Heritage Hall North

F-F677

Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 68 225766 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225766 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Agawam North Rehab and Nursing 55 Cooper Street Agawam, MA 01001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0551 Give the resident's representative the ability to exercise the resident's rights.

Level of Harm - Minimal harm or 51466 potential for actual harm Based on interview, and record review, the facility failed to uphold resident rights for one Resident (#13), out Residents Affected - Few of a total sample of 23 residents, relative to rights exercised by the Resident's Representative (RR #1).

Specifically, the facility failed to provide Resident #13's Representative with a copy of the Resident's medical

record when RR #1 was exercising the Resident's right to review a copy of the medical records, and the medical records were requested through the appropriate process from the facility by RR #1.

Findings include:

Review of the facility's HIPPA Notice of Privacy Practices, undated, from the Office of Civil Rights, indicated

the following:

-Rights that you have regarding your protected health information:

>Access to your protected health information- you have the right to copy and/or inspect much of the protected health information that we retain on your behalf.

>For protected health information that we maintain in any electronic designated record set, you may request

a copy of such health information in a reasonable electronic format, if readily producible.

>Requests for access must be made in writing and signed by you or your legal representative.

Resident #13 was admitted to the facility in November 2023 with diagnoses including Unspecified Dementia.

Review of Resident #13's clinical record indicated a Health Care Proxy (HCP) Invocation form, dated 6/12/24, to have the Resident Representative make decisions due to the Resident's cognitive impairment.

Review of the facility's Authorization for Release of Information, dated and signed by the Resident's Representative on 5/24/24, indicated that a copy of all Resident #13's medical records for personal reasons was requested.

Review of the Comprehensive Minimum Data Set (MDS) Assessment, dated 12/7/24 indicated Resident #13 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of four out of a total of 15 possible points.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 68 225766 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225766 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Agawam North Rehab and Nursing 55 Cooper Street Agawam, MA 01001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0551 During an interview on 4/8/25 at 1:08 P.M., with Resident #13 and his/her Resident Representative (RR) #1, RR #1 said he/she had requested a copy of the Resident's medical record on 5/24/24, after the Resident Level of Harm - Minimal harm or developed a wound in the facility. Resident #13 said he/she knew RR #1 requested the medical records at potential for actual harm that time and was not surprised they were not received. RR #1 said a form was completed and submitted to

the facility Administrator who told him/her that it could take three to six months to obtain the records from Residents Affected - Few facility headquarters. RR #1 said he/she followed-up with the facility Administrator a few times since the request on 5/24/24, and was told the facility was still working on obtaining the medical records. RR #1 said when he/she visited Resident #13 on 4/6/25, he/she told the Administrator that he/she was still waiting for the requested medical records. RR #1 said he/she was told that the Medical Records staff would get them for him/her. RR #1 said the next day (4/7/24), the Medical Records Staff told RR #1 that she was told by the Administrator to obtain Resident #13's medical record and the Medical Records Staff was working on it. RR#1 said he/she had not yet received the requested medical records as requested.

During an interview on 4/8/25 at 1:14 P.M., Medical Record Staff said she was told on 4/7/25 by the Administrator that RR#1 had requested Resident #13's medical record. Medical Records Staff said she was unsure of the original date the medical records was requested because the Administrator had that information.

On 4/8/25 at 2:03 P.M., Medical Records Staff provided the surveyor a copy of the Authorization for Release of Information Medical Request Form for all Medical Records, completed by RR #1, and dated 5/24/24. The Medical Records Staff said she was unaware of the 5/24/24 request.

During an interview on 4/8/25 at 2:37 P.M., with the Administrator and Medical Records Staff, the Administrator said he received the request for Resident #13's medical records on 5/24/24 and thought he had told Medical Records to mail the records because the Resident was in the hospital. The Medical Records Staff said that she had not received a request from the Administrator to gather Resident #13's medical records prior to 4/7/25 and had not mailed any medical records to RR#1. The Administrator said that

the facility policy was to provide medical records upon written request within 48 hours, but this did not happen. The Administrator said that the facility had a miscommunication and did not provide the medical records documents that were requested when they should have. The Medical Records Staff said that she would not mail a medical record unless she was instructed to do so by the Administrator and if she did mail anything, it would be sent by certified mail. The Medical Records Staff was unable to show evidence that the medical records certified mail had been sent to RR #1.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 68 225766 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225766 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Agawam North Rehab and Nursing 55 Cooper Street Agawam, MA 01001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0553 Allow resident to participate in the development and implementation of his or her person-centered plan of care. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 37400

Residents Affected - Some Based on interviews, and record reviews, the facility failed to ensure that six Residents (#2, #45, #48, #108, #3 and #9) and/or their Resident Representatives were afforded the right to participate in the scheduled interdisciplinary (IDT) care plan meetings, out of a total sample of 23 residents.

Specifically, the facility failed to:

-For Resident #2, Resident #45, and Resident #108, ensure quarterly IDT care plan meetings occurred and that the Resident was invited to participate in the meetings.

-For Resident #48, ensure quarterly IDT care plan meetings occurred and the Resident and/or Resident Representative were invited to participate in the meetings.

-For Resident #3, and Resident #9, ensure IDT care plan meetings occurred and the Resident and/or Resident Representative were invited to participate in the meetings.

Findings include:

Review of the facility policy titled Care Plans, revised 11/20/24, indicated the following:

-The resident, the resident's family and/or the legal representative/guardian or surrogate are encouraged to participate in the development of any revisions to the resident's care plan.

-Every effort will be made to schedule care plan meetings at the best time of the day for the resident and family.

-The mechanics of how the IDT meets its responsibilities in the development of the interdisciplinary care plan (face-to-face, teleconference, written communication .) is at the discretion of the care planning committee.

1. Resident #2 was admitted to the facility in October 2022 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Heart Failure (HF), Dementia and Adult Failure to Thrive.

Review of the Minimum Data Set (MDS) Assessment, dated 1/14/25, indicated for Resident #2:

-he/she was understood and understands

-had moderate cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of nine out of 15 possible points

-Health Care Proxy (HCP: designated person who makes medical decisions if the resident was no longer able) was invoked.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 68 225766 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225766 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Agawam North Rehab and Nursing 55 Cooper Street Agawam, MA 01001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0553 Review of the IDT Care Plan Meeting schedule indicated meetings were scheduled for the following dates/times: Level of Harm - Minimal harm or potential for actual harm -9/19/24 at 1:00 P.M.

Residents Affected - Some -12/19/24 at 1:30 P.M.

-4/16/25 at 1:30 P.M.

Review of the Resident's clinical record failed to indicate documented evidence that IDT care plan meetings

on 9/19/24 and 12/19/24 occurred as scheduled for Resident #2.

During an interview on 4/9/25 at 2:56 P.M., Unit Manager (UM) #1 said she was unable to find evidence that

an IDT care plan meeting occurred on 12/19/24 as scheduled. UM #1 further said that even though the Resident's HCP was invoked, the Resident should be invited to attend the meeting and there should be documentation that the Resident was invited and declined to attend the 9/19/24 IDT care plan meeting.

2. Resident #45 was admitted to the facility in April 2024 with diagnoses including Osteoporosis, Parkinson's Disease, dizziness and giddiness, difficulty walking and unsteadiness on feet, and Hypotension.

Review of the MDS Assessment, dated 3/25/25, indicated the following relative to Resident #45:

-he/she understands and was understood

-was cognitively intact as evidenced by a BIMS score of 14 out of a possible 15 points.

Review of the Resident's clinical record failed to indicate documented evidence of the required quarterly IDT care plan meetings for Resident #45.

On 4/8/25 at 3:33 P.M., the surveyor requested evidence of the IDT care plan meetings since admission for Resident #45 from UM #1.

During an interview on 4/8/25 at 3:35 P.M., Resident #45 said he/she was not aware of any IDT care plan meetings about his/her care. Resident #45 said if there were meetings to discuss his/her care, he/she would like to be included in them.

During an interview on 4/8/25 at 4:30 P.M., UM #1 said the Resident's IDT care plan meeting was not held

on 10/10/24 because the Resident was out of the facility on a medical leave of absence. UM #1 said there was no evidence that the IDT care plan meeting was held when the Resident returned to the facility and UM #1 was only able to find evidence that a meeting occurred with the Social Worker and the Resident Representative via telephone on 1/9/25. UM #1 said there was no indication of any other IDT members that participated in the meeting on 1/9/25 or that Resident #45 was invited to attend. UM #1 further said she was unable to find evidence of other scheduled IDT care plan meetings for Resident #45.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 68 225766 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225766 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Agawam North Rehab and Nursing 55 Cooper Street Agawam, MA 01001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0553 3. Resident #48 was admitted to the facility in November 2024 with diagnoses including Parkinson's Disease, Depression and Dementia. Level of Harm - Minimal harm or potential for actual harm Review of the MDS Assessment, dated 1/6/25, included the following relative to Resident #48:

Residents Affected - Some -he/she understands and was understood

-was moderately cognitively impaired as evidenced by a BIMS score of 11 out of a possible 15 points.

Review of the Social Service Note, dated 1/31/25, indicated an IDT care plan meeting was scheduled for 2/6/25 at 10:30 A.M.

Review of the April 2025 Physician's orders indicated Resident 48's HCP was invoked on 1/18/25.

Review of the Resident's clinical record failed to indicate documented evidence that IDT care plan meetings were held and that the Resident and/or HCP were invited to attend.

During an interview on 4/9/25 at 11:06 A.M., Resident #48's HCP said he/she has not been invited to participate in any IDT care plan meetings scheduled for Resident #48 since his/her admission. Resident #48's HCP said he/she would like to be included in any IDT care plan meetings as the Resident was requesting a plan to be discharged from the facility.

During an interview on 4/9/25 at 2:23 P.M., UM #1 said the facility was unable to find evidence that an IDT care plan meeting occurred on 2/6/25.

50563

4. Resident #108 was admitted to the facility in February 2025 with diagnoses including Traumatic Subdural Hemorrhage and Anxiety Disorder.

Review of Resident #108's MDS Assessment, dated 3/1/25, indicated the Resident was cognitively intact as evidenced by a BIMS score of 15 out of a total possible score of 15.

Review of Resident #108's medical record failed to indicate documented evidence that an IDT care plan meeting took place at the facility since his/her admission in February 2025.

During an interview on 4/8/25 at 2:35 P.M., UM #2 said that there was no evidence that Resident #108 had

an IDT care plan meeting that involved the Resident. UM #2 further said Resident #108 was not involved in

the care plan process for the comprehensive care plan that was developed based off the MDS assessment completed on 3/1/25.

5. Resident #3 was admitted to the facility in March 2025 with diagnoses including Schizophrenia.

Review of Resident #3's MDS assessment dated [DATE REDACTED], indicated the Resident had severe cognitive impairment as evidenced by a BIMS score of six out of a total possible score of 15.

Review of Resident #3's medical record indicated the following:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 68 225766 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225766 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Agawam North Rehab and Nursing 55 Cooper Street Agawam, MA 01001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0553 -the Resident had a court appointed Guardian

Level of Harm - Minimal harm or -no evidence that the Resident's Representative had been included in the care planning process after potential for actual harm completion of the MDS Assessment.

Residents Affected - Some During a telephone interview on 4/8/25 at 2:31 P.M., Resident Representative #3 said he/she had not been invited to a care plan meeting for Resident #3.

During an interview on 4/8/25 at 2:35 P.M., UM #2 said that there was no evidence that Resident #3 had an IDT care plan meeting that involved the Resident Representative. UM #2 further said that the Resident and Resident Representative were not involved in the care plan process for the comprehensive care plan that was developed based off the MDS assessment completed on 3/11/25.

42690

6. Resident #9 was admitted to the facility in December 2024 with diagnoses including Cerebral Palsy,

suicidal ideation (SI), and Depression.

Review of Resident #9's medical record failed to indicate documented evidence that an IDT care plan meeting took place at the facility since his/her admission in December 2024.

Review of the MDS assessment dated [DATE REDACTED], indicated the Resident was cognitively intact as evidenced by

a BIMS score of 15 out of 15.

During an interview on 4/8/25 at 11:26 A.M., Resident #9 said he/she did not recall participating in any type of team meeting at the facility that included different departments from the facility.

During an interview on 4/8/25 at 11:20 A.M., the Social Worker Assistant said that she could not find evidence that any care plan meetings took place for Resident #9.

During an interview on 4/8/25 at 11:53 A.M., MDS Nurse #1 said that a 48-hour or 72-hour meeting occurs when a Resident was admitted to the facility. MDS Nurse #1 said that a care plan meeting was scheduled within two weeks after a Resident's quarterly assessment had been completed. MDS Nurse #1 said to the best of her knowledge, no care plan meetings were scheduled in between the date of admission and that first quarterly assessment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 68 225766 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225766 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Agawam North Rehab and Nursing 55 Cooper Street Agawam, MA 01001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0565 Honor the resident's right to organize and participate in resident/family groups in the facility.

Level of Harm - Minimal harm or 42690 potential for actual harm Based on interview, and record review, the facility failed to act upon, provide timely responses, and Residents Affected - Few document written responses and rationale to grievances of resident care and services brought to facility administration by the Resident Council.

Specifically, the facility failed to promptly respond to resident grievances relative to laundry delays, loss and errors.

Findings include:

Review of the facility policy titled Resident and Family Concerns and Grievances, revised on 10/5/24, indicated the following in part:

-Residents or their family members, guardian, or representative may voice a grievance to the facility staff in person, by telephone or via written communication.

-The facility shall provide a grievance report form to facilitate the voicing of a grievance if requested by a resident or family member the facility compliance and ethics officer or a designated staff will document and keep a log of all grievances expressed either orally and or in writing on the day that it is received or as soon as possible after the event or events that precipitated the grievance.

-The facility will follow up with the resident, or their family members, guardian or representative within 72 hours of filing the grievance.

-The facility will make a reasonable effort to ensure that all grievances are adequately resolved within 30 calendar days from the day the grievance was received

-The facility will advise the resident of the outcome of the grievance investigation and shall make reasonable efforts to contact the resident's family members to advise them of the outcome of the grievance investigation.

-The facility will provide the residents with a written grievance decision which shall include the date the grievance was received, a summary statement of the residents grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the residents' concerns, a statement as to whether the grievance was confirmed or not confirmed, any action taken or to be taken by the facility as

a result of the grievance and the date the written decision was issued.

-In the event the facility cannot resolve the grievance within 30 calendar days, the facility will notify the resident, their family members, guardian or representative of the status and estimated completion date with

the grievance resolution.

-The facility will document all steps of the grievance resolution and the facility's records including whether or not the resident/family was satisfied with the grievance.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 68 225766 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225766 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Agawam North Rehab and Nursing 55 Cooper Street Agawam, MA 01001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0565 -The documentation will be kept for a minimum of three years.

Level of Harm - Minimal harm or Review of the Grievance Log provided by the facility indicated: potential for actual harm -a grievance was filed by three residents on 9/16/24, and 9/18/24 relative to laundry concerns. Residents Affected - Few -these laundry concerns had not been resolved.

-no grievance forms corresponding to the 9/16/24 and 9/18/24 dates were available to review.

Review of the Resident Council Meeting Minutes, dated 12/18/24, indicated the following:

-Laundry/Housekeeping concern:

--Reports of residents' clothing missing and not returned from the laundry department.

Review of the Resident Council Meeting Minutes, dated 1/15/25, indicated the following:

-Laundry/Housekeeping concern:

--Laundry delays/loss/errors.

Review of the Resident Council Meeting Minutes, dated 2/19/25, indicated the following:

-Laundry/Housekeeping concern:

--Laundry delays/loss/errors.

Review of the Resident Council Meeting Minutes, dated 3/26/25, indicated the following:

- Laundry/Housekeeping/Maintenance concern:

--Laundry delays/loss/errors.

-- Action - Improve laundry process.

