SEO_DESCRIPTION: Heritage Hall North in Agawam failed to develop suicide risk care plans and missed infected MRSA wounds, federal inspectors found during April 2025 review.
OG_TITLE: Nursing Home Missed Suicide Risk, Infected Wounds in Federal Inspection
OG_DESCRIPTION: Federal inspectors cited Heritage Hall North for failing to create comprehensive care plans for residents with suicidal thoughts and missing serious skin infections that required isolation and antibiotic treatment.
FB_POST: Nursing home failed to plan care for suicidal resident, missed infected wounds requiring isolation - federal inspection reveals
ARTICLE:
Heritage Hall North: Care Plan, Skin Assessment Failures - MA
AGAWAM, MA - Federal health inspectors cited Heritage Hall North for multiple care planning and assessment failures during an April 2025 inspection, including inadequate mental health care plans and missed skin infections requiring antibiotic treatment.
Mental Health Care Planning Deficiencies
Heritage Hall North failed to develop comprehensive care plans for a resident with documented suicidal ideation, according to the Centers for Medicare & Medicaid Services inspection report. The resident had been admitted in December 2024 with diagnoses including cerebral palsy, Type II diabetes, and depression.
Hospital records from December 8, 2024, documented that the resident "alluded to passive suicidal ideation" and "said he/she wished he/she would go to sleep and not wake up." A safety consultation noted the resident was withdrawn and had expressed frustration with being hospitalized and his overall health condition.
Despite this documented history, facility staff did not create appropriate mental health care plans until February 27, 2025 - more than two months after admission. Even then, the care plan failed to address the resident's documented history of suicidal thoughts.
The situation escalated in March 2025 when the resident again "endorsed passive suicidal ideation with plans to stop taking his/her insulin and medication" during a provider encounter. Medical notes described the resident as "visibly distressed and appeared depressed."
Facility nurses acknowledged the oversight during the inspection. "MDS Nurse #1 said she added the SI diagnosis on 4/7/25, when she learned about the diagnosis while completing the Resident's quarterly review," the report stated. "MDS Nurse #2 said this was new information to them and did not know that Resident #9 had been seen by Psychiatry while at the hospital."
Mental health care planning in nursing homes requires immediate assessment and intervention development upon admission when residents have documented psychiatric conditions or safety risks. Suicidal ideation represents a serious safety concern requiring specialized monitoring, therapeutic interventions, and coordinated care between medical and mental health professionals.
Critical Skin Assessment Failures
The inspection revealed more serious deficiencies in wound identification and treatment. A resident with diabetes and leg weakness developed infected wounds on both sides of his lower left leg that went undetected by nursing staff for days.
On April 6, 2025, inspectors observed "two round quarter-sized areas with yellow centers" on the resident's outer and inner left calf. The resident attributed these wounds to a leg brace he used when leaving the facility. Despite having weekly skin assessment orders and daily diabetic foot care requirements, staff failed to identify or document these developing wounds.
The wounds were eventually cultured during a dermatology appointment on April 1, 2025, but facility staff were not informed of this testing. When the dermatology office called on April 7 with positive MRSA results, it marked the first time facility staff became aware of the serious infection.
MRSA (Methicillin-Resistant Staphylococcus Aureus) is a dangerous bacterial infection that resists many antibiotics and can spread to other residents if proper isolation protocols are not followed. The infection required immediate contact isolation, meaning the resident had to be confined to his room to prevent transmission to other residents and staff.
Facility policy required weekly skin assessments by licensed nurses and daily observation by certified nursing assistants during routine care. The policy specifically stated that "any skin impairments, including pressure ulcers, non-pressure ulcer wounds, surgical wounds, skin tears, abrasions, etc., should be assessed and documented weekly."
Documentation showed the resident received regular diabetic foot checks and weekly showers, but nursing staff failed to notice or report the developing wounds. A skin assessment completed on April 1, 2025, noted only "redness present on his/her left and right front lower legs" with "skin intact," missing the actual wound areas.
Communication and Follow-up Breakdown
The inspection revealed systematic communication failures regarding outside medical appointments. When the resident returned from his dermatology visit on April 1, facility staff did not obtain consultation notes or follow up on the appointment details.
Medical Records Staff explained the standard protocol: "when the resident returned to the facility, the completed consult sheet would be given to the nursing staff and they would review it for orders/recommendations." However, staff failed to contact the dermatology office when no consultation information was provided.
This breakdown meant the facility remained unaware that wound cultures had been obtained and were pending results. Had staff followed proper protocols, contact isolation could have been initiated immediately after the appointment rather than waiting six days for the dermatology office to call with results.
Personal Care and Dignity Issues
The inspection also documented failures in basic personal care that affected resident dignity and comfort. Three residents experienced inadequate assistance with activities of daily living, including grooming and dressing needs.
One resident with moderate cognitive impairment but clear communication abilities told inspectors he "did not like to have facial hair and would like to have staff remove it but no one had offered to remove the facial hair." Despite care plans requiring extensive grooming assistance, staff had not provided facial hair removal for several days.
Another cognitively intact resident reported that a specific night shift aide routinely provided only partial care, washing and dressing his upper body while leaving his lower half for the next shift. "Resident #17 said this had been occurring with this specific CNA for one to two months, that he/she had reported the concern to multiple staff, and the CNA refusing to wash/dress his/her lower half continued," according to the inspection report.
Regulatory Standards and Expectations
Federal regulations require nursing homes to provide comprehensive care that maintains residents' highest practicable physical, mental, and psychosocial well-being. This includes developing individualized care plans within seven days of admission that address all identified needs and risks.
For residents with mental health conditions, facilities must ensure appropriate treatment and monitoring to prevent deterioration. Suicidal ideation requires immediate risk assessment, safety planning, and ongoing therapeutic intervention.
Skin integrity monitoring is particularly critical for residents with diabetes, circulation problems, or mobility limitations. Early identification of skin breakdown can prevent serious complications including infection, hospitalization, and potentially life-threatening sepsis.
Facility Response and Ongoing Oversight
The inspection findings resulted in citations for failure to develop comprehensive care plans and provide appropriate treatment according to professional standards. Heritage Hall North must submit corrective action plans to address these deficiencies and demonstrate sustained compliance.
State survey agencies will conduct follow-up visits to verify that corrective measures have been implemented and are effectively preventing similar incidents. The facility faces potential enforcement actions if violations are found to be widespread or pose immediate threats to resident health and safety.
The inspection report provides detailed documentation of these violations and serves as a public record of care quality concerns. Families and potential residents can access these inspection results through the Medicare.gov Nursing Home Compare website to make informed decisions about care options.
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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