AGAWAM, MASSACHUSETTS - Federal inspectors documented multiple violations at Heritage Hall North nursing facility during an April 2025 survey, including failure to provide medical records for nearly a year, missed care plan meetings affecting six residents, and delayed medical notifications that resulted in one resident's hospitalization for a serious bone infection.
Eleven-Month Delay in Providing Resident Medical Records
The facility failed to provide a resident's complete medical records despite a formal request submitted in May 2024 by the resident's legal representative. The representative had requested the records after the resident developed a wound while at the facility, following proper procedures by completing and submitting an Authorization for Release of Information form directly to the facility administrator on May 24, 2024.
According to the inspection report, the administrator initially told the representative that obtaining records from facility headquarters could take three to six months. However, documentation shows the records were never provided. When the representative followed up multiple times over the subsequent months, they were repeatedly told the facility was "still working on obtaining the medical records."
The situation remained unresolved until April 7, 2025 - nearly eleven months after the initial request - when the administrator finally instructed medical records staff to gather the resident's documentation. The medical records staff member stated she was unaware of the May 2024 request until that point, contradicting the administrator's claim that he had instructed staff to mail the records months earlier.
During interviews with inspectors, the administrator acknowledged "the facility had a miscommunication and did not provide the medical records documents that were requested when they should have." The facility's own policy requires medical records to be provided within 48 hours of a written request. This violation affected a resident with severe cognitive impairment who had a Brief Interview for Mental Status score of four out of 15 possible points, making the representative's access to medical information particularly critical for care decisions.
Systemic Failures in Care Planning Process
Inspectors identified widespread failures in conducting required interdisciplinary team care plan meetings, affecting six residents across the facility. These meetings are fundamental to resident care, bringing together medical staff, social workers, dietary specialists, and other disciplines to coordinate treatment plans with resident and family input.
The investigation revealed that multiple residents went months without the quarterly care plan meetings required by federal regulations. In one case, a resident admitted in April 2024 had no documented evidence of any interdisciplinary team meetings since admission. When asked, this cognitively intact resident stated "he/she was not aware of any IDT care plan meetings about his/her care" and expressed that "if there were meetings to discuss his/her care, he/she would like to be included in them."
Another resident's scheduled meetings in September and December 2024 never occurred, with no documentation that the resident was invited or that the meetings were rescheduled. A third resident, whose health care proxy was invoked in January 2025 due to cognitive decline, had a meeting scheduled for February 6, 2025, but facility staff could find no evidence it took place. The resident's representative reported never being invited to participate in any care planning meetings since admission, despite expressing interest in being included to discuss discharge planning.
For residents admitted more recently, including one with schizophrenia whose court-appointed guardian had not been contacted about care planning, and another with cerebral palsy and depression who could not recall participating in any team meetings, the facility failed to conduct initial care planning sessions beyond brief admission assessments. The MDS nurse acknowledged that to her knowledge, no care plan meetings were typically scheduled between admission and the first quarterly assessment, potentially leaving new residents without coordinated care plans for up to three months.
Critical Delay in Wound Care Leads to Hospitalization
The most serious violation involved a 48-hour delay in notifying medical providers about a deteriorating heel wound, resulting in a resident's emergency hospitalization for suspected bone infection. The resident, who had paraplegia, peripheral vascular disease, and dementia, was particularly vulnerable to infections due to their medical history.
On March 23, 2025, two certified nursing assistants observed significant changes in the resident's right heel wound, including new black discoloration surrounding a previously documented scab, along with swelling and redness of the entire foot. The CNAs immediately reported these concerning changes to two nurses on duty, including the Assistant Director of Nursing. However, neither nurse documented the assessment nor contacted the medical provider that day.
The physician assistant was not notified until March 25 - two full days after staff first observed the changes. By that time, the wound had significantly worsened, showing increased warmth, spreading redness, and blackening tissue. X-rays revealed findings suspicious for calcaneal osteomyelitis, a serious bone infection. The resident required emergency transfer to the hospital on March 27 for intensive treatment.
Medical professionals interviewed stated that immediate notification on March 23 could have led to earlier intervention. The facility's own policies require providers to be notified of skin condition changes "that same shift or sooner if emergent." The Director of Nursing acknowledged the resident was at extremely high risk for infection and that "any change to the right heel wound or foot should have been reported immediately," noting that the delay put the resident at higher risk for developing serious infection.
Additional Issues Identified
Beyond these major violations, inspectors documented problems with resident mail privacy, with four residents reporting they had received opened mail, including personal letters and medical correspondence. The facility also failed to monitor and report significant weight loss for a resident who lost over 17 pounds - more than 11% of body weight - in one month following hospitalization, delaying nutritional interventions.
Persistent laundry service problems affected multiple residents, with documented complaints dating back to September 2024 remaining unresolved. During the April 2025 resident council meeting, residents reported waiting up to four weeks for clothing return, receiving wrinkled clothes, and permanently losing labeled items. The administrator attributed ongoing problems to high staff turnover, with four laundry managers in six months.
These violations occurred at Heritage Hall North, located at 55 Cooper Street in Agawam, Massachusetts, during a standard health inspection completed April 9, 2025. The Centers for Medicare & Medicaid Services rates these deficiencies at levels ranging from minimal harm to actual harm, with several affecting multiple residents throughout the facility.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Heritage Hall North from 2025-04-09 including all violations, facility responses, and corrective action plans.
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