During a Resident Council Meeting held on 4/7/25 from 10:00 until 10:50 A.M., the following was discussed:

-Resident #5 said that he/she was missing five pairs of pants that were labeled with his/her name.

-Resident #14 said when he/she received his/her clothing after a long wait, the clothes were so wrinkled that he/she did not want to wear them.

-Resident #6 said that he/she waited nearly four weeks to get clothes back from the laundry.

-Resident #11 said that he/she sometimes never received his/her items back from the laundry.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 68 225766 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225766 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Agawam North Rehab and Nursing 55 Cooper Street Agawam, MA 01001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0565 With a show of hands, eight out of 22 Residents indicated they had experienced waiting long periods of time to have their clothing returned to them, and said this concern has been going on for a long time. Level of Harm - Minimal harm or potential for actual harm During an interview on 4/7/25 at 3:17 P.M., the Administrator said the facility had been experiencing laundry challenges due to a high turnover in laundry managers, a total of four managers in the last six months. The Residents Affected - Few Administrator said that the facility now has a new laundry manager, but he had been at the facility for less than 30 days.

During a follow-up interview on 4/9/25 at 10:20 A.M., the Administrator said he was unable to locate at this time the three missing grievances that had been filed on 9/16/24 and 9/18/24. The Administrator further said

they have been aware of the ongoing laundry concerns but due to the turnover in that department, the laundry concerns continued to be an issue.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 68 225766 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225766 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Agawam North Rehab and Nursing 55 Cooper Street Agawam, MA 01001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0576 Ensure residents have reasonable access to and privacy in their use of communication methods.

Level of Harm - Minimal harm or 42690 potential for actual harm Based on interviews, and record review, the facility failed to ensure that four Resident's (#12, #6, #45 and Residents Affected - Some #84), out of a total sample of 23 residents, had the right to privacy when receiving letters, packages and other materials delivered to the facility via postal services.

Specifically, for Resident's #12, #6, #45 and #84, the facility failed to ensure that mail addressed to the Residents' was delivered unopened.

Findings include:

Review of the facility policy titled Communication Rights, revised on 11/5/24, indicated the following in part:

-The resident has the right to send and receive mail and to receive letters, packages and other materials delivered to the facility for the resident through a means other than a Postal Service including the right to privacy .

During a Resident Council Meeting held on 4/7/25 from 10:00 until 10:50 A.M., the following was discussed:

-Resident #12 said he/she had received his/her mail opened about two weeks ago. Resident #12 said the opened mail was a letter from his/her doctor's office and that the facility did not have the right to open the mail. Resident #12 said he/she spoke to the person who opened the mail and declined to provide additional information to the surveyor.

-Resident #6 said he/she received his/her mail opened about one month ago. Resident #6 said while it was only junk mail, it had his/her name, and that the facility should not be opening his/her mail.

-Resident #45 said he/she received his/her mail opened about one month ago. Resident #45 said it was a letter from his/her brother, and the facility should not have opened his/her mail because it was a federal offense.

During an interview on 4/7/25 at 3:05 P.M., the Director of Activities and the Activity Assistant (AA) said the mailman brings the mail to the facility, separated by department and then the mail goes into the Activities mailbox. The Director of Activities said she and her staff distribute the resident mail every day except Sundays. The Director of Activities said that she recently encountered an opened box that belonged to Resident #84. The Director of Activities said she was not aware of who opened the box belonging to Resident #84 and said residents' mail should never be opened prior to giving it to them, as it was a privacy concern.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 68 225766 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225766 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Agawam North Rehab and Nursing 55 Cooper Street Agawam, MA 01001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0578 Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Level of Harm - Minimal harm or potential for actual harm 37400

Residents Affected - Few Based on interview and record review, the facility failed to ensure that advanced directives were honored for one Resident (#2), out of a total sample of 23 residents.

Specifically, for Resident #2, the facility failed to ensure that the Medical Orders for Life-Sustaining Treatment (MOLST: legal document that allows individuals to communicate their preferences for life-sustaining treatment to healthcare providers) form and Physician's orders accurately reflected the Resident/Resident Representative's wishes putting the Resident at risk for being resuscitated (perform full measures including cardiopulmonary resuscitation and intubation) when the advanced directive wishes were for no resuscitation (do not resuscitate [DNR] and intubate [DNI]).

Findings include:

Review of the facility policy titled Advanced Directives, dated 10/16/23, indicated it was the policy for the facility to ensure the residents' right to request, refuse, and/or discontinue treatment, to participate or refuse

in experimental research and to formulate an advance directive.

The policy also included the following:

-the MOLST form is designed to improve patient care by creating a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency, taking the patient's current medical condition into consideration.

-upon admission, the facility should determine whether the resident has an advance directive, and, if not, determine whether the resident wishes to formulate an advance directive.

-the Advanced Directive shall be reviewed and updated upon resident request, with the comprehensive care plan, and with significant changes in resident condition.

-if the resident or the resident's representative has executed an advance directive, or executes one upon admission, copies of these documents must be obtained and maintained in the same section of the resident's medical record readily retrievable by facility staff. Facility staff must document in a prominent part of the resident's current medical record whether or not the resident has executed an advance directive and what those wishes are.

-The facility shall:

>not be required to provide care that conflicts with an advance directive.

>not be required to implement an advance directive if, as a matter of conscience, the facility cannot implement an advance directive and state law allows any health care provider or any agent of such provider to conscientiously object.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 68 225766 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225766 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Agawam North Rehab and Nursing 55 Cooper Street Agawam, MA 01001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0578 -the facility will implement the instructions outlined in the Advanced Directive.

Level of Harm - Minimal harm or To ensure appropriate implementation, the facility will: potential for actual harm >periodically assess the resident for decision-making capacity and invoke health care agent or Residents Affected - Few representative if the resident is determined not to have decision-making capacity.

>identify the primary decision-maker (assessing the resident's decision-making capacity and identifying or arranging for an appropriate representative for the resident assessed as unable to make relevant health care decisions).

>define and clarify medical issues and present the information regarding relevant health care issues to the resident or his or her representative, as appropriate.

>identify situations where health care decision-making is needed, such as a significant decline or improvement in the resident's condition.

-to be legally binding, the advanced directive must be signed by the resident or legal guardian as recognized by the state. If utilizing a MOLST form, the order will take effect after signatures of the resident/resident representative AND order is signed by the Provider (Physician or designee), or two Nurses receive the order and place the order on the form.

Resident #2 was admitted to the facility in October 2022 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Heart Failure (HF), Dementia and Adult Failure to Thrive.

Review of Resident #2's clinical record indicated a MOLST form which included:

-full code status (attempt resuscitation, intubate and ventilate, transfer to the hospital and provide all other life saving measures).

-the form was signed and dated by Resident #2 on 10/26/22.

-the form was signed and dated by the Provider on 10/28/22.

Review of the Advanced Directive Care Plan, initiated 10/26/22, indicated Resident #2 had an established advanced directive and included the following:

-Health Care Proxy (HCP: representative designated to make medical decisions when a person was no longer able) was invoked.

-MOLST- see document for details.

-Activate Resident's advanced directive as indicated.

Review of the HCP Invocation Form, signed and dated by the Provider on 5/29/24, indicated the Resident's designated HCP was invoked indefinitely.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 68 225766 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225766 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Agawam North Rehab and Nursing 55 Cooper Street Agawam, MA 01001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0578 Review of the Minimum Data Set (MDS) Assessment, dated 1/14/25, indicated the following for Resident #2:

Level of Harm - Minimal harm or -he/she had moderate cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score potential for actual harm of nine out of a possible 15 points.

Residents Affected - Few -HCP was invoked.

-do not resuscitate (DNR), do not hospitalize (DNH), do not intubate (DNI) and feeding and other treatment restrictions were in place.

Review of the April 2025 Physician's orders included the following relative to advanced directives for Resident #2:

-DNR, DNI, DNH, no dialysis, no artificial nutrition, use artificial hydration but short term only, invoked (HCP), dated 3/27/25.

On 4/8/25 at 3:27 P.M., the surveyor and Unit Manager (UM) #1 reviewed Resident #2's clinical record. UM #1 said the Resident's wishes for advanced directives were located in the electronic medical record (EMR) under the Physician's orders and a copy of the MOLST form should also be scanned into the system. UM #1 reviewed Resident #2 current advanced directives orders and said Resident #2 was a DNR, DNI, DNH, no dialysis, no artificial nutrition and artificial hydration for short term only. The surveyor and UM #1 reviewed

the MOLST form located in Resident #2's clinical record which indicated he/she was a full code status. UM #1 said the Resident's HCP had updated the Resident's advanced directives recently, but the HCP updates did not appear to be in the Resident's record.

During an interview on 4/8/25 at 3:29 P.M., Nurse #2 said if Resident #2 was found unresponsive and not breathing, she would refer to the Resident's MOLST Form to determine what measures the Resident wanted for advanced directives. Nurse #2 said the current MOLST Form for Resident #2 indicated he/she was a full code status so she would attempt to resuscitate Resident #2. Nurse #2 said regardless of what the electronic health record indicated under the April 2025 Physician's orders, she would refer to the MOLST form for advanced directives.

During a follow-up interview on 4/8/25 at 3:30 P.M., UM #1 said she would have to clarify Resident #2's advanced directives. UM #1 said she could recall a new MOLST Form being completed by the HCP but was not sure where the updated MOLST Form was. UM #1 said at this time, Resident #2 was considered a full code status.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 68 225766 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225766 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Agawam North Rehab and Nursing 55 Cooper Street Agawam, MA 01001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 51466 Residents Affected - Few Based on observation, interview, and record review, the facility failed to notify the Physician/Nurse Note: The nursing home is Practitioner (NP) timely of a change in condition for two Residents (#13 and #47) out of a total sample of 23 disputing this citation. residents.

Specifically:

1. For Resident #13, the facility staff failed to:

-notify the Physician/NP timely when a right heel wound change in condition was identified resulting in delayed treatment and monitoring of the Resident, deterioration of the wound and hospitalization for infection and management of worsening wound condition.

2. For Resident #47, facility staff failed to:

-obtain weight when the Resident was readmitted to the facility after a hospitalization .

-notify the Physician/NP and/or Dietician of a significant weight loss (greater than 5%) in one month, resulting

in delayed treatment of the weight loss and continued weight loss experienced by the Resident.

Findings include:

Review of the facility's policy titled Change in Condition Procedure, revised date October 2024, indicated:

-This facility will provide guidelines for the appropriate handling of a resident's change in condition. We recognize that each situation is unique and must be handled in the manner that is most appropriate at the time and for the nature of the change in condition.

- Full assessment by nursing staff including but not limited to:

>Full Vitals

>Level of consciousness.

>Functional status:

>Pain.

-Notify Medical Doctor (MD) of change and give assessment information. Receive orders, if any.

-Initiate vital signs every shift for a minimum of 72 hours or until condition stabilizes or improves.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 68 225766 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225766 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Agawam North Rehab and Nursing 55 Cooper Street Agawam, MA 01001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 -If not during normal business hours for provider, place call to provider to update on resident's condition if issue unresolved or there is a significant change. Level of Harm - Actual harm

Review of the facility's policy titled Skin Prevention, Assessment and Treatment, revised date October 2024, Residents Affected - Few indicated:

Note: The nursing home is -If an infection is suspected, notify the physician and obtain clinically appropriate orders. disputing this citation. -Nursing staff should keep the attending physician aware of the progress of all ulcers, especially those in higher-risk residents, those that do not heal as anticipated, and those that develop complications.

1. Resident #13 was admitted to the facility in November 2023, with diagnoses including Paraplegia, Polyneuropathy, Peripheral Vascular Disease (PVD) and Unspecified Dementia.

Review of the Skin Care Plan, initiated on 5/14/24, indicated Resident #13:

-was at risk for skin breakdown related to moisture due to incontinence, impaired mobility, involuntary bilateral lower extremity spasms causing friction, and Dementia.

The Skin Care Plan included the following intervention:

-will be monitored for a change in condition and the Medical Doctor (MD) will be notified, initiated 5/15/24.

Review of the Comprehensive Minimum Data Set (MDS) Assessment, dated 12/7/24, indicated Resident #13:

-had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of four out of a total of 15 points.

-was at risk for developing pressure injuries.

-had one Stage 2 Pressure Injury (partial-thickness skin loss with exposed inner layer of skin), that was not present upon admission.

-has diagnoses that included osteomyelitis (bone infection).

Review of the Weekly Skin checks, dated 12/5/24 and 1/25/25, indicated a scab was present over a wound

on Resident #13's right heel.

Review of Resident #13's medical record failed to indicate any evidence that the scabbed area identified on

the 12/5/24 and 1/25/25 skin checks was reported to the Physician or assessed as a newly identified skin issue.

Review of the Physician Progress note, dated 3/25/25, indicated Resident #13:

-had worsening redness to the right heel and had a scab present centrally.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 68 225766 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225766 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Agawam North Rehab and Nursing 55 Cooper Street Agawam, MA 01001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 -had increased warmth to the right heel and foot.

Level of Harm - Actual harm -had Antibiotics started.

Residents Affected - Few -will have x-ray of the right heel to be obtained the following day to rule out osteomyelitis.

Note: The nursing home is Review of the Provider (Physician Assistant [PA]) Progress note, dated 3/27/25, indicated Resident #13: disputing this citation. -had redness of the right foot that was darkening and turning black.

-had an x-ray of the right heel that revealed findings suspicious of calcaneal osteomyelitis.

-in the setting of worsening wound appearance, fever and concern for osteomyelitis, the decision was made to transfer the Resident to the emergency room (ER).

During an interview on 4/9/25 at 8:41 A.M., CNA #7 said on 3/23/25 she and CNA #8 noticed Resident #13's right foot and heel were swollen, and the right heel had a new black area surrounding the original scabbed area. CNA #7 said she notified the Resident's Nurse (the Assistant Director of Nursing [ADON]) and Nurse #5 who was being trained. CNA #7 said both Nurses evaluated the right foot and heel on 3/23/25 and said that since the Resident's foot was not hot, to just leave it alone at that time.

During an interview on 4/9/25 at 10:18 A.M., CNA #8 said that while working on 3/23/25, she and CNA #7 noticed that the Resident had right foot swelling and redness, and the right heel wound looked different. CNA #8 said she noticed that the Resident was acting differently and was kind of quiet, which was not the Resident's usual behavior. CNA #8 said that both she and CNA #7 were concerned, and that CNA #7 reported the change in heel condition to the Resident's Nurses (Nurse #5 and the ADON).

During an interview on 4/9/25 at 10:50 A.M., the ADON said that she worked on 3/23/25 from 7:00 A.M. to 7:00 P.M., but did not recall hearing anything about a change in Resident #13's condition. The ADON said it could have been because she had worked 27 hours that weekend due to a staffing shortage. The ADON said that if there was any change in condition then the Physician should have been notified right away, and further said she did not recall notifying the Physician.

During an interview on 4/9/25 at 1:02 P.M., Nurse #5 said she worked on 3/23/25 on the 7:00 A.M. to 3:00 P. M. shift. Nurse #5 said that the CNA's had reported that Resident #13's right heel had increased redness. Nurse #5 said that she did not recall the change in condition being reported to the Provider on 3/23/25, but believed the ADON was reporting the change in condition. Nurse #5 said she worked the following day (3/24/25) and Resident #13 was not assigned to her but she remembered hearing that the Resident's right heel had worsened. Nurse #5 said the Resident had been sent to the hospital.

