Agawam East Rehab and Nursing

In the surveyor’s words

From the most serious findings on record at Agawam East Rehab and Nursing, in the surveyor’s own words.

• Actual harm, isolatedF656Apr 19, 2022

  Based on record review and staff interviews, the facility failed to ensure for one Resident (#294), who was assessed to be at high risk for falls and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE], Resident #294, whose plan of care identified that he/she required extensive assistance to total assistance of one staff person with toileting, was observed by staff to be unattended while on the toilet, but staff failed to intervene or offer the necessary assistance. […]

• Actual harm, isolatedF658Apr 19, 2022

  Based on record review and interviews, the facility failed to ensure services provided by nursing met professional standards of practice for one Resident (#294), who had fallen and nursing staff physically transferred the resident without fully evaluating and assessing the resident for potential injury. On [DATE], Resident #294 sustained an unwitnessed fall off the toilet and was found on the floor by staff. Nursing staff, without first completing a thorough assessment and evaluation of Resident #294 to determine the extent of injury but having noted a lower extremity deformity and unable to straighten the lower extremity, physically lifted Resident #294 off the floor into a chair and then transferred him/her into bed. […]

• Actual harm, isolatedF689Apr 19, 2022

  Based on record review and interviews, the facility failed to ensure Resident #294 was toileted to maintain his/her safety. On [DATE] Resident #294, who required extensive assistance from staff with toileting needs, was observed by staff to be unattended in the bathroom and staff did not intervene or offer assistance. Resident #294 sustained an unwitnessed fall from the toilet, resulting in multiple fractures including a comminuted (broken ends of the bone are shattered into many pieces) impacted (broken ends of the bone are jammed together by the force of the injury) left femoral intertrochanteric (hip) fracture, acute fracture through the right superior and inferior pubic ramus (hip bones) along with vertically oriented insufficiency fracture through the right sacral area (fracture of… […]

• No harm, potential for more than minimal, patternF628Nov 25, 2025

  Based on records reviewed and interviews for three of three sampled residents (Resident #1, #2, and #3), the facility failed to ensure that a copy of their transfer discharge notifications were provided to the Office of the State Long Term Care Ombudsman, as required.Findings include:During a telephone interview on 11/21/25 at 11:58 A.M., the Ombudsman said the Facility has not provided copies of discharge and transfer notices to her office in several months. Specifically, the Ombudsman said she has not received any discharge notices since March 2025 and said she has not received any transfer notices since August 2025. […]

• No harm, potential for more than minimal, patternF677Dec 16, 2024

  Based on observation, interview, and record review, the facility failed to ensure that activities of daily living (ADLs) were performed for one Resident (#4) out of a total sample of 19 residents. Specifically, the facility failed to provide assistance with removing facial hair for Resident #4, when the Resident was dependent on staff for grooming care and needs. Findings include: Resident #4 was admitted to the facility in September 2021, with diagnoses including Unspecified Dementia and Depression. Review of the facility's policy titled Activities of Daily Living (ADL), effective 1/2024 indicated: -Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. […]