When inspectors observed her on September 2, bandages covered her amputation site.
Nursing Home News — Page 353
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The confusion at Agawam East Rehab and Nursing emerged during a September federal inspection that found systematic gaps in care documentation.
He requires complete assistance with transfers and toileting, and needs help with showers.
Resident 3 was moved from his room on August 8, 2025, and again on August 28, 2025, without proper notification or consent documentation at The Earlwood.
After leaving those contaminated rooms, CNA H proceeded directly to resident 11's room to deliver food.
The worker had been touching meal tickets and using serving ladles before handling the rolls without gloves or utensils.
Pauls Health Care Center told investigators this was his "routine practice" with residents he considered heavy wetters.
The incident began Monday when a certified nursing assistant noticed swelling in Resident 1's wrist and reported it to Licensed Vocational Nurse H.
Resident 1 had been dealing with a pulmonary embolism when a medical provider visited on July 11, 2025.
Resident #11 remained in his wheelchair wearing gray sweatpants that were "visibly wet in the front" from 3:10 p.m.
The breakdown occurred at multiple levels.
The violation occurred despite facility policies requiring staff to place the devices where bedridden residents could easily access them.