Review of Resident #13's medical record failed to indicate documented evidence that the Resident's right heel was assessed on 3/23/25 and that a change in condition was reported to the Provider.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 68 225766 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225766 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Agawam North Rehab and Nursing 55 Cooper Street Agawam, MA 01001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 During an interview on 4/9/25 at 12:56 P.M., with Physician Assistant's (PA) #1 and #2, PA #1 said that she was notified of the heel wound worsening on 3/25/25 (two days after the change in condition was identified) Level of Harm - Actual harm and first examined the Resident on 3/25/25. PA #1 said that she was not notified that the right heel wound had worsened on 3/23/25 but should have been. PA #2 reviewed the Provider Triage Notes in the Provider Residents Affected - Few portal and said that Resident #13's change in condition had not been reported to any Providers on 3/23/25. PA #2 said if the facility staff had called any Provider on 3/23/25, the communication would have been Note: The nursing home is logged into the system and the Provider would have made new recommendations at that time or disputing this citation. recommended a hospital transfer.

During an interview on 4/9/25 at 2:52 P.M., the Director of Nursing (DON) said that if a resident has a change

in condition such as a change in skin condition or worsening of a wound, the change should be reported to

the Provider that same shift or sooner if emergent. The DON said that Nurses were responsible for performing weekly skin checks on every resident and reporting any new changes or concerns to the Provider. The DON said that Resident #13 was a very high risk for infection due to a history of wounds and infections, and any change to the right heel wound or foot should have been reported immediately. The DON said if staff did not report increased redness, swelling or a change in wound condition immediately to the Provider, this would put Resident #13 at a higher risk for developing a serious infection.

2. Review of the facility policy titled Weight Assessment & Interventions, revised 12/30/24, indicated:

-It is the policy of the facility to prevent significant unplanned or unavoidable weight loss for our residents.

-Any weight change of five or more pounds within 30 days will be retaken the next day for confirmation. If the weight is verified, nursing will notify:

>The Provider

>Dietary Manager/Dietician.

Resident #47 was admitted to the facility in February 2025 with diagnoses including multiple fractures of ribs, Pneumonia, Acute Respiratory Failure (ARF), and muscle weakness.

Review of the Resident #47's Nutritional Risk Care Plan, initiated 2/24/25, indicated:

-Monitor weight, initiated 2/21/25.

-Monitor weight changes and notify MD and Dietician as needed, initiated 2/24/25.

Review of the Dietician's Assessment on 2/24/25 indicated Resident #47:

-weighed 148.4 pounds (lbs.) on 2/21/25.

Review of the Comprehensive MDS Assessment, dated 2/28/25, indicated Resident #47:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 68 225766 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225766 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Agawam North Rehab and Nursing 55 Cooper Street Agawam, MA 01001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 -had a mild cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of a total of 15. Level of Harm - Actual harm -weighed 148 lbs. Residents Affected - Few -had no weight loss. Note: The nursing home is disputing this citation. -had no weight gain.

Review of Resident #47's Weight Record indicated the following:

-2/25/25: 142.4 lbs.

-2/25/25: 142.4 lbs.(re-weigh)

-3/2/25: 143.0 lbs.

-3/18/25: 131.6 lbs.

-3/25/25: 130.4 lbs.

-4/1/25: 131.2 lbs.

-4/4/25: 125.8 lbs.

Review of Resident #47's medical record indicated that the Resident was hospitalized [DATE REDACTED] through 3/11/25, and returned to the facility on [DATE REDACTED].

Review of the Hospital Transfer Summary, dated 3/11/25, indicated Resident #47 weighed 131 lbs. on 3/11/25 while in the hospital.

Further review of the Resident's medical record failed to indicate any evidence that a weight was obtained when Resident #47 was readmitted from the hospital on 3/11/25 or that the hospital weight of 131 lbs. was reported to the Provider and/or Dietician upon readmission.

During an interview on 4/7/25 at 3:50 P.M., Unit Manager (UM) #4 said a Resident that experienced a significant weight loss was considered a change in condition and should be reported to the Dietician and Provider. UM #4 said when a Resident loses or gains weight, the Resident should be re-weighed the next day and all weights are documented in the Resident's electronic medical record (EMR). UM #4 was unable to provide any evidence that Resident #47's weight was obtained when the Resident returned to the facility on [DATE REDACTED], or that the Resident's Provider and/or Dietician was notified of the 131 lbs weight obtained in the hospital on 3/11/25. UM #4 was also unable to provide evidence that the weights obtained in the facility on 3/18/25 and 3/25/25 which indicated significant weight loss were reported to the Provider and/or Dietician. UM #4 said that the Resident should have been weighed on 3/11/25, upon return to the facility from the hospital. UM #4 said Resident #47's continued weight loss should have been reported to the Provider and Dietician but was not reported.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 68 225766 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225766 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Agawam North Rehab and Nursing 55 Cooper Street Agawam, MA 01001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 During an interview on 4/7/25 at 4:45P.M., the DON said the facility staff were unable to provide evidence that Resident #47 was weighed upon return to the facility from the hospital on 3/11/25, or that the Provider Level of Harm - Actual harm and/or Dietician were notified of any subsequent weight loss that occurred after 3/11/25. The DON said that

the staff should obtain resident weights upon admission and re-admission. The DON said that facility staff Residents Affected - Few should be reporting any weight loss immediately to the Provider and Dietician but did not report Resident #47's weight loss. Note: The nursing home is disputing this citation. During an interview on 4/8/25 at 10:54 A.M., PA #1 said she reviewed the Provider documentation and could not find evidence that the Providers were notified of Resident #47's weight loss when the Resident returned from the hospital on 3/11/25. PA #1 also said she was not made aware of the Resident's continued weight loss since re-admission. PA #1 said that if she had been made aware of the weight loss, she would have implemented interventions such as health shakes right away, but health shakes were not implemented until 4/2/25. PA #1 said that she knows the Resident was receiving diuretic therapy (medications that help reduce fluid buildup in the body) and was not sure if the weight loss was related to fluid loss but regardless would expect the Dietician to be notified by the facility staff of a Resident's weight loss immediately so interventions can be recommended.

Please refer to

F-F686.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 68 225766 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225766 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Agawam North Rehab and Nursing 55 Cooper Street Agawam, MA 01001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Minimal harm or potential for actual harm 42690

Residents Affected - Few Based on record reviews, and interviews, the facility failed to ensure a comprehensive care plan was initiated for the care and services of one Resident (#9), out of a total sample of 23 residents.

Specifically, the facility failed to develop a comprehensive care plan for Resident #9 relative to Suicidal Ideations (SI) that the Resident experienced in the hospital, prior to his/her admission to the facility, which continued after his/her admission to the facility.

Findings include:

Resident #9 was admitted to the facility in December 2024 with diagnoses including Cerebral Palsy, Type II Diabetes and Depression.

Review of a Hospital Consultation Note, dated 12/8/24, indicated the following for Resident #9:

-was seen for a safety consult as he/she alluded to passive SI, expressed frustration with being in the hospital and his/her overall health.

-was withdrawn, reporting he/she did not want to continue medication or procedures.

-said he/she wished he/she would go to sleep and not wake up.

-had a history of Depression with outpatient psychiatry and psychotherapy support.

-reported feeling depressed at the time of the assessment.

Review of the Provider Encounter Note, dated 3/3/25, indicated Resident #9:

-endorsed passive SI with plans to stop taking his/her insulin and medication.

-was visibly distressed and appeared depressed.

Review of Resident #9's Alteration in Mood Care Plan, initiated on 2/27/25 (greater than two months after the Resident's admission to the facility) failed to indicate any documented evidence relative to the Resident's history of SI.

During an interview on 4/8/25 at 10:54 A.M., with Minimum Data Set (MDS) Nurse #1 and MDS Nurse #2,

the following was discussed relative to Resident #9:

-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, which was in progress now.

-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 for SI.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 68 225766 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225766 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Agawam North Rehab and Nursing 55 Cooper Street Agawam, MA 01001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 -MDS Nurse #1 said an Alteration in Mood Care Plan had been developed for Resident #9, however she would have expected a care plan to have been developed upon admission for a Resident with history of SI, Level of Harm - Minimal harm or but one had not been developed. potential for actual harm -MDS Nurse #1 and MDS Nurse #2 said based on the Resident's history, comprehensive care plans for both Residents Affected - Few mood and SI should have been developed upon admission and sooner than the 2/27/25 care plan.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 68 225766 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225766 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Agawam North Rehab and Nursing 55 Cooper Street Agawam, MA 01001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 37400 potential for actual harm Based on observations, interviews, and record review, the facility failed to ensure that three Residents (#2, Residents Affected - Few #17, and #88), were provided activity of daily living (ADL) care in accordance with their needs/preferences, out of a total sample of 23 residents.

Specifically, the facility failed to:

1. For Resident #2, ensure grooming assistance relative to facial hair removal was provided when the Resident was dependent on staff for personal hygiene needs.

2. For Resident #17, ensure dressing assistance was provided in accordance with his/her preferences when

the Resident required assistance from staff with dressing needs.

3. For Resident #88, provide grooming assistance when the Resident required extensive physical assistance with grooming and had a preference for facial hair removal daily.

Findings include:

Review of the facility policy titled Resident Rights, revised 11/5/24, indicated it was the policy of the facility to respect the rights of the residents by providing comprehensive care with an approach aimed at maintaining dignity while respecting the core rights of patients and residents .

The policy also included the following:

-the facility supports the resident's right to knowledgeably participate in decisions concerning their healthcare and medical treatment .

1. Resident #2 was admitted to the facility in November 2022 with diagnoses including Dementia, Adult Failure to Thrive and need for assistance with personal care.

Review of the ADL Care Plan, initiated 10/25/22, indicated Resident #2 required assistance with ADL care and included the following interventions:

-provide two staff with all care, initiated 9/23/23

-provide extensive assistance for personal hygiene (grooming). Resident was dependent on staff when fatigued, revised 10/16/23

Review of the Minimum Data Set (MDS) Assessment, dated 1/14/25, indicated the following relative to Resident #2:

-he/she was understood and understands.

-has moderate cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of nine out of a possible 15 points.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 68 225766 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225766 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Agawam North Rehab and Nursing 55 Cooper Street Agawam, MA 01001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 -was dependent on staff for personal hygiene (including grooming/hair removal).

Level of Harm - Minimal harm or Review of Resident #2's April 2025 Physician's orders included the following: potential for actual harm -monitor for rejection of care every shift, dated 10/8/24 Residents Affected - Few -weekly shower on evenings (3:00 P.M. to 11:00 P.M. shift) on Fridays, dated 2/28/25

Review of Resident #2's April 2025 Medication and Treatment Administration Record (MAR and TAR) indicated no refusals of care.

Review of the Certified Nurses Aide (CNA) Care Card (resident specific information to assist with care) included the following relative to Resident #2:

-two staff for all care

-extensive assistance with personal care for grooming

-dependent for care when the Resident was fatigued

Review of the CNA documentation for March 2025 and April 2025 indicated Resident #2 required assistance from staff with grooming needs, accepted care and had no refusals of care.

Further review of the CNA documentation failed to indicate documented evidence that shaving (facial hair removal) assistance was provided to Resident #2.

The surveyor observed Resident #2 dressed and lying in bed with numerous long facial hairs measuring approximately 1/2 inch to one inch in length on the Resident's upper lip and chin on the following occasions:

-4/6/25 at 10:42 A.M.

-4/7/25 at 11:39 A.M. and 2:04 P.M.

On 4/8/25 at 10:37 A.M., the surveyor observed Resident #2 lying in bed and dressed in a hospital gown.

The surveyor observed numerous long facial hairs remained on the Resident's upper lip and chin. During an

interview at the time, Resident #2 said he/she had not been washed/dressed yet and that he/she waited for staff to come in to assist him/her when staff were able. Resident #2 said he/she 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 for him/her.

During an interview on 4/8/25 at 11:45 A.M., CNA # 4 and #5 were observed entering Resident #2's room to provide morning care. During an interview at the time, CNA #5 said Resident #2 required assistance from staff with all personal care including grooming and hygiene.

During an interview on 4/8/25 at 12:18 P.M., CNA #4 said Resident #2 required assistance from staff with ADL care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 68 225766 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225766 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Agawam North Rehab and Nursing 55 Cooper Street Agawam, MA 01001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 On 4/8/25 at 12:22 P.M., the surveyor and Nurse #3 observed that Resident #2 was dressed and lying in bed. During an interview at the time, Resident #2 said he/she would like to have his/her facial hair removed Level of Harm - Minimal harm or and did not like having hair on his/her face. potential for actual harm

During an interview on 4/8/25 at 12:25 P.M., Nurse #3 said he observed the facial hair on the Resident's Residents Affected - Few upper lip and chin and would alert the CNA's to assist in removing the facial hair for him/her.

2. Resident #17 was admitted to the facility in November 2010 with diagnoses including Cerebral Palsy, contractures of unspecified wrist and hand, contractures of the right and left knee, Torticollis (condition in which the neck muscles contract causing the head to twist to one side), and muscle weakness.

Review of the ADL Care Plan, initiated 10/12/24, indicated Resident #17 required the following:

-extensive assistance of one staff for dressing. Allow sufficient time for dressing and undressing ., revised 10/12/24

-extensive assistance of one staff for personal hygiene/oral care . revised 10/16/24

-encourage Resident to participate to the fullest extent possible with each interaction, revised 10/12/24

Review of the MDS assessment dated [DATE REDACTED], indicated the following relative to Resident #17:

-was understood and understands

-was cognitively intact as evidenced by a BIMS score of 14 out of a possible 15 points.

-had no behaviors

-had range of motion (ROM) impairments on both upper and lower extremities

-was dependent on staff for bathing, dressing, toileting and personal hygiene/grooming needs

Review of the CNA Care Card, indicated the following for Resident #17:

-required extensive assist of one for personal hygiene

-please have Resident toileted, washed and dressed daily around 6:00 A.M.

-respect Resident preferences at all times

-required extensive assist of one staff to dress. Allow sufficient time for dressing and undressing.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 68 225766 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225766 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Agawam North Rehab and Nursing 55 Cooper Street Agawam, MA 01001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 On 4/6/25 at 11:17 A.M., the surveyor observed Resident #17 lying in bed dressed in a shirt. A blanket was observed covering the Resident's lower half. During an interview at the time, Resident #17 said one of the Level of Harm - Minimal harm or CNAs on the 11:00 P.M. to 7:00 A.M. (night) shift would wash and dress only his/her upper half and leave potential for actual harm the lower body for the next shift (7:00 A.M. to 3:00 P.M. [day]). 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 Residents Affected - Few CNA refusing to wash/dress his/her lower half continued. Resident #17 said he/she preferred to be fully washed and dressed and could not understand why this continued to occur with this CNA. Resident #17 said he/she had filed a grievance relative to this concern. After the observation and interview, the surveyor notified Resident #17's concerns to the Director of Nursing (DON) and Assistant Director of Nurses (ADON).

On 4/6/25 at 11:34 A.M., the surveyor observed the DON knock and enter Resident #17's room. Shortly after, the DON was observed exiting the Resident's room and told the surveyor he spoke to the Resident about the concerns he/she had relative to the 11:00 P.M. to 7:00 A.M. CNA who provided personal care.

On 4/9/25 at 8:43 A.M., the surveyor observed Resident #17 lying in bed with shirt on and a blanket covering his/her lower body. During an interview at the time, Resident #17 said he/she was washed on the 11:00 P.M. to 7:00 A.M. shift by the CNA and the CNA put a shirt on him/her but did not dress his/her lower half even when the Resident requested to be fully dressed. Resident #17 showed the surveyor that he/she had on underwear and no pants at the time. Resident #17 said that he/she liked to be fully dressed because he/she got cold. Resident #17 said it was the same CNA who was previously reported on 4/6/25, and he/she could not understand why this continued to occur. Resident #17 said CNA #3, who worked on the 7:00 A.M. to 3:00 P.M. shift was aware of his/her concerns.

