out of a total of three units. Specifically, the facility failed to: 1) ensure that wound care supplies used inside a Resident's room were not removed from the room and stored in the clean utility room on C Wing. 2) ensure infection control standards were maintained during wound care for Resident #346. 3) ensure that staff wore the necessary Personal Protective Equipment (PPE: items such as a gown, gloves, mask, eye protection, etc. [...]

Inspectors wroteBased on observation, and interview, the facility failed to maintain a clean, comfortable, and homelike environment for one Resident (#79) out of a total sample of 20 residents. Specifically, for Resident #79, the facility failed to maintain the resident's wheelchair in a clean and sanitary manner.

Inspectors wroteBased on interview, and record review, the facility failed to notify the state mental health authority for a resident review (person-centered assessment taking into account all relevant information) after a significant change in mental condition occurred for one Resident (#12) out of a total sample of 20 residents. Specifically, the facility failed to request a Preadmission Screening and Resident Review Level II screen (PASRR-and evaluation done to determine if a resident has an intellectual or developmental disability [ID/DD] and/or serious mental illness [SMI] and is in need of additional specialized support services at the facility) after Resident #12 received a diagnosis of Bipolar Disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and experienced limitations in major life activities due to mental illness.

Inspectors wroteBased on interview, and record review, the facility failed to ensure a baseline care plan was created within 48 hours of admission to the facility for two Residents (#47 and #36) out of a total sample of 20 residents. Specifically, the facility failed to: 1. for Resident #47, ensure a baseline care plan was created within 48 hours of admission relative to Resident #47 being actively treated for Methicillin-Resistant Staphylococcus Aureus (MRSA - an infection caused by a type of staph bacteria that has become resistant to many antibiotics, that is contagious and easy to spread by both direct and indirect contact requiring special precautions to be in place to prevent further spread) in a wound. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in accordance with professional standards of practice for one Resident (#346), for one applicable resident reviewed, out of a total sample of 20 residents. Specifically, for Resident #346, the facility failed to ensure the external catheter length and arm circumference were measured as ordered by the Physician when the Resident had a Peripherally Inserted Central Catheter (PICC: a thin, soft tube that is inserted into a vein in the arm, for long-term antibiotics, nutrition, medications, and blood draws. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure Activities of Daily Living (ADLs) were provided for one Resident (#45), out of a total sample of 20 residents. Specifically, the facility failed to provide assistance for Resident #45 to ensure daily oral hygiene was completed when the resident was unable to carry out ADLs independently.

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide respiratory care and services consistent with professional standards of practice for one Resident (#12), out of one applicable resident, out of a total sample of 20 residents. Specifically, the facility failed to ensure: -a Physician's order was in place for the use of Continuous Positive Airway Pressure (CPAP- a type of non-invasive device that involves the administration of air usually through the nose and/or mouth by an external device at a predetermined level of pressure to keep the airways open) -respiratory equipment was stored in such a manner to prevent contamination and risk of infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure that Medication Regimen Review (MRR) was addressed timely by the Physician and facility for one Resident (#28), of five applicable residents reviewed for unnecessary medications, out of a total sample of 20 residents. Specifically, the facility failed to address the MRR recommendations made by the Consultant Pharmacist pertaining to Resident #28's use of a cholesterol medication and laboratory testing to monitor the Resident's cholesterol levels.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a medication pass error rate of less than five percent (%) for one Resident (#28), out of four applicable residents, out of 35 opportunities. Specifically, the medication error rate was observed to be 5.71% when Resident #28 was administered two scheduled medications later than the allowed timeframe.

Inspectors wroteBased on interview, and record review, the facility failed to obtain lab work as ordered by the Physician for two Residents (#28 and #52), of five applicable residents, out of a total sample of 20 residents. Specifically, the facility failed to: 1. For Resident #28, obtain lab work to monitor his/her valproic acid level (measures the amount of valproic acid [medication used for the treatment of seizures or to manage behaviors] in the blood). 2. For Resident #52, obtain routine lab work to monitor his/her blood glucose levels, thyroid hormone levels, and lipid [fat]/cholesterol levels.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the dietary plan as recommended by the Registered Dietitian (RD) to meet the nutritional needs and preferences of one Resident (#50), out of a total sample of 20 residents. Specifically, for Resident #50, the facility failed to ensure that food as recommended by the RD and as indicated on the meal tickets were provided to the Resident at meal times.

Inspectors wroteBased on observations, interviews and policy review, the facility failed to store, prepare, distribute and serve food used for resident consumption in accordance with professional standards for food service safety within the main kitchen, and on three of three unit nourishment kitchens observed. Specifically, the facility failed to: -ensure that all food stored in the main kitchen area, walk-in refridgerator and unit nourishment kitchens were labeled and dated and expired food discarded to prevent cross-contamination and food-borne illnesses. -maintain the main kitchen and the unit nourishment kitchens in a clean and sanitary manner to prevent contamination and food-borne infections.

Inspectors wroteBased on interview and record review, the facility failed to provide written notice of the reason for a room change for one Resident (#49) out of a sample of 18 residents. Specifically, the facility failed to provide Resident #49 and/or his/her Representative a written explanation of the room change prior to moving the the Resident.

Inspectors wroteBased on interview and record review the facility failed to obtain the necessary Physician's orders prior to the administration of a vaccination for two Residents (#24 and #49) for an applicable sample of five residents, out of a total sample of 18 residents. Specifically, the facility failed to ensure a Physician's order was in place prior to the administration of a COVID-19 vaccination.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide colostomy (a surgical opening [stoma] from the large intestine through the abdominal wall that allows stool to pass from the intestine to outside the body into a bag [appliance] which is attached to the abdomen) care for one Resident (#28) out of a total sample of 18 residents. Specifically, the facility staff failed to obtain Physician orders relative to the care and maintenance of Resident 28's colostomy and provide colostomy care according to professional standards.

Inspectors wroteBased on observations, interviews and policy review, the facility failed to ensure that one Resident (#32) out of a total sample of 18 residents, received dialysis (a process by which dissolved substances are removed from a patient's body by diffusion from one fluid compartment to another across a semipermeable membrane) care and services consistent with professional standards of practice. Specifically, the facility staff failed to ensure that emergency dialysis catheter equipment was easily accessible at the Resident's bedside, to provide timely intervention in the event the dialysis catheter became dislodged and bleeding resulted.

Inspectors wroteBased on observations, interviews and records reviewed for one Resident (#47) of five applicable residents, out of a total sample of 18 residents, the facility failed to ensure the Resident's drug regimen was free from unnecessary medications. Specifically, the facility staff failed to ensure adequate monitoring for harmful side-effects was in place for a prescribed blood-thinning medication, putting the Resident at risk for bleeding.

Inspectors wroteBased on observations, interviews and records reviewed for one Resident (#47) of five applicable residents out of a total of 18 sampled residents, the facility failed to ensure the Resident's drug regimen was free from unnecessary medications. Specifically, they failed to ensure adequate monitoring was in place for psychotropic medications (medication used to stabilize or improve mood, mental status, or behavior), putting the Resident at risk for adverse side effects.

Inspectors wroteBased on observations, interviews and records reviewed for one Resident (#65) out of a total sample of 18 residents, the facility failed to ensure the Resident received dental care as required. Specifically, the facility staff failed to accommodate dental services for Resident #65, resulting in the Resident reporting mouth pain and increased difficulty eating his/her meals.