AGAWAM, MA - A state inspection at Heritage Hall North rehabilitation and nursing facility revealed significant care failures, including inadequate wound management that led to a resident developing a severe heel infection requiring surgical intervention and ultimately hospice care, along with improper fall prevention protocols that resulted in a resident being dropped during transfer.
Critical Wound Care Failures Lead to Life-Threatening Infection
The most serious violation involved a resident with paraplegia and dementia who developed a severe heel infection after facility staff failed to properly assess and monitor a scabbed area on their right heel for several months. The resident, who had a history of pressure ulcers and bone infections, experienced a catastrophic deterioration that required hospitalization and surgical debridement.
According to the inspection report dated April 9, 2025, the resident's right heel pressure injury had been declared healed by the wound physician in November 2024. However, nursing staff documented a scabbed area on the heel during skin checks on December 5, 2024, and January 25, 2025. Despite facility protocols requiring weekly skin assessments and immediate physician notification of any skin changes, no evidence was found that this newly identified scabbed area was ever reported to the physician or wound specialist.
The situation deteriorated dramatically in March 2025. On March 23, certified nursing assistants noticed the resident's right foot was swollen with increased redness, and the heel wound appeared different with new black areas surrounding the original scab. The CNAs reported these concerning changes to nursing staff, including the Assistant Director of Nurses, but no physician was notified that day. The facility's medical record showed no documentation that the heel was assessed or that any provider was contacted about these significant changes.
Two days later, on March 25, when a physician assistant finally examined the resident, they noted right heel redness, foot and ankle swelling, and a central scab on the heel. Antibiotics were started for suspected cellulitis. By March 26, the resident developed a fever of 101.9 degrees, and x-rays revealed possible osteomyelitis - a serious bone infection. The resident was transferred to the emergency room on March 27 with what was described as a right heel that had turned "red/black in color."
Devastating Hospital Findings Reveal Extent of Infection
The hospital admission revealed the severity of the infection that had developed. Medical records indicated the resident had an abscess of the right heel with significant pus drainage requiring surgical incision and drainage. The infection had progressed to sepsis - a life-threatening condition where the body has an extreme response to infection. Hospital diagnoses included not only the heel abscess but also cellulitis, osteomyelitis, and sepsis.
The severity of the infection led physicians to recommend an above-the-knee amputation. The resident's representative, faced with this devastating recommendation, opted instead for hospice care, believing the resident could not tolerate such a major surgery. During an interview, the representative expressed being "very upset that the wound deteriorated" to such an extent.
Systemic Failures in Wound Monitoring Protocols
The inspection revealed multiple breakdowns in the facility's wound care system. Despite having a comprehensive policy requiring weekly skin assessments by licensed nurses and immediate reporting of any impairments, the facility failed to follow these protocols for this high-risk resident.
The Director of Nursing acknowledged during the inspection that when staff identified the new scabbed area in December 2024, it should have been immediately reported to both the primary physician and wound specialist. He stated that "a scab like appearance to skin is not considered healed and should be monitored" and that the resident "was very high risk for infection due to a history of wounds and infections."
The facility's wound care policy specifically required that certified nursing assistants observe skin integrity during daily care and report any impairments to the charge nurse. However, when CNAs did report significant changes on March 23, their concerns were dismissed. One CNA stated that after reporting the swelling and color changes to two nurses, including the Assistant Director of Nurses, she was told to "leave the resident's heel/foot alone" because the foot was not hot to the touch.
The two-day delay in physician notification proved critical. The physician assistant who eventually examined the resident on March 25 stated they "should have been made aware on that day when the facility staff noticed a change" and confirmed that no providers had been contacted on March 23 when the changes were first observed.
Inadequate Fall Prevention Results in Dropped Resident
In a separate but equally concerning violation, the facility failed to provide proper assistance during transfers for a resident with Parkinson's disease, osteoporosis, and hypotension, resulting in the resident being dropped to the floor on April 5, 2025.
The resident's care plan clearly specified that transfers required a mechanical lift with two staff members assisting. However, on the evening of April 5, only one certified nursing assistant attempted the transfer from wheelchair to bed. The resident told inspectors that "there were not enough staff to assist" and that "two staff were supposed to assist with transfers." The resident's legs gave out during the single-staff transfer, and they were lowered to the floor, requiring four to five staff members to help get them back into bed.
The facility's failure extended beyond the improper transfer itself. No fall investigation was completed following the incident, despite facility policy requiring immediate investigation and documentation of all accidents. The Director of Nursing confirmed that the required fall protocol and risk assessment were not completed, and the resident's care plan was not updated until two days later when state inspectors were present.
Staff interviews revealed confusion about transfer requirements, with some CNAs believing the resident only needed one-person assistance despite the care plan specifying two-person assistance. One CNA who was involved in the incident stated she had received conflicting information about the resident's transfer needs and was unaware that two-person assistance was required on the evening shift.
Additional Issues Identified
The inspection also revealed problems with routine skin care for multiple residents. Weekly skin checks required by care plans were not consistently performed or documented. One resident with chronic kidney disease and heart failure reported that staff "rarely" applied prescribed lotion to their dry, swollen lower extremities "because the staff are too busy and running around." Documentation showed gaps of several weeks where required skin assessments were not completed.
Medical Implications of Care Failures
Pressure injuries and wounds in individuals with conditions like paraplegia and peripheral vascular disease require vigilant monitoring because these patients often have reduced sensation and impaired healing capacity. The progression from a healed wound to a scabbed area should trigger immediate medical evaluation, as scabs can mask underlying tissue damage or infection. In patients with a history of osteomyelitis, any changes to previous wound sites demand urgent attention since bone infections can recur and spread rapidly.
The delay in recognizing and treating the heel infection allowed it to progress from a localized issue to systemic sepsis. Sepsis has a mortality rate that increases significantly with each hour of delayed treatment. Early intervention with appropriate antibiotics and wound care could have prevented the progression to abscess formation and the need for surgical intervention.
For fall prevention, proper transfer techniques are crucial for residents with neurological conditions like Parkinson's disease. These individuals experience muscle rigidity, tremors, and sudden freezing of movement that make them particularly vulnerable during transfers. Using mechanical lifts with adequate staffing protects both residents and staff from injury. When protocols are not followed, residents face risks including fractures, head injuries, and loss of confidence that can lead to further functional decline.
The facility's pattern of documentation failures and protocol violations suggests systemic issues with staff training, communication, and adherence to established care standards that placed multiple residents at risk for preventable complications.
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.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.