During an interview on 4/9/25 at 8:46 A.M., CNA #3 said she regularly worked the 7:00 A.M. to 3:00 P.M. shift, and that Resident #17 required total assist of staff with bathing, dressing, and personal hygiene. CNA #3 said because there were more residents on the unit and they were short staffed, there were times when residents had to wait. CNA #3 said Resident #17 was supposed to get washed and dressed for 6:00 A.M., that the Resident had a routine in the morning, and would ring for staff assistance with bathroom needs. CNA #3 said certain CNAs would not fully wash/dress Resident #17, and when this occurred, she encouraged Resident #17 to tell administration. CNA #3 said Resident #17 wanted to be fully washed and dressed including having his/her shoes on in the morning because he/she would get cold. CNA #3 said she was aware of Resident #17's concern for about a year and that it was a particular CNA on the 11:00 P.M. to 7:00 A.M. shift who did not fully wash/dress the Resident on that shift. CNA #3 further said Resident #17 deserved to have the care he/she requested and could not understand why this continued. CNA #3 said she had provided Resident #17 with the morning routine which included toileting, washing and dressing and it took a total of 15 to 20 minutes to provide the care the Resident wanted which was not a long time, so staff should be able to do as he/she requests/prefers.

51466

2. Resident #88 was admitted to the facility in September 2023 with diagnoses including Parkinson's Disease, muscle weakness and Adult Failure to Thrive.

Review of the MDS assessment dated [DATE REDACTED], indicated Resident #88:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 68 225766 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225766 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Agawam North Rehab and Nursing 55 Cooper Street Agawam, MA 01001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 -was cognitively intact, as evidenced by a BIMS score of 14 out of 15.

Level of Harm - Minimal harm or -required maximum assistance from staff for personal hygiene, including facial hair removal. potential for actual harm -exhibited no behaviors or refusals of care. Residents Affected - Few

During an interview on 4/6/25 at 4:30 P.M., Resident #88 said that he/she has not had his/her facial hair removed in over a week. The surveyor observed facial hair about 1/4 inch in length on the Resident's neck, cheeks and chin. Resident #88 said he/she had always preferred to have no facial hair and prior to admission at the facility he/she used to remove his/her facial hair daily. Resident #88 said he/she had asked to have his/her facial hair removed that morning and was told it could happen after suppertime.

On 4/7/25 at 8:22 A.M., the surveyor observed that facial hair about 1/4 inch in length remained on the Resident's neck, cheeks, and chin. During an interview at the time, Resident #88 said staff did not offer to remove his/her facial hair last night after suppertime and when he/she asked again this morning, he/she was told the staff would do it that night.

During an interview on 4/7/25 at 2:25 P.M., CNA #6 said residents should have their facial hair removed every week on their shower day unless they requested or wanted their facial hair removed in between the shower days. CNA #6 said residents should not have unwanted facial hair.

During an interview on 4/8/25 at 7:36 A.M., Resident #88 said his/her facial hair was not removed when care was provided the previous night. Resident #88 said the CNA was going to come back to provide assistance with removing his/her facial hair if they had time but the CNA never came back. Resident #88 said the staff helped him/her get washed and out of bed this morning, but facial hair removal was not offered. The surveyor observed that the Resident remained with hair about 1/4 inch in length on the cheeks, upper lip, neck and chin. Resident #88 said he/she has always preferred to have no facial hair.

During an interview on 4/8/25 at 8:43 A.M., CNA #8 said Resident #88 was assigned to her, but she did not offer facial hair removal because the Resident was provided morning care on the 11:00 P.M. to 7:00 A.M. shift. CNA #8 said that a few weeks prior, Resident #88 told her that he/she preferred to not have facial hair and had removed his/her facial hair every day prior to coming to the facility. CNA #8 said she provided facial grooming to the Resident on the assigned shower day on 3/27/25 and was unsure if he/she has had his/her facial hair removed since. CNA #8 said that CNAs were expected to remove residents' facial hair weekly on their shower day but that CNAs' should also ask residents if they wanted to have their facial hair removed daily. CNA #8 said sometimes when staffing was lower (two CNAs versus three or three and half CNA's) the facial hair removal did not always happen.

During an interview on 4/8/25 at 11:45 A.M., Unit Manager (UM) #4 said CNAs should be offering residents facial hair removal daily. UM #4 said facial hair removal for residents has been an ongoing issue in the building and that staff have been educated on this concern but it continued to be a problem.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 68 225766 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225766 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Agawam North Rehab and Nursing 55 Cooper Street Agawam, MA 01001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or 37400 potential for actual harm Based on observation, interview and record review, the facility failed to ensure treatment and care in Residents Affected - Few accordance with professional standards of practice relative to monitoring and assessing skin conditions for two Residents (#30 and #45), out of a total of 23 sampled residents.

Specifically, the facility failed to:

1. For Resident #30, identify, assess and implement interventions timely when skin areas developed on his/her inner and outer left lower leg.

2. For Resident #45, perform weekly skin assessments as per the comprehensive plan of care.

Findings include:

Review of the facility policy titled Skin Prevention, Assessment and Treatment, revised October 2024, indicated the following:

- purpose of the policy was to identify factors that place the residents at risk for the development of pressure ulcers

- implement appropriate interventions to prevent the development of clinically avoidable wounds

- all residents should have their skin integrity examined thoroughly at least weekly by the licensed nurse .

- findings from the weekly skin assessment should be documented by the licensed nurse

- Certified Nurse Aides (CNAs) should observe skin integrity during the daily provision of routine cares and report any impairments to the Charge Nurse for appropriate follow-up.

- any skin impairments, including pressure ulcers, non-pressure ulcer wounds, surgical wounds, skin tears, abrasions, etc., should be assessed and documented weekly by the Wound Nurse, or designee, in the medical record.

- documentation should cover all pertinent characteristics of existing ulcers, including location, size, depth, maceration, color of the ulcer and surrounding tissues, and a description of any drainage, eschar, necrosis, odor, tunneling, or undermining.

- upon identification of the development of a wound, the wound assessments/treatments will be documented

in the medical record and start the weekly Wound Log.

- Nursing staff should keep the attending physician aware of the progress of all ulcers

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 68 225766 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225766 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Agawam North Rehab and Nursing 55 Cooper Street Agawam, MA 01001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 1. Resident #30 was admitted to the facility in September 2023 with diagnoses including Type 2 Diabetes Mellitus with neuropathy and Hemiplegia and Hemipararesis following a Cerebral Infarction affecting the Left Level of Harm - Minimal harm or Non-Dominant side. potential for actual harm

Review of the Minimum Data Set (MDS) Assessment, dated 2/8/25, indicated the following for Resident #30: Residents Affected - Few - he/she understood and understands

- was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of a possible 15 points

- had no behaviors or rejections of care

- had bilateral lower extremity range of motion (ROM) impairments

- utilized a wheelchair

- required substantial/maximum assistance from staff with bathing and upper and lower body dressing

- was dependent on staff for personal hygiene and putting on shoes

- was at risk for pressure ulcers, had no pressure ulcers and had no arterial and venous ulcers

- had application of medications/ointments other than to feet

Review of the Weekly Wound Log, dated 3/7/25, indicated Resident #30 had a left lower leg blister that was resolved (healed) at that time.

Review of the April 2025 Physician's orders included the following:

- Diabetic foot care/check daily, observation of feet, toes, ankles, soles noting any alteration in skin integrity, color, temperature, and cleanliness. Inspect shoes for proper fit and excessive wear, check pedal pulses every evening shift, initiated on 9/4/23

- Follow initial wound care dressing guidelines if provider was not in office. May utilize until the provider examines or other orders are obtained. Place order individually for documentation of the wound as needed ., initiated 12/28/23

- May be followed by the in-house wound provider for wound evaluation and treatment, initiated 12/28/24

- Weekly skin check on Tuesdays, 7:00 A.M. to 3:00 P.M. shift. Please complete weekly skin assessments in charting under assessments, initiated 2/27/25

- Weekly shower on Tuesdays, 7:00 A.M. to 3:00 P.M. shift, initiated on 2/27/25

Review of the March 2025 through April 6th 2025 Treatment Administration Records indicated:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 68 225766 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225766 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Agawam North Rehab and Nursing 55 Cooper Street Agawam, MA 01001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 - Diabetic foot care was performed daily with the exception of on 3/27/25 and on 3/28/25 where if was marked NA Level of Harm - Minimal harm or potential for actual harm - received weekly showers and skin checks as ordered

Residents Affected - Few - the Resident had no documented refusals of care

- there was no documented evidence of treatments for the Resident's left lower extremity areas

Review of the Weekly Skin Check form, completed on 4/1/25, indicated Resident #30's skin had redness present on his/her left and right front lower legs and the skin was intact.

On 4/6/25 at 9:59 A.M., the surveyor observed Resident #30 dressed in shorts and seated in a wheelchair in his/her room. The Resident was wearing a sock and shoe on his/her right foot and had on a non-skid sock on his/her left foot. The Resident's left lower extremity was observed to be swollen and the left calf was pink and had peeling skin. Two round quarter-sized areas with yellow centers were observed on the outer and inner middle left calf. During an interview, Resident #30 said the open areas on the outer and inner left calf were caused from his/her brace and pointed to a leg brace which was near his/her dresser. Resident #30 said he/she had a dermatology appointment on 4/1/25 for removal of skin tags and the skin doctor also looked at his/her left lower leg.

On 4/06/25 at 3:32 P.M., the surveyor observed Resident #30 dressed in shorts and seated in a wheelchair

in his/her room. The areas remained on his/her left lower extremity. Shortly after the observation, the Resident was observed to self propel out of the room, down the hallway and off the unit passing several staff.

Review of Resident #30's clinical record included the following:

- Provider Visit Note, dated 3/19/25, that indicated Resident #30 had a dermatology appointment on 4/1/25 at 2:00 P.M. for skin tags

- Provider Visit Note, dated 4/4/25, that indicated the Resident had a follow-up appointment with dermatology

on 8/5/25 at 2:15 P.M.

- there was no documented evidence of identification, assessment or that interventions were in place for the Resident's areas located on his/her inner and outer middle lower left leg.

- no documented evidence of the Resident's results from the dermatology consult that occurred on 4/1/25.

On 4/7/25 at 11:27 A.M., the surveyor observed Resident #30 dressed in shorts and seated in a wheelchair

in his/her room. The Resident's left lower leg remained swollen, was pink in color and had peeling skin. The two round quarter-sized areas on the Resident's middle left outer and inner calf were visible and remained with a yellow center. During an interview, Resident #30 said he/she was going out of the facility for a bit with

a friend in the afternoon.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 68 225766 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225766 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Agawam North Rehab and Nursing 55 Cooper Street Agawam, MA 01001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Review of a Nurse's Note, dated 4/7/25, indicated the dermatology office contacted the facility at 3:50 P.M. to report results from a culture that was obtained from Resident #30 at his/her appointment last week (on Level of Harm - Minimal harm or 4/1/25). The Resident was positive for Methicillin Resistant Staphylococcus Aureus (MRSA: type of bacteria potential for actual harm that can cause a serious infection and was difficult to treat with antibiotics) in his/her left lower extremity. The facility requested a copy of the laboratory results and the on-call provider was contacted regarding the Residents Affected - Few results and requested the dermatology provider write the order for antibiotics and the dermatology office was closed at that time. The on-call provider gave an order for one time dose of antibiotic and requested the facility staff contact the dermatology office on 4/8/25 to obtain additional orders for antibiotics and wound care treatment orders.

Review of the April 2025 Physician's orders indicated the following:

- Infection Precautions- Contact Isolation: Resident is isolated in room, without a roommate or cohort with like pathogen, due to active infection with transmissible significant pathogens. Above standard transmission precautions maintained, with activities and all services brought to the resident, every shift, initiated 4/7/25

- Bactrim DS (antibiotic) 800-160 milligrams (mg), twice daily for one day pending dermatology recommendations on 4/8/25, initiated 4/7/25

- Doxycycline Monohydrate (antibiotic), 100 mg twice daily for ten days for MRSA infection in left lower leg, initiated 4/8/25

- Wound- left lower leg: cleanse with wound cleanser, xeroform/ABD/rolled gauze daily. Elevate legs as tolerated every day shift, initiated 4/8/25

Review of the Wound Logs, dated 4/7/25 indicated the following:

- left shin lateral aspect (outer), acquired on 4/7/25, quarter-sized blister caused by leg brace and was 50% yellow slough and 50% epithelial tissue which measured 2.5 centimeters (cm) length by 2.5 cm width by 0.1 cm depth. The peri-wound was red, inflammation was present and infection was suspected, positive MRSA.

- left shin medial aspect (inner), acquired on 4/7/25, quarter-sized blister caused by leg brace and was 50% yellow slough and 50% epithelial tissue which measured 2.5 centimeters (cm) length by 2.5 cm width by 0.1 cm depth. The peri-wound was red, inflammation was present and infection was suspected, positive MRSA

During an interview, on 4/8/25 at 10:55 A.M., Medical Records Staff said she was responsible for coordinating resident medical appointments. She said resident information including the medication list, physician notes, most recent laboratory work and a blank consult sheet would be sent with the resident for

the appointment. Medical Records Staff said 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 and ensure

the provider was aware. Medical Records Staff said if a resident returned from a medical appointment without a completed consult sheet, the nurses would notify her and she would contact the outside provider for information regarding the appointment. Medical Records Staff said she was not notified that consult information was not obtained when Resident #30 returned from the dermatology appointment on 4/1/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 68 225766 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225766 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Agawam North Rehab and Nursing 55 Cooper Street Agawam, MA 01001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 During an interview, on 4/8/25 at 10:58 A.M., Nurse #3 said when Resident #30 returned from the dermatology appointment on 4/1/25 without consult information, the nurse should have contacted the Level of Harm - Minimal harm or dermatology office to obtain information about the appointment and receive any orders if any. potential for actual harm

During an interview, on 4/8/25 at 11:10 A.M., Unit Manager (UM) #1 said when a resident returns from an Residents Affected - Few outside medical appointment, the nurse would receive the information from the resident regarding the visit and any instructions that would need to be relayed to the provider. UM #1 said if a resident returns without information from an appointment, the facility would contact the outside provider for information regarding the visit, and she was not sure this was done for Resident #30. UM #1 said she was unaware Resident #30 had left leg wounds or that a culture was obtained until the dermatology office contacted the facility on 4/7/25 (six days after the appointment). UM #1 said the Resident had skin checks that were performed weekly, but said there were times when he/she refused them. UM #1 said the Resident required assistance from staff with ADL care and that the Certified Nurse Aides (CNAs) also would report skin changes. The surveyor relayed

observations of the Resident's left lower extremity from 4/6/25 which was swollen, pink with peeling skin and

the presence of two round quarter-sized areas with yellow centers located on the outer and inner middle left calf. UM #1 said she was unaware of these areas and said the Resident did wear a brace on his/her left leg when he/she was out of the facility and that she observed him/her wearing the brace on 4/7/25.

Review of the Weekly Skin Check, dated 4/8/25, indicated the Resident's skin was warm and dry, had no skin or foot problems and also indicated the Resident refused to be assessed.

During an interview, on 4/8/25 at 11:54 A.M. and at 1:51 P.M., the Director of Nurses (DON) said the Resident's left lower leg areas were obviously missed by facility staff and should have been identified prior to 4/7/25. The DON said Resident #30 had an appointment on 4/1/25 to remove skin tags, but the facility was not aware that a lower extremity skin culture was obtained on that day. The DON said when a resident had a medical appointment outside of the facility and returns with no information, the facility should contact the outside provider to obtain information on what transpired at the appointment and this did not occur for Resident #30. The DON said had the facility known a culture of the Resident's left lower extremity was pending, contact precautions would have been initiated (on 4/1/25) pending the result of the culture.

