Agawam West Rehab And Nursing
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
received a telephone call from the ADON informing her that Resident #1 had fallen out of bed during care and that he/she was bleeding.The DON said she conducted a re-enactment of the incident with CNA #1 on 09/24/25. The DON said CNA #1 demonstrated how she rolled Resident #1 onto his/her left side and how
she turned away to obtain incontinent supplies from the tray table located diagonally behind her. The DON said CNA #1 told her she did not leave Resident #1's bedside, that Resident #1 was just out of her reach, and when she turned back to face him/her, he/she had rolled off the bed and onto the floor.On 10/15/25,
the Facility was found to be in past Non-Compliance with an effective date of 9/26/25, and provided the surveyor with a plan of correction which addressed the area of concern as evidenced by: A) Upon return from the Hospital, Resident #1's care plan was immediately updated to:- require two staff members be present at all times for personal care and bed mobility.- a perimeter mattress with positioning wedges are always provided while in bed. B) On 09/24/25, the Staff Development Coordinator (SDC) re-educated CNA #1 on Positioning/ADL Care, which included but was not limited to the following:-When providing care to a resident in bed, do not leave them unattended until they are safely positioned - this includes reaching for personal care items such as barrier creams, linens, briefs, etc. followed by a written competency, and demonstration. C) On 09/24/25, the Staff Development Coordinator (SDC) or her designee re-educated all clinical staff (Nursing and CNAs) where Resident #1 resides on Positioning/ADL Care, followed by written competencies, and demonstrations. D) On 09/26/25, the Facility completed a whole house Fall From Bed Audit that encompassed the dates between 07/24/25 and 09/24/25 to determine whether residents who fell were provided with the level of assistance they required during the event, determined the root cause for the fall, and identified any interventions that were added as a result of the fall. E) The Director of Nursing, Staff Development Coordinator or their Designee are conducting weekly audits, followed by random audits to ensure all residents are receiving the necessary level of assistance needed for bed mobility, including turning and repositioning a resident in bed to provide care, as well as ensuring residents' care plans are updated and accurate. F) The deficient practice will be presented at the next monthly Quality Assurance Improvement (QAPI) meeting and will continue to be discussed at monthly QAPI meetings as needed to ensure substantial compliance is achieved and maintained. G) The Director of Nursing and/or their Designee are responsible for overall compliance.
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AGAWAM WEST REHAB AND NURSING in AGAWAM, MA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in AGAWAM, MA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from AGAWAM WEST REHAB AND NURSING or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.