During a follow-up interview on 4/08/25 at 3:17 P.M., with the DON, UM #1 and the Director of Rehabilitation (DOR), the DOR said the therapy department was not made aware that Resident #30 was wearing a left leg brace, that there was no Physician's order for the Resident to use the brace and that it had been discontinued for quite some time. UM #1 said she was aware the Resident wore the brace at times when he/she was going out of the facility but was not aware Resident #30 had two areas on his/her left lower legs that he/she said were caused by the brace.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 68 225766 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225766 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Agawam North Rehab and Nursing 55 Cooper Street Agawam, MA 01001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 On 4/09/25 at 4:03 P.M., the surveyor observed Resident #30's wound with UM #1. Resident #30 was observed dressed in shorts and seated in a wheelchair in his/her room. The Resident's left foot remained Level of Harm - Minimal harm or swollen and the Resident had a non-skid sock in place. A gauze wrap was observed dated 4/9/25 around the potential for actual harm Resident's middle left lower leg. UM #1 removed the dressing and two quarter-sized circular areas were observed on the Resident's inner and outer left middle calf. The open area on the left inner leg was clean Residents Affected - Few and no yellow discoloration was observed. The open area on the outer left calf had a yellow center. The Resident's left lower leg remained pink and had some flaking skin. During an interview following the

observation, UM #1 said the Resident's left lower extremity wounds were not identified by the facility until the surveyor brought it to their attention on 4/7/25. UM #1 said Resident #30 had a history of lower extremity wounds, but the current wounds were not previously identified.

Please refer to

F-F725

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 68 225766 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225766 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Agawam North Rehab and Nursing 55 Cooper Street Agawam, MA 01001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50563

Residents Affected - Some Based on observations, interviews, and record review, the facility failed to ensure that there was sufficient nursing staff to assist residents in attaining and maintaining the highest practicable physical, mental, and psycho-social well-being on four units (A-Wing, C-Wing, D-Wing, and F-Wing), out of a total of four units, and for three Residents (#51, #45, and #13), out of a total sample of 23 residents.

Specifically,

1. The facility failed to ensure that staffing levels on the A-Wing, C-Wing, D-Wing and F-Wing were provided to meet the residents needs of each unit safely.

2. For Resident #51, the facility failed to ensure toileting assistance was provided promptly when the Resident was indisposed and had the call light on for over 20 minutes.

3. For Resident #45, the facility failed to provide assistance of two staff with transfers as required resulting in

a fall when the Resident was transferred with one staff memebr.

4. For Resident #13, the facility failed to provide timely notification to the Physician when the Resident experienced a change in condition and the Nurse responsible for providing care had worked 27 hours that weekend in addition to her regularly worked 40-hour schedule.

Findings include:

1. Review of the Facility Assessment (self-completed assessment that indicate what types of care the facility provided as well as what their staffing and educational plans are to meet the residents residing in the facility's needs), dated 1/28/25, failed to indicate evidence that the facility had assessed for how many Certified Nurses Aides (CNAs) were required per resident, unit or shift to ensure appropriate care was provided to the residents residing in the facility.

During an interview on 4/8/25 at 11:37 A.M., the Director of Nursing (DON) said the facility staffing plan was to have:

-three CNAs on each unit for the Day (7:00 A.M. to 3:00 P.M.) shift

-three CNAs on each unit for the Evening (3:00 P.M. to 11:00 P.M.) shift

-two CNAs on each unit for the Night (11:00 P.M. to 7:00 A.M.) shift.

The DON said in an ideal world they would additionally have one CNA split between the A-Wing and C-Wing, and one split CNA between the D-Wing and F-Wing during day and evening shifts, but that the facility could run adequately with three CNAs on each unit.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 68 225766 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225766 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Agawam North Rehab and Nursing 55 Cooper Street Agawam, MA 01001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 During a follow-up interview on 4/8/25 at 1:58 P.M., the DON said he knew there were staffing shortages, and it was visible on the schedule. Level of Harm - Minimal harm or potential for actual harm Review of the CNA schedule from 3/2/25 through 4/5/25 indicated the following:

Residents Affected - Some -On 3/2/25: F-Wing was staffed with two CNAs working on the Day shift and was staffed with two CNAs for

the Evening shift

-On 3/4/25: A-Wing was staffed with one CNA working on the Evening shift

-On 3/5/25: C-Wing was staffed with two CNAs working on the Day shift

-On 3/7/25: A-Wing was staffed with two CNAs working on the Day shift and C-Wing was staffed with two CNAs working on the Evening shift

-On 3/10/25: C-Wing was staffed with two CNAs working on the Day shift

-On 3/15/25: C-Wing was staffed with two CNAs working on the Evening shift

-On 3/16/25: A-Wing was staffed with two CNAs working on the Evening shift

-On 3/18/25: C-Wing was staffed with two CNAs working on the Day shift

-On 3/24/25: C-Wing was staffed with two CNAs working on the Day shift and D-Wing was staffed with one CNA working on the Day shift

-On 3/25/25: F-Wing was staffed with two CNAs working on the Day shift

-On 4/2/25: A-Wing was staffed with two CNAs working on the Evening shift

Review of the Resident Council Meeting Minutes, dated 2/19/25, indicated the following:

-Residents shared concerns about staffing levels affecting timely care.

Review of the Resident Council Meeting Minutes, dated 3/26/25, indicated the following:

-Concerns relative to slow response times

-Delay in help

-Staff not listening

During the initial pool process on 4/5/25 and 4/6/25, the following included information shared with the survey team:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 68 225766 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225766 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Agawam North Rehab and Nursing 55 Cooper Street Agawam, MA 01001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 -Resident #41 said the facility was short-staffed and the 11:00 P.M. to 7:00 A.M. (Night) shift was the worst. Resident #41 said there are usually two CNAs at night but sometimes there is one CNA. Resident #41 said Level of Harm - Minimal harm or he/she would have to wait 35-40 minutes several times a week for staff assistance. Resident #41 said the potential for actual harm DON was aware of these concerns.

Residents Affected - Some -Resident #94 said it could take up to one to two hours for staff to answer his/her call light and provide assistance. Resident #94 said that he/she needed assistance from staff to use the bathroom and facility staff have told him/her to hold it until they are able to assist him/her. Resident #94 said this occurred on all shifts at least weekly, and that he/she had not been incontinent but had to try hard to not have incontinence happen.

-Resident #18 said it took sometimes an hour for facility staff to assist him/her with toileting assistance and has had episodes of incontinence due to having to wait for staff assistance.

-Resident #108 said he/she sometimes had to wait up to a half hour for the call light to be answered and that

this occurred typically on the Day shift.

During a Resident Council Meeting held on 4/7/25 from 10:00 until 10:50 A.M., the following was discussed:

-Resident #6 said that the call bell wait times can range anywhere from five minutes to one hour. Resident #6 further said that his/her experience with long call bell wait times had primarily been with the Evening shift.

-Resident #11 said that his/her experience with long waiting times had been mainly on the Day shift. Resident #11 said about a week ago, he/she called for help, but no one came for quite some time. Resident #11 said that he/she could not wait any longer, so he/she walked to the nurses station alone, even though there is a sign in his/her room on the mirror, that says to call before you fall. Resident #11 said he/she went to the nurses station, there was no one around, he/she was afraid that he/she might fall but needed help and could not wait any longer for someone to answer the call bell. Resident #11 said that he/she could not recall how long he/she waited but it was well over five minutes.

During an interview on 4/7/25 at 2:30 P.M., two CNAs, who requested to remain anonymous said the following:

-one CNA felt it could be neglectful to not have at least three CNAs on the unit for care because the CNAs are rushing and unable to provide the time and care to the residents.

-the second CNA said he/she had told administration about the need for three CNAs on the shift, that they were exhausted, burnt out and unable to provide the care that they deserve to the residents. The second CNA said they did not feel appreciated and administration staff did not usually assist on the units with resident meals or check in with the staff to see how they were managing their residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 68 225766 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225766 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Agawam North Rehab and Nursing 55 Cooper Street Agawam, MA 01001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 During an interview on 4/8/25 at 9:05 A.M., a Nurse, who requested to remain anonymous, said there were currently four CNAs on the unit today which was not typical. The Nurse said they usually have three CNAs Level of Harm - Minimal harm or and often have two CNAs for 30 to 31 residents which was not enough. The Nurse said when there was a potential for actual harm call-out of staff on one of the other floors, administration will pull a CNA from his/her unit, even if there were three CNAs, leaving them with two CNAs. The Nurse said when the main dining room was open, it was Residents Affected - Some difficult to manage the unit because a Nurse had to be in the main dining room from 11:30 A.M. until 1:00/1:30 P.M. or until the last resident in the main dining room had completed eating and that left the unit with less staff. The Nurse said it had been very difficult to work and felt it was not safe for the residents who live on the unit. The Nurse said these concerns have been relayed by staff to administration and nothing changes.

During an interview on 4/8/25 at 10:32 A.M., a CNA, who requested to remain anonymous, said when there are two and a half CNAs on each of the second floor units (F-Wing and D-Wing), it was not manageable. The CNA said the main resident dining room was not typically open on the weekends and there were staff call-outs on the weekend and there were not enough staff to have the main dining room open. The CNA said

the resident's really enjoy the main dining room and were excited to have their meals there because the atmosphere was nice and the residents enjoy the socialization.

During an interview on 4/9/25 at 4:40 P.M., the Administrator said the main dining room was not open during

the weekends due to staffing shortages because a Nurse and a CNA need to observe the residents during that time.

37400

2. Resident #51 was admitted to the facility in February 2019 and resided on the F-Wing Unit.

Review of the Minimum Data Set (MDS) assessment dated [DATE REDACTED], indicated the following for Resident #51:

-he/she understands and was understood.

-was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 13 out of a possible 15 points.

-had bilateral range of motion (ROM) impairments of his/her lower extremities.

-was dependent on staff for toileting needs.

During an interview on 4/7/25 at 8:07 A.M., Resident #51 said he/she had a horrible night last night (4/6/25). Resident #51 said he/she rang his/her call light on the Evening shift for assistance with toileting and a staff person came in and turned off the light, left the room and did not provide toileting assistance until two hours later. Resident #51 said he/she was so upset that he/she could not go to sleep until 4:00 A.M. the next morning. After the interview, the surveyor immediately notified the DON of the Resident's concern.

On 4/7/25 from 10:40 A.M. through 11:01 A.M., the surveyor observed the following:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 68 225766 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225766 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Agawam North Rehab and Nursing 55 Cooper Street Agawam, MA 01001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 -10:40 A.M.: a red blinking light was lit outside of Resident #51's room. Two CNAs were previously observed

in other residents' room and there was no staff visible in the hallway. A light was observed blinking near the Level of Harm - Minimal harm or nurses station and there was an audible beeping coming from the nurses station. potential for actual harm -10:58 A.M.: Resident #51's call light remained on and no staff were observed to enter the Resident's room. Residents Affected - Some -11:00 A.M.: Resident #51's call light remained lit. The surveyor knocked and entered the Resident's room and observed the bathroom door to the room was open and Resident #51 was seated on the toilet. During an

interview at the time, Resident #51 said he/she had been on the toilet and utilized the call light for assistance

in the bathroom but no one had come to see him/her yet.

-11:01 A.M.: CNA #2 entered the Resident's room at the time to provide assistance (21 minutes after the call light was initiated).

During an inteview on 4/7/25 at 11:04 A.M., CNA #1 said Resident #51 required assistance of two staff with transfers and the Unit was scheduled with two and a half (2.5) CNAs today. CNA #1 said two CNAs on the hallway where Resident #51 resides was not enough. CNA #1 said she and CNA #2 were running around to get residents washed and dressed and up for the day, and they did not have time to take their scheduled breaks. CNA #1 said there are 11 residents on the F-Wing that required assistance of two staff.

During an interview on 4/7/25 at 1:29 P.M., the DON said when a resident call light was initiated, it should be answered within five minutes. The DON said the staffing at the facility was a challenge, the facility was currently working on this concern, had hired nursing and understood the concern relative to CNAs. The DON said that the facility needed to work on the staffing.

3. Resident #45 was admitted to the facility in April 2024 and resided on the F-Wing Unit.

Review of the Activities of Daily Living (ADL) Care Plan, initiated 4/4/24, indicated Resident #45 had an alteration in ability to care for him/herself and required assistance.

The ADL Care Plan included the following interventions:

-requires mechanical lift with two staff assistance with transfers, initiated 4/4/24.

Review of the Nursing Progress Note dated 4/5/25, indicated Resident #45:

-was lowered to the floor during a transfer from the wheelchair to the bed.

-said his/her legs gave out and he/she was lowered to the floor by the CNA who was assisting him/her.

-was in stable condition and vital signs were stable.

-reported no pain to the Nurse and no injuries were sustained.

Review of the CNA Care Card on 4/7/25 at 12:03 P.M., indicated the following:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 68 225766 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225766 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Agawam North Rehab and Nursing 55 Cooper Street Agawam, MA 01001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 -Resident transfers with assistance of two staff with mechanical lift.

Level of Harm - Minimal harm or On 4/6/25 at 10:16 A.M., the surveyor observed Resident #45 dressed and seated in a wheelchair in the potential for actual harm common room located on the unit. During an interview at the time, Resident #45 said he/she had a fall last night (4/5/25) because there were not enough staff to assist in transferring him/her from the wheelchair to the Residents Affected - Some bed. Resident #45 said one CNA assisted him/her and two staff were supposed to assist with transfers. Resident #45 said four to five staff had to assist him/her off the floor and to the bed, and his/her elbow hurt from the fall.

Review of the facility schedule on 4/5/25 for the 3:00 P.M. to 11:00 P.M. shift on Resident #45's unit (F-Wing) indicated that two CNAs were scheduled.

During an interview on 4/7/25 at 4:00 P.M., the Director of Rehabilitation (DOR) said staff should provide assistance of two staff for all transfers for Resident #45.

4. Resident #13 was admitted to the facility in November 2023 and resided on the C-Wing.

Review of the person-centered Integumentary (skin) Care Plan, initiated 5/15/24, indicated Resident #13:

-had an alteration in the integumentary system due to cerebrovascular accident (CVA: stroke), Left hemiparesis, Dementia, use of anticoagulation, neuropathy, wound on left ischium, right 1st metatarsal head, and right heel.

The Integumentary Care Plan included the following intervention:

>will be monitored for a change in condition and the Physician will be notified, initiated 5/15/24.

Review of the MDS Assessment, dated 3/7/25, indicated Resident #13:

-had severe cognitive impairment as evidenced by a BIMS score of four out of a total of 15 points.

-was at risk for developing Pressure injuries.

-had no unhealed Pressure Injuries.

During an interview on 4/9/25 at 10:18 A.M., CNA #8 said Resident #13 had a right heel wound that had a black area in the center for a long time. CNA #8 said that while working on 3/23/25, she and CNA #7 identified that the Resident had right foot swelling and redness, and that the Resident's right heel wound looked different. CNA #8 said she had also noticed the Resident was acting differently and was quiet, which was not the Resident's usual behavior. CNA #8 said both she and CNA #7 were concerned, and that CNA #7 reported the concern about the Resident's change in condition to Nurse #5 and the Assistant Director of Nurses (ADON).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 68 225766 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225766 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Agawam North Rehab and Nursing 55 Cooper Street Agawam, MA 01001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 During an interview on 4/9/25 at 10:50 A.M., the ADON said she had worked on 3/23/25 from 7:00 A.M. to 7:00 P.M. but did not recall hearing anything about Resident #13's change in condition relative to his/her Level of Harm - Minimal harm or right heel. The ADON said she may have been unable to recall hearing anything because she had worked 27 potential for actual harm hours that weekend, after working her regular 40-hour schedule, due to a staffing shortage.

Residents Affected - Some During an interview on 4/9/25 at 2:52 P.M., the DON said that weekend (3/22/25 and 3/23/25) was hell weekend due to staffing. The DON said he also had to work on the Units during that time.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 68 225766 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225766 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Agawam North Rehab and Nursing 55 Cooper Street Agawam, MA 01001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Level of Harm - Minimal harm or potential for actual harm 50563

Residents Affected - Few Based on interview, and record review, the facility failed to ensure that competency in skills and techniques necessary to provide resident care were demonstrated for four staff members (#7, #8, #9 and #10) out of a total of five staff reviewed.

Specifically, for Staff Member's #7, #8, #9, and #10, the facility failed to ensure that the staff members completed the necessary competencies as indicated in the Facility Assessment.

Findings include:

Review of the Facility Assessment (self-completed assessment that indicated what types of care a facility provided as well as what their staffing and educational plans to meet the Resident's needs), dated 1/28/25, indicated the following competencies would be completed during new employee orientation, annually, and as needed:

-For all staff: person-centered care, infection control-hand hygiene, infection control-universal precautions, infection control-protective equipment, disaster planning.

-For clinical staff: activities of daily living, caring for people with Dementia, Alzheimer's and cognitive impairments, caring for residents with mental and psychosocial disorders.

-For Nurses: medication administration, resident assessment.

-For Nurses aide and Nurses: measurements - vital signs and intake and output.

-For social services, clinical staff, activities, and therapy: non - pharmacological management of responsive behaviors, caring for residents with trauma/Post Traumatic Stress Disorder (PTSD).

Review of Staff Member #7's education records failed to indicate evidence that any competencies had been completed.

Review of Staff Member #8's education records failed to indicate evidence that any competencies had been completed.

Review of Staff Member #9's education records failed to indicate evidence that any competencies had been completed.

Review of Staff Member #10's education records failed to indicate evidence that any competencies had been completed.

During an interview on 4/9/25 at 2:32 P.M., the Administrator said the facility was unable to provide any evidence that the competencies indicated by the Facility Assessment had been completed for Staff Members #7, #8, #9 and #10.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 68 225766 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225766 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Agawam North Rehab and Nursing 55 Cooper Street Agawam, MA 01001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Level of Harm - Minimal harm or potential for actual harm 42690

Residents Affected - Some Based on record review, and interview, the facility failed to ensure that recommendations made by the Consultant Pharmacist during a monthly Medication Regimen Review (MRR) were reviewed by the Physician as required for five Residents (#29, #23, #48, #84 and #32), out of a total sample of 23 residents.

Specifically, the facility failed to:

1. For Resident #29, ensure that a MRR was reviewed by the Physician for the month of December 2024 when recommendations had been made by the Consultant Pharmacist.

2. For Resident #23, ensure MRRs were reviewed and responded to by the Physician when recommendations were made by the Consultant Pharmacist on 9/19/24, 11/20/24, 12/18/24, and 1/23/25.

3. For Resident #48, ensure MRRs were reviewed and responded to timely by the Physician when recommendations were made by the Consultant Pharmacist on 12/13/24, 1/21/25, and 2/24/25.

4. For Resident #84, ensure MRRs were reviewed and responded to by the Physician when recommendations were made by the Consultant Pharmacist on 4/17/24, 7/24/24, and 9/19/24.

5. For Resident #32, ensure the Physician reviewed and responded to the MRR completed by the Consultant Pharmacist.

Findings include:

Review of the facility policy Medication Regimen Review, revised on 11/5/24, indicated the following:

-Any irregularities will be communicated to the physician utilizing a written recommendation and report for consideration

-Copies of the medication regimen review and written recommendations will be maintained as a part of the permanent medical record

-Information on the medical regimen reviews and written recommendations will be reviewed by the Director of Nursing (DON).

1. Resident #29 was admitted to the facility in October 2023 with diagnoses including Cerebral Infarction (stroke), Type II Diabetes Mellitus, Depression, Mood Disorder, and Orthostatic Hypotension.

Review of Resident #29's medical record indicated a MRR had been conducted on 12/17/24 and indicated to see the report for details.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 68 225766 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225766 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Agawam North Rehab and Nursing 55 Cooper Street Agawam, MA 01001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Further review of the medical record failed to indicate any documented evidence of the MRR report for 12/17/24. Level of Harm - Minimal harm or potential for actual harm During an interview on 4/7/25 at 1:59 P.M., the DON said that at this time he was unable to locate the report for the December 2024 MRR. Residents Affected - Some 37400

2. Resident #23 was admitted to the facility in October 2023 with diagnoses including Dementia and Type 2 Diabetes.

Review of the Resident's clinical record indicated the Consultant Pharmacist had recommendations for the following dates and noted to refer to the report for details on:

-9/19/24

-11/20/24

-12/18/24

-1/23/25

Further review of the Resident's clinical record failed to indicate documented evidence on what the Consultant Pharmacist recommendations were or that the recommendations were addressed by the facility and/or the Physician.

On 4/9/25 at 2:21 P.M., the surveyor requested the Consultant Pharmacy Recommendations for Resident #23 from the DON.

During an interview on 4/9/25 at 5:20 P.M., the Administrator said he was unable to find evidence of the Consultant Pharmacist's Recommendations made on 9/19/24, 11/20/24, 12/18/24 and on 1/23/25 and whether the recommendations were addressed by the facility and/or the Physician.

3. Resident #48 was admitted to the facility in November 2024 with diagnoses including Parkinson's Disease, Depression and Dementia.

Review of the Resident's clinical record indicated the Consultant Pharmacist made recommendations for the following dates and noted to refer to the report for details on:

-12/13/24

-1/21/25

-2/24/25

Further review of the Resident's clinical record failed to indicate documented evidence on what the Consultant Pharmacist Recommendations were or indication that the recommendations were addressed by

the facility and/or the Physician.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of 68 225766 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225766 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Agawam North Rehab and Nursing 55 Cooper Street Agawam, MA 01001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 During an interview on 4/9/25 at 11:33 A.M., the DON said he receives the recommendations from the Consultant Pharmacist and they are given to the Unit Managers (UM) to address with the Physician. The Level of Harm - Minimal harm or DON said when the Consultant Pharmacist Recommendations are responded to by the facility and/or the potential for actual harm Physician, the DON would keep the original recommendation in his/office. The surveyor requested the Consultant Pharmacist Recommendations from the DON for Resident #48. Residents Affected - Some

On 4/9/25 at 12:35 P.M., the DON provided Resident #48's Consultant Pharmacy Recommendations as requested. The DON said the recommendation from 12/13/24 was not addressed until 2/28/25, after the Consultant Pharmacist made the recommendation again on 2/24/25. The DON said he was unable to see that the recommendation from 1/21/25 was addressed by the Physician.

45429

4. Resident #84 was admitted to the facility in October 2023 with diagnoses including Hemiplegia and Dementia.

Review of Resident #84's Consultant Pharmacist Progress Notes indicated the following:

-4/17/24: MRR completed Medications reviewed. Please see the Consultant Pharmacist Report for the Recommendations.

-7/24/24: MRR completed Medications reviewed. Please see the Consultant Pharmacist Report for the Recommendations.

-9/19/24: MRR completed Medications reviewed. Please see the Consultant Pharmacist Report for the Recommendations.

Review of Resident #84's medical record failed to provide any evidence of the Pharmacy Recommendations and Clinical Pharmacy Reports indicated in the Pharmacist Progress Notes on 4/17/24, 7/24/24, and 9/19/24.

Further review of Resident #84's medical record failed to indicate that the Physician had reviewed the 4/17/24, 7/24/24, and 4/17/24, Pharmacy Recommendations.

During an interview on 4/9/25 at 2:30 P.M., the DON said that he was unable to locate the Pharmacy Recommendations for the requested dates and was also unable to provide evidence that the Clinical Pharmacy Reports had been reviewed by the Physician as required.

The facility was unable to provide any additional information pertaining to the Clinical Pharmacy Reports and Physician Review of the Pharmacy Recommendations to the survey team at the time of survey exit.

50563

5. Resident #32 was admitted to the facility in October 2024 with diagnoses including Cerebral Infarction.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 59 of 68 225766 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225766 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Agawam North Rehab and Nursing 55 Cooper Street Agawam, MA 01001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Review of Resident #32's medical record indicated a Consultant Pharmacist MRR Recommendation, undated, printed on 1/29/25, that had not been reviewed by the Physician as evidenced by an Level of Harm - Minimal harm or incomplete/blank Physician/Prescriber response section. potential for actual harm

During an interview on 4/9/25 at 2:34 P.M., the surveyor and the DON reviewed the undated Pharmacy Residents Affected - Some Recommendation printed on 1/29/25. The DON said that there was no evidence that the Physician had reviewed and addressed the MRR printed on 1/29/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 60 of 68 225766 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225766 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Agawam North Rehab and Nursing 55 Cooper Street Agawam, MA 01001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 37400

Residents Affected - Many Based on observations, interviews and record review, the facility failed to maintain a clean and sanitary facility kitchen and on two units (A-Wing and F-Wing) out of four units observed.

Specifically, the facility failed to:

-ensure Dietary Staff adhered to the hair restraint policy to minimize the potential for physical contamination

during food preparation and meal service in the main facility kitchen.

-label, date and store foods in the facility kitchen to decrease potential for food contamination and food-borne illnesses.

-ensure that outside windows to the facility kitchen had screens to prevent pests/rodents from entering.

-maintain and store food service equipment in a clean and sanitary manner in the main facility kitchen and on A-Wing and F-Wing units.

Findings include:

Review of the facility policy titled Staff Attire, revised 10/2023, indicated all employees wear approved attire for the performance of their duties.

The Staff Attire policy also included the following:

-All staff members will have their hair off their shoulders, confined in a hair net or cap, and facial hair properly restrained.

Review of the facility policy titled Environment, revised 9/2017, indicated all food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition.

The Environment policy also included the following:

-The Food Service Director (FSD) will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation.

-The FSD will ensure that all employees are knowledgeable in the proper procedures for cleaning and sanitizing of all food service equipment after each use.

-All food contact services will be cleaned and sanitized after each use, including tables, chairs, and floors.

Review of the Labeling and Dating Inservice, undated, indicated the following:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 61 of 68 225766 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225766 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Agawam North Rehab and Nursing 55 Cooper Street Agawam, MA 01001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 -Proper labeling and dating ensures that all foods are stored, rotated, and utilized in a First In First Out (FIFO) manner. This will minimize waste and ensure that items that are past their due date are discarded. Level of Harm - Minimal harm or potential for actual harm -All foods should be dated upon receipt before being stored.

Residents Affected - Many -Food labels must include:

>the food item name

>the date of preparation/receipt/removal from freezer

>the use by date as outlined in the attached guidelines

-Items that are removed from a labeled case in the freezer and placed in the refrigerator for thawing should be labeled with the date of removal from the freezer and an appropriate use by date as outlined in the Retention Guide .

-Leftovers should be labeled and dated with the date they were prepared and the use by date.

On 4/6/25 from 7:15 A.M. through 7:38 A.M., the surveyor conducted an initial tour of the kitchen and observed the following:

-two Dietary Aides preparing the breakfast meal with no facial hair restraints being worn.

-ice machine external filter had evidence of dust. The ice scoop was observed hanging on the outside of the ice machine exposing it to dust and potential contamination.

-reach-in refrigerator had two bagels that were not labeled and dated, and an unlabeled energy drink.

-walk-in refrigerator:

>contained a rack that had uncovered raw hamburger patties on a tray with a use by date 3/26/25.

>Below the raw hamburger tray was a tray of individual covered cups of cranberry sauce that were unlabeled and undated.

>The bottom of the rack had a tray containing a closed package of raw white meat that was unlabeled and undated. >Another rack had multiple trays with styrofoam cups which were uncovered (open to air) and had applesauce and canned fruit that were unlabeled and undated.

-shelving near the walk-in refrigerator was observed to be dirty, with debris and had clean pans stored.

-closed container of a sugar-like substance that was unlabeled and undated. A container of thickener was undated, loosely covered and left open to air.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 62 of 68 225766 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225766 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Agawam North Rehab and Nursing 55 Cooper Street Agawam, MA 01001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 -the ovens had dark dried cooked on debris on the bottom and internal doors.

Level of Harm - Minimal harm or During an interview at the time, the [NAME] said he thought the ovens were cleaned monthly. potential for actual harm -shelving over the three compartment sink was dirty with multiple different colored substances, and was Residents Affected - Many tacky and greasy to the touch.

-A window sill located next to the shelf and over the three compartment sink had multiple plates, a knife and cleaning pads.

-a window located next to a pot/pan storage rack was open and did not have a screen.

-a vent above the clean pot/pan storage rack had a thick gray coating of dust.

-an open plastic bag with stained rags was on the floor next to the pot/pan storage rack and had fallen over and stained rags were observed spilling onto the floor.

The surveyor observed an ice machine on the A-Wing unit, an ice scoop that was stored uncovered on a hook hanging on the outside of the ice machine with the ice scoop open to air on the following days:

-4/6/25 at 9:45 A.M.

-4/7/25 at 12:45 P.M.

On 4/8/25 at 7:21 A.M., the surveyor conducted another walk through of the facility kitchen with the FSD and observed the following:

-the [NAME] serving the breakfast line did not have a facial hair restraint on.

-the ice machine external filter had evidence of dust. The ice scoop was observed hanging on the outside of

the ice machine exposing it to dust and contamination.

During an interview with the [NAME] at 8:42 A.M., he said he thought the ice scoop should be in a closed container to protect it from dust, debris and potential contamination.

-visible dust was observed on the ceiling and lighting over the food preparation and service areas, in the vents near shelving above the food preparation sink and the dust was visibly blowing outward into the kitchen, and the vent above the clean pot/pan storage rack had a thick gray coating of dust.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 63 of 68 225766 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225766 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Agawam North Rehab and Nursing 55 Cooper Street Agawam, MA 01001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 During an interview at the time, the surveyor relayed previous observations from 4/6/25 with the FSD and

she said she heard the kitchen was a mess when the initial tour was conducted. The FSD said the Level of Harm - Minimal harm or maintenance department takes care of the dust on the vents, ceiling and lighting, but she was not sure how potential for actual harm often this was done. The FSD said the kitchen windows should not be open unless there was a screen because it could allow pests/rodents to enter into the kitchen. The FSD said she saw the open window on Residents Affected - Many 4/6/25 when she came into work that day. The FSD said that the ice scoop was supposed to be in a housing station, she had asked for one and was awaiting approval. The FSD said the way the ice scoop was stored currently was a potential infection control issue because it was exposed and could be contaminated and then used to get ice.

During an interview on 4/8/25 at 1:14 P.M., the Director of Maintenance (DOM) said the vents in the facility kitchen were cleaned about two months ago and probably needed to be cleaned more frequently. The DOM said the dust on the walls, ceiling and lights in the facility kitchen were the responsibility of the kitchen staff.

On 4/8/25 at 1:30 P.M. on the F-Wing unit, the surveyor observed an ice machine with an ice scoop stored uncovered on a hook hanging on the outside of the ice machine.

On 4/9/25 at 3:40 P.M., the surveyor conducted another observation of the facility kitchen with the Regional FSD, and observed the following:

-two Dietary Staff in the kitchen with no facial hair restraints on.

During an interview at the time, the Regional FSD said hair restraints including facial hair restraints, should be worn to cover head and facial hair, if present. The surveyor relayed previous observations from 4/6/25 and 4/8/25 to the Regional FSD who said he understood the concerns relative to kitchen sanitation.

During an interview on 4/9/25 at 3:52 P.M., the [NAME] said hair restraints should be worn to prevent hair from contaminating the food, that the hair restraint should cover all hair and included facial hair. The [NAME] said when items were pulled from the freezer, they should be dated when the item was pulled, covered and have a use by date. The [NAME] said all food items should be labeled and dated. The [NAME] further said

the cranberry sauce observed on 4/6/25 should not have been stored under the tray of raw meat and that the hamburger patties should have been covered and discarded if the use by date was 3/26/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 64 of 68 225766 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225766 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Agawam North Rehab and Nursing 55 Cooper Street Agawam, MA 01001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50563 potential for actual harm Based on observation, interview, and record review, the facility failed to adhere to infection control standards Residents Affected - Few to prevent the transmission of communicable diseases and infections for two Residents (#272 and #30), out of a total sample of 23 residents.

Specifically,

1. For Resident #272, the facility failed to ensure infection control practices were maintained in donning (putting on)Personal Protective Equipment (PPE: items worn to protect from the spread of infection such as a gown or gloves) before administering medication through a [NAME] Catheter (a type of central intravenous line that is inserted through the chest into a larger vein near the heart) placing the Resident at risk for contamination and infection of the [NAME] Catheter.

2. For Resident #30, the facility failed to ensure Contact Precautions were implemented when the Resident was pending labwork for potential transmissible organisms and that facility staff adhered to infection control practices by donning PPE as required, to decrease the risk of potential transmission and exposure of infection.

Findings include:

1. Review of the facility policy titled Hand Washing, revised 10/28/24, indicated the following:

-Handwashing is an integral part of an effective infection control program. Its purpose is to reduce the risk of blood borne illness and prevent cross contamination.

-Hands should be washed before resident care .

Review of the facility policy Enhanced Barrier Precautions, revised 10/28/24, indicated the following:

-Enhanced Barrier Precautions (EBP) is used during high-contact care activities for residents with chronic wounds or indwelling medical device .

-Indwelling medical device: examples include but are not limited to central lines .

Resident #272 was admitted to the facility in April 2025 with diagnoses including acute and subacute infective Endocarditis and Bacteremia.

Review of the Enhanced Barrier Precautions sign posted outside of Resident #272's room indicated:

-Everyone Must: clean their hands, including before entering and when leaving the room.

-Providers and staff must also wear gloves and gown for the following high contact Resident care activities:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 65 of 68 225766 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225766 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Agawam North Rehab and Nursing 55 Cooper Street Agawam, MA 01001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 >Device care use: central line .

Level of Harm - Minimal harm or On 4/8/25 at 10:30 A.M., during an intravenous (IV) medication administration observation by Nurse #4, the potential for actual harm surveyor observed the following:

Residents Affected - Few -Nurse #4 obtained medications from the medication storage room

-Nurse #4 obtained an alcohol preparation pad from inside her medication cart

-Nurse #4 proceeded to Resident #272's room where she donned a gown and gloves without performing hand hygiene and entered the room to complete the medication administration process

-Nurse #4 administered the medication, doffed (removed) her PPE, and performed hand hygiene before exiting the room.

During an interview on 4/8/25 at 10:46 A.M., Nurse #4 said she should have performed hand hygiene before donning her PPE due to the risk of contamination of the [NAME] catheter, but she did not.

During an interview on 4/9/25 at 9:52 A.M., the surveyor reviewed Nurse #4's intravenous medication

observation with the Director of Nursing (DON) and Assistant Director of Nursing/Infection Preventionist (ADON/IP). The ADON/IP said that Nurse #4 should have performed hand hygiene between touching her medication cart and donning PPE. The DON said not performing hand hygiene posed a risk for potential contamination of a central line.

37400

2. Resident #30 was admitted to the facility in September 2023 with diagnoses including Type 2 Diabetes Mellitus with neuropathy and Hemiplegia and Hemipararesis following a Cerebral Infarction affecting the Left Non-Dominant side and Methicillin Resistant Staphylococcus Aureus (MRSA: type of bacteria that could cause a serious infection and was difficult to treat with antibiotics).

Review of the facility policy titled Contact Precautions, revised 10/29/24, indicated Contact Precautions are used to prevent transmission of infectious organisms spread by direct or indirect contact with the patient or

the patient's environment. The policy also included the following:

-Contact Precautions include:

>handwashing .

>glove use .

>gowns .

Review of the Minimum Data Set (MDS) Assessment, dated 2/8/25, indicated the following for Resident #30:

-he/she understood and understands

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 66 of 68 225766 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225766 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Agawam North Rehab and Nursing 55 Cooper Street Agawam, MA 01001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 -was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of a possible 15 points Level of Harm - Minimal harm or potential for actual harm On 4/6/25 at 9:59 A.M., the surveyor observed Resident #30 dressed in shorts and seated in wheelchair in his/her room. The Resident's left lower extremity was observed to be swollen and the calf was pink with Residents Affected - Few peeling skin. Two round quarter-sized areas with yellow centers were observed on the outer and inner middle left calf. During an interview at the time, Resident #30 said the open areas on the outer and inner calf were caused from his/her brace and pointed to a leg brace which was near his/her dresser. Resident #30 said he/she had a dermatology appointment on 4/1/25 for removal of skin tags and the skin doctor also looked at his/her left lower leg.

Review of Resident #30's clinical record included the following:

-Provider Visit Note, dated 3/19/25, indicated Resident #30 had a dermatology appointment on 4/1/25 at 2:00 P.M. for skin tags

-no documented evidence of the Resident's results from the Dermatology Consult on 4/1/25

Review of a Nurse's Note, dated 4/7/25, indicated the dermatology office contacted the facility at 3:50 P.M. to report results from a culture that was obtained from Resident #30 at his/her appointment last week (on 4/1/25) which indicated the Resident was positive for MRSA infection in his/her left lower extremity. The facility requested a copy of the lab results and the on-call Provider was contacted regarding the results and requested the Dermatology Provider write the order for antibiotics and the dermatology office was closed at that time. The on-call Provider gave an order for one time dose of antibiotic and requested the facility staff contact the dermatology office on 4/8/25 to obtain additional orders for antibiotics and wound care treatment orders.

Review of the April 2025 Physician's orders indicated the following:

-Infection Precautions- Contact Isolation: Resident is isolated in room, without a roommate or cohort with like pathogen, due to active infection with transmissible significant pathogens. Above standard transmission precautions maintained, with activities and all services brought to the resident, every shift, initiated 4/7/25

-Bactrim DS (antibiotic) 800-160 milligrams (mg), twice daily for one day pending dermatology recommendations on 4/8/25, initiated 4/7/25

-Doxycycline Monohydrate (antibiotic), 100 mg twice daily for ten days for MRSA infection in left lower leg, initiated 4/8/25

-Wound- left lower leg: cleanse with wound cleanser, xeroform/ABD/rolled gauze daily. Elevate legs as tolerated every day shift, initiated 4/8/25

On 4/8/25 at 10:48 A.M., the surveyor observed the following:

-Contact Precaution signage posted outside of Resident #30's room which indicated to conduct hand hygiene prior to and upon exiting the room and to put on a gown and gloves prior to room entry.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 67 of 68 225766 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225766 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Agawam North Rehab and Nursing 55 Cooper Street Agawam, MA 01001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 -a bin was outside of the Resident's room and did not contain gowns.

Level of Harm - Minimal harm or During an interview at the time, UM #1 said Contact Precautions were put into place for Resident #30 potential for actual harm because he/she had an MRSA infection. UM #1 said she had contacted laundry approximately 20 minutes prior to request more gowns and they have not been provided yet. When the surveyor asked if there were Residents Affected - Few gowns available elsewhere on the unit, UM #1 said she checked the clean utility room and there were none available.

On 4/8/25 at 10:54 A.M. through 11:00 P.M., the surveyor observed the following:

-Housekeeping Staff #1 entered Resident #30's room without a gown. Several minutes later, UM #1 approached the surveyor, who was outside of the Resident's room. UM #1 said Housekeeping Staff #1 should have a gown on when in the Resident's room.

-Rehabilitation Staff entered Resident #30's room with no gown or gloves worn and was observed to exit the room several minutes after, perform hand hygiene and walk down the hallway.

During an interview on 4/8/25 at 11:10 A.M., UM #1 said when a Resident returns from an outside medical appointment, the Nurse would receive the information from the Resident regarding the visit and any instructions that would need to be relayed to the Provider. UM #1 said if a Resident returns without information from an appointment, the facility would contact the outside Provider for information regarding the visit, and she was not sure this was done for Resident #30. UM #1 said she was unaware Resident #30 had

a culture obtained until the dermatology office contacted the facility on 4/7/25.

During an interview on 4/8/25 at 11:54 A.M., and at 1:51 P.M., the DON said Resident #30 had an appointment on 4/1/25 to remove skin tags, but the facility was not aware that a lower extremity skin culture was obtained. The DON said when a Resident had a medical appointment outside of the facility and returns with no information, the facility should contact the outside Provider to obtain information on what transpired at the appointment and this did not occur for Resident #30. The DON said had the facility known a culture of

the Resident's left lower extremity was pending, contact precautions would have been initiated (on 4/1/25) pending the result of the culture. The DON further said he was made aware of the infection control concerns relative to facility staff not donning the appropriate PPE for Resident #30.

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F-F880.

2. Resident #45 was admitted to the facility in April 2024 with diagnoses including Chronic Kidney Disease (CKD), Dementia and heart failure.

Review of the Resident's At Risk for Skin Alteration Care Plan, initiated 4/4/24 indicated Resident #45 was at risk for skin concerns related to possible shearing due to sliding down in bed, impaired mobility and incontinence, and included the following interventions initiated 4/4/25:

- weekly nurse skin review,

- lotion to dry skin, and

- skin checks weekly

Review of the MDS Assessment, dated 3/25/25 indicated the following for Resident #45:

- he/she understands and was understood

- was cognitively intact as evidenced by a BIMS score of 14 out of a possible 15 points.

- required assistance of staff with dressing, toileting and personal hygiene

- was at risk for pressure ulcers and had none at the time of the assessment.

Review of the clinical record indicated no documented evidence that weekly skin checks were performed on

after 1/14/25 until 3/4/25.

On 4/6/25 at 10:16 A.M., the surveyor observed Resident #45 dressed and seated in a wheelchair. A bruise was observed on the top of the Resident's left hand and the Resident's bilateral lower extremities were observed to be swollen and had very dry, flaky skin. During an interview at this time, Resident #45 said the bruise on his/her left top hand was from an intravenous (IV) line from a recent hospitalization . Resident #45 said the edema in his/her lower legs had improved and that staff were supposed to apply lotion to his/her lower extremities daily but this rarely happened because the staff are too busy and running around.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 68 225766 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225766 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Agawam North Rehab and Nursing 55 Cooper Street Agawam, MA 01001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 During an interview, on 4/9/25 at 10:34 A.M., the Assistant Director of Nurses (ADON) said skin checks for all residents were to be performed weekly and the nurses would be completing a head to toe entire body Level of Harm - Minimal harm or assessment weekly to identify any new skin areas or changes. The ADON said this information would be potential for actual harm documented in the resident's electronic medical record. At this time, the surveyor reviewed Resident #45's clinical record with the ADON and she said weekly skin checks should have been completed between Residents Affected - Few 1/14/25 through 3/4/25. The ADON further said Resident #45 was not a person who would refuse care or a skin assessment.

On 4/9/25 at 2:40 P.M., the DON said he was unable to provide documented evidence that weekly skin checks had been performed during the week of 1/21/25, 1/28/25, 2/11/25 and 2/18/25. The DON said monthly skin assessments were completed on 2/2/25 and on 3/2/25 by the nurses and the CNAs observe the Resident's skin during care but the CNA's were not able to assess the Resident's skin.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 68 225766 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225766 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Agawam North Rehab and Nursing 55 Cooper Street Agawam, MA 01001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 51466

Residents Affected - Few Based on observation, interview, and record review, the facility failed to provide care consistent with professional standards of practice to prevent and treat a pressure ulcer (localized damage to the skin and/or Note: The nursing home is underlying soft tissue usually over a bony prominence or related to a medical or other device) and prevent disputing this citation. further skin decline for one Resident (#13), of 5 applicable residents, out of a total sample of 23 residents.

Specifically, for Resident #13, the facility failed to:

-appropriately and timely assess an identified scab of the right heel after a previous wound had healed, when

the Resident was identified as being at high risk for developing pressure ulcers.

-assess the Resident's condition timely after an identified change in condition of the Resident's right heel and surrounding skin was identified by staff, resulting in hospitalization for infection of the right foot that required surgical debridement.

Findings include:

Review of the facility's policy titled Skin Prevention, Assessment and Treatment, revised October 2024, indicated:

-To identify factors that place the residents at risk for the development of pressure ulcers.

-To promote a systematic approach and monitoring process for the care of residents with existing wounds and for those who are at risk for skin breakdown.

-To promote healing of existing pressure ulcers.

-All residents should have their skin integrity examined thoroughly at least weekly by a licensed nurse to identify existing pressure ulcers.

-Certified Nurses Aides (CNAs) should observe skin integrity during the daily provision of routine care and report any impairments to the charge nurse for appropriate follow-up.

-The skin care program will be utilized following the guidelines of the National Pressure Ulcer Advisory Panel and current standards of clinical practice.

-Any skin impairments, including pressure ulcers, non-pressure ulcer wounds, surgical wounds, skin tears, abrasions, etc., should be assessed and documented weekly by the Wound Nurse, or designee in the medical record.

-Upon identification of the development of a wound, the wound assessments/ treatments will be documented

in the medical record and start the Weekly Wound Log.

-If infection is suspected, notify the physician and obtain clinically appropriate orders.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 68 225766 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225766 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Agawam North Rehab and Nursing 55 Cooper Street Agawam, MA 01001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 -Nursing staff should keep the attending physician aware of the progress of all ulcers, especially those in higher-risk residents, those that do not heal as anticipated, and those that develop complications. Level of Harm - Actual harm Resident #13 was admitted to the facility in November 2023, with diagnoses including Paraplegia, Residents Affected - Few Polyneuropathy, Peripheral Vascular Disease (PVD) and Unspecified Dementia.

Note: The nursing home is Review of Resident #13's person-centered Skin Care Plan, initiated 11/30/23, indicated: disputing this citation. -was at risk for skin breakdown related to moisture due to incontinence, impaired mobility, involuntary bilateral lower extremity spasms causing friction, and Dementia.

The Skin Care Plan included the following interventions:

>Weekly Nurse Skin Review, initiated 11/30/23.

>Pay attention to heels, initiated 11/30/23.

>Skin and wound checks weekly, initiated 11/30/23.

>low air mattress, set to Resident's weight, help prevent skin breakdown per patients request for comfort, initiated 7/10/24

Review of the Comprehensive Minimum Data Set (MDS) Assessment, dated 12/7/24, indicated Resident #13:

-had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 4 out of a total of 15 points.

-had Range of Motion (ROM) impairments on both sides of his/her upper and lower extremities.

-was dependent on staff for completion of Activities of Daily Living (ADLS).

-was always incontinent of bowel and bladder.

-was at risk for developing pressure injuries.

-had one Stage 2 Pressure Injury (PI: partial-thickness skin loss with exposed inner layer of skin), that was not present upon admission.

-had diagnoses that included osteomyelitis (bone infection).

Review of Resident #13's Wound Logs, indicated the following:

-2/9/24: right heel Stage 1 pressure injury.

-3/13/24, 4/17/24, 5/29/24: right heel Stage 2 pressure injury

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 68 225766 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225766 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Agawam North Rehab and Nursing 55 Cooper Street Agawam, MA 01001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 -6/20/24, 7/19/24, 8/20/24, 9/23/24, 10/28/24: right heel Stage 3 pressure injury.

Level of Harm - Actual harm Review of the Wound Physician Progress Note, dated 11/18/24, indicated Resident #13:

Residents Affected - Few -right heel pressure injury was healed.

Note: The nursing home is -recommendation to start Skin prep (liquid film-forming treatment that forms a protective film on the skin) to disputing this citation. the right heel.

Review of Weekly Skin Checks, documented on 12/5/24 and 1/25/25, indicated Resident #13 had a scabbed area over a wound on the right heel.

Review of Resident #13's medical record failed to indicate any evidence that the scabbed area identified on 12/5/24 and 1/25/25 were reported to the Physician and/or Wound Physician or assessed as a newly identified skin issue.

Further review of Resident #13's medical record failed to indicate any updated care planning relative to the scabbed right heel area identified on 12/5/24 and 1/25/25.

Review of Resident #13's Treatment Administration Record (TAR) for November 2024, December 2024, January 2025, February 2025, and March 2025 indicated that Skin Prep was applied as ordered from 11/23/24 to 3/26/25.

Review of the Resident's Wound Care Specialist's Progress Note, dated 3/24/25, indicated the Resident was examined for a wound located on the left ischium (lower back part of the hip bone).

Further review of the Wound Care Specialist's Progress Note failed to indicate any evidence that the Wound Care Physician examined the Resident's right heel during the 3/24/25 visit.

Review of Physician Assistant (PA) #1's Progress Note dated 3/25/25, indicated Resident #13:

-had right heel redness, and right foot/ankle swelling

-was started on an antibiotic for suspicion of cellulitis (skin infection)

-had a history of recurrent wounds on bilateral heels

-had a history of osteomyelitis

-had Nurses applying skin prep to prevent opening of right heel

-right heel had a scab present centrally

Review of the Nursing Progress Note dated 3/26/25, indicated Resident #13:

-developed a body temperature of 101.9 degrees

-redness to the right heel.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 68 225766 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225766 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Agawam North Rehab and Nursing 55 Cooper Street Agawam, MA 01001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 -had an x-ray ordered and was pending.

Level of Harm - Actual harm Review of the Nursing SBAR Note, dated 3/27/25, indicated Resident #13:

Residents Affected - Few -needed to be evaluated at the hospital for increased body temperature.

Note: The nursing home is -increased pain and redness to the right foot with swelling. disputing this citation. -right heel scab had turned red/black in color.

-x-ray showed possible osteomyelitis which the Resident had in the past.

Review of the Provider (Physician Assistant [PA] #1) Progress Note, dated 3/27/25, indicated Resident #13:

-had redness of the right foot that was darkening and turning black.

-x-ray of the right heel revealed findings suspicious for calcaneal osteomyelitis.

-had worsening wound appearance, fever and concern for osteomyelitis, and the decision was made to transfer Resident #13 to the emergency room (ER).

Review of the Physician Progress Note, dated 4/3/25, indicated Resident #13:

-returned from a hospitalization after being transferred to the hospital from the facility for evaluation of worsening right heel/abscess/cellulitis.

-was given IV (intravenous) antibiotics (medications used to treat infection) in the hospital.

-had an incision and drainage of the right heel while hospitalized that resulted in [NAME] pus drainage.

-it was recommended that the Resident have an above the knee amputation.

-condition was discussed with the Resident Representative who opted for Hospice care.

-hospital diagnoses included abscess of the right heel, sepsis (life threatening emergency when the body has

an extreme response to an infection), cellulitis, and osteomyelitis.

During an interview on 4/8/25 at 1:08 P.M., Resident Representative (RR) #1 said the Resident's right heel wound developed in the facility. RR #1 said he/she was very upset that the wound deteriorated. RR #1 said

during the hospitalization when told the Resident needed to have an amputation, he/she did not think the Resident could tolerate an amputation and made the decision to consider Hospice care to be initiated for the Resident.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225766 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Agawam North Rehab and Nursing 55 Cooper Street Agawam, MA 01001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 During an interview on 4/9/25 at 8:35 A.M., CNA #6 said Resident #13 had a right heel wound that healed several months ago and the Nurses started applying skin prep on the right heel. CNA #6 said the Resident's Level of Harm - Actual harm healed right heel wound was a scabbed area measuring approximately one and a half inches in diameter. CNA #6 said Resident #13's right heel was scabbed, flat to the skin level and had a black spot in the center Residents Affected - Few of the scab that was half the size of the scab that never went away. CNA #6 said the black area was surrounded by white skin and had been present since the time the right heel was said to be healed. CNA #6 Note: The nursing home is said at one point the Resident's right heel became swollen, red and looked worse and the Resident was sent disputing this citation. to the hospital in March 2025.

During an interview on 4/9/25 at 8:41 A.M., CNA #7 said on 3/23/25, she and CNA #8 observed Resident #13's right heel and foot to be swollen and had a new black area surrounding the original scabbed area on

the right heel. CNA #7 said she told the Resident's Nurse at that time who was the Assistant Director of Nurses [ADON], and Nurse #5 (who was being trained by the ADON). CNA #7 said both Nurses assessed

the Resident's right foot and heel on 3/23/25 and said that since the Resident's foot was not hot, instructed CNA #7 to leave the Resident's heel/foot alone at that time.

During an interview on 4/9/25 at 10:18 A.M., CNA #8 said that while working on 3/23/25, she and CNA #7 identified that the Resident had right foot swelling and redness, and that the Resident's right heel wound looked different. CNA #8 said she had also noticed the Resident was acting differently and was quiet, which was not the Resident's usual behavior. CNA #8 said both she and CNA #7 were concerned, and CNA #7 reported the concern about the Resident's change in condition to Nurse #5 and the ADON.

During an interview on 4/9/25 at 10:50 A.M., the ADON said she had worked on 3/23/25 from 7:00 A.M. to 7:00 P.M., but did not recall hearing anything about Resident 13's change in condition relative to his/her right heel. The ADON said she may have been unable to recall hearing anything because she had worked 27 hours that weekend, after working her regular 40-hour schedule, due to a staffing shortage. The ADON said if there was any change in the Resident's condition the Resident's Physician should have been notified right away. The ADON said she could not recall notifying the Resident's Physician about a change in the Resident's condition on 3/23/25.

Review of Resident #13's medical record failed to indicate any evidence that the Resident's right heel wound was assessed on 3/23/25 and that a Provider was notified of the right foot/ heel redness, swelling and changes to the right heel wound.

On 4/9/25 at 11:08 A.M., the surveyor with Nurse #6 observed Resident #13's right heel wound was open and had a deep pink wound base mixed with slough (yellow non-viable tissue) at the base. The surveyor further observed there was scant (minimal) light pink drainage present. During an interview at the time, Nurse #6 said the Resident's heel wound had been surgically debrided (removal of dead/ infected skin tissue to help heal a wound) while he/she was in the hospital.

During an interview on 4/9/25 at 1:02 P.M., Nurse #5 said she had worked on 3/23/25 on the 7:00 A.M. to 3:00 P.M. shift. Nurse #5 said the CNA's had reported that Resident #13's right heel had increased redness. Nurse #5 said that she was unable to recall if the change in condition to the Resident's right heel had been reported to the Provider, but believed the ADON was reporting the change. Nurse #5 said she had worked

the following day (on 3/24/25) and Resident #13 was not assigned to her but recalled hearing that the Resident's right heel had worsened. Nurse #5 said the Resident was sent to the hospital on 3/27/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 68 225766 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225766 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Agawam North Rehab and Nursing 55 Cooper Street Agawam, MA 01001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 During an interview on 4/9/25 at 12:56 P.M, with Physician Assistant's (PA) #1 and #2, PA #1 said she was first notified of the Resident's right heel wound worsening on 3/25/25 and evaluated the Resident on 3/25/25. Level of Harm - Actual harm PA #1 said she was not made aware that the Resident's right heel wound had worsened on 3/23/25 (two days prior) and should have been made aware on that day when the facility staff noticed a change. PA #2 Residents Affected - Few reviewed the Provider Triage Notes in the Provider portal and said that nothing had been reported to any Providers relative to a change in condition for Resident #13 on 3/23/25. PA #2 said if the facility staff had Note: The nursing home is contacted any Provider on 3/23/25, the communication would have been present in the Provider portal disputing this citation. system and the Provider would have made new recommendations at that time or recommended a hospital transfer.

During an interview on 4/9/25 at 2:52 P.M., the Director of Nursing (DON) said that if a Resident has a change in condition such as a worsening wound, the change in condition should be reported to the Resident's Provider that same shift or sooner if emergent. The DON said when the Wound Physician identifies a wound was healed, that meant the wound was completely healed, but if staff notice a change to

an area such as a scab, then the scab should be reported to the Physician and the Wound Physician. The DON said the facility staff should monitor the scab as an active wound and conduct weekly skin checks. The DON said a scab like appearance to skin is not considered healed and should be monitored. The DON said when nursing staff identified a new scabbed area on 12/5/24, it should have been reported to a Physician and monitored weekly with the Wound Physician. The DON said Resident #13 was very high risk for infection due to a history of wounds and infections. The DON said any change to the Resident's right heel wound, or foot should have been reported immediately. The DON said that not reporting increased redness, swelling or

a change in wound condition would put Resident #13 at a higher risk for developing a serious infection.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 68 225766 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225766 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Agawam North Rehab and Nursing 55 Cooper Street Agawam, MA 01001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm 37400

Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure one Resident (#45) out of a total sample of 23 residents, was provided assistance as required to prevent falls.

Specifically, for Resident #45, the facility failed to provide assistance of two staff with transferring resulting in

the Resident sustaining a fall with assistance of one staff for a transfer from wheelchair to bed.

Findings include:

Review of the facility policy titled Accidents and Incident Investigation, dated 11/15/15, indicated the purpose was to ensure all accidents, incidents and allegations of abuse involving residents, visitors, or employees are investigated and reported to the facility administration. The policy also included the following:

-an employee witnessing an accident, incident or abuse involving a resident, visitor,or employee shall report such occurrence as soon as practical. The victim of an accident or incident should not be left unattended to summons help unless absolutely necessary.

-the assigned nurse or nursing supervisor shall complete an assessment and provide medical interventions as warranted.

-the assigned nurse or nursing supervisor shall:

>examine all accident, incident or abused victims

>notify the attending physician or medical director of the occurrence

>follow the physician orders and instructions for rendering care

>designate an employee to accompany the victim if necessary

>minor injuries shall be treated per facility protocol

>investigative action shall be initiated by the attending nurse and/or nursing supervisor . and forwarded to

the Director of Nurses (DON), or designee

>the administrative staff shall complete the investigation .

>complete the Incident/Event Investigation form or the Investigation Follow-up form including specifics as indicated, such as:

a. date, time and location of the accident/event .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 68 225766 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225766 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Agawam North Rehab and Nursing 55 Cooper Street Agawam, MA 01001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 b. nature of the injury .

Level of Harm - Minimal harm or c. circumstances surrounding the occurrence potential for actual harm d. name(s) of witness(s) and their account of the occurrence- account should be conducted by an in-person Residents Affected - Few or phone interview

e. the injured person's account of the occurrence, if they are able to convey the information

f. date and time the physician/responsible party notification

g. condition of the resident- including vital signs

h. disposition of the resident .

i. corrective action taken

j. documentation in medical record completed, recorded on the 24 hour report

k. care plan updated if indicated

l. follow up information-such as 72 hour assessment and charting .

m. other pertinent data

n. signature and title of the person completing the form.

Resident #45 was admitted to the facility in April 2024 with diagnoses including Osteoporosis, Parkinson's Disease, dizziness and giddiness, difficulty walking and unsteadiness on feet and Hypotension.

Review of the Activities of Daily Living (ADL) Care Plan initiated 4/4/24, indicated Resident #45 had an alteration in ability to care for him/herself and required assistance.

The ADL Care Plan included the following interventions:

-wheelchair with supervision, initiated 4/7/25.

-required mechanical lift with assistance of two staff with transfers, initiated 4/4/24.

Review of the Falls Care Plan initiated 5/7/24, indicated the Resident was at risk for falls and included the following interventions:

-follow facility fall protocol initiated 5/7/24.

Review of the Nursing Progress Note dated 4/5/25, indicated the following relative to Resident #45:

-was lowered to the floor during a transfer from the wheelchair to the bed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 68 225766 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225766 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Agawam North Rehab and Nursing 55 Cooper Street Agawam, MA 01001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 -said his/her legs gave out and was lowered to the floor by the CNA who was assisting him/her.

Level of Harm - Minimal harm or -was in stable condition and vital signs were stable. potential for actual harm -reported no pain to the Nurse and no injuries were sustained. Residents Affected - Few

Review of the Certified Nurses Aide (CNA) Care Card on 4/7/25 at 12:03 P.M., indicated the following:

-Resident #45 transfers with assistance of two staff with mechanical lift.

On 4/6/25 at 10:16 A.M., the surveyor observed Resident #45 dressed and seated in a wheelchair in the common room located on the unit. During an interview at the time, Resident #45 said he/she had a fall last night (4/5/25) because there were not enough staff to assist in transferring him/her from the wheelchair to the bed. Resident #45 said one CNA assisted him/her and two staff were supposed to assist with transfers. Resident #45 said four to five staff had to assist him/her off the floor and to the bed. Resident #45 said his/her elbow hurt from the fall.

Review of the facility schedule on 4/5/25 for the 3:00 P.M. to 11:00 P.M. shift on Resident #45's unit indicated two CNAs were scheduled.

On 4/7/25 at 1:55 P.M., the surveyor requested the fall investigation for Resident #45 on 4/5/25, from Unit Manager (UM) #1.

On 4/7/25 at 2:18 P.M., the Director of Nursing (DON) said they were unable to locate a completed fall investigation on 4/5/25 for Resident #45. The DON said the facility had a fall protocol and risk assessment that should be completed when a Resident falls. The DON further said that staff statements would be obtained at the time of the fall and that Resident falls were reviewed in the morning meeting.

During an interview on 4/7/25 at 2:46 P.M., CNA #1 and CNA #2 said Resident #45 was one assist of staff with transfers from the wheelchair to the bed, but sometimes he/she needed assistance of two staff because of fatigue. When the surveyor asked how the CNA's would know how much assistance the Resident would need at any given time, CNA #1 and CNA #2 said they were regular staff, knew the residents and knew what

they needed. CNA #1 and CNA #2 said the specific resident care information was available in the computer. CNA #1 said Resident #45 had a recent fall on the 3:00 P.M. to 11: 00 P.M. shift during a transfer and the Resident was lowered to the floor. Both CNA #1 and CNA #2 said they were unaware of any changes to the Resident's plan of care after his/her recent fall.

During an interview on 4/7/25 at 2:57 P.M., Nurse #1 said she worked on the 3:00 P.M. to 11:00 P.M. shift on 4/5/25 when Resident #45 fell . Nurse #1 said the Resident was lowered to the floor by the CNA. Nurse #1 said that she had not completed a fall investigation for this incident and should have.

During an interview on 4/7/25 at 3:29 P.M., UM #1 said a fall investigation for Resident #45 was not completed on 4/5/25 and they were currently completing one.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 68 225766 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225766 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Agawam North Rehab and Nursing 55 Cooper Street Agawam, MA 01001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 During an interview on 4/7/25 at 3:44 P.M., the DON and Assistant Director of Nurses (ADON) said there was no fall investigation completed for Resident #45 on 4/5/25. The DON said at a minimum, the Resident's Level of Harm - Minimal harm or care plan should have been adjusted but it was not adjusted until today (4/7/25). The DON said the potential for actual harm Resident's care plan indicated he/she required assistance of two staff with transfers and the Resident had assistance of one staff when the fall occurred on 4/5/25. Residents Affected - Few

During an interview on 4/7/25 at 3:55 P.M., CNA #5 said she worked on the 3:00 P.M. to 11:00 P.M. shift on 4/5/25, and was present when Resident #45 fell . CNA #5 said she had worked with Resident #45 previously

on the 7:00 A.M. to 3:00 P.M. shift and that the Resident usually required assistance from one staff for transfers during that shift. CNA #5 said she received a verbal report from the CNAs on the care needs of residents when she worked and said that it could be difficult to get information that was needed for resident care because when staff were asked, sometimes they did not know. CNA #5 said after Resident #45 fell ,

she was told by the 3:00 P.M. to 11:00 P.M. staff that the Resident required assistance of two staff with transfers on that shift. CNA #5 said that prior to the Resident's fall, she was unaware of this information.

During an interview on 4/7/25 at 4:00 P.M., the Director of Rehabilitation (DOR) said staff should have provided assistance of two staff for all transfers for Resident #45.

Please refer to