A list of the most recent deficiencies for Agawam West Rehab and Nursing. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-04 | 2023-06-16 | N |
| Have proper openings in smoke barrier doors. | Fire Safety | 2023-05-04 | 2023-06-15 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-04-26 | 2023-06-06 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-04-26 | 2023-06-06 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-04-26 | 2023-06-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-26 | 2023-06-06 | N |
| Provide activities to meet all resident's needs. | Health | 2023-04-26 | 2023-06-06 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-04-26 | 2023-06-06 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-04-26 | 2023-06-06 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-04-26 | 2023-06-06 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-04-26 | 2023-06-06 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-04-26 | 2023-06-06 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-01-17 | 2023-02-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-06-03 | 2021-06-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-06-02 | 2021-06-25 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-06-02 | 2021-06-24 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-05-03 | 2021-06-16 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-05-03 | 2021-06-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-05-03 | 2021-06-16 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2021-05-03 | 2021-06-16 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-05-03 | 2021-06-16 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-05-03 | 2021-06-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-05-03 | 2021-06-16 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-05-03 | 2021-06-16 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-06-19 | 2019-07-26 | N |
| 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. | Health | 2019-06-06 | 2019-07-20 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-06-06 | 2019-07-20 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-06-06 | 2019-07-20 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-06-06 | 2019-07-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-06-06 | 2019-07-20 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-06-06 | 2019-07-20 | N |
| Provide activities to meet all resident's needs. | Health | 2019-06-06 | 2019-07-20 | N |
| Provide appropriate foot care. | Health | 2019-06-06 | 2019-07-20 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-06-06 | 2019-07-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-06-06 | 2019-07-20 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-06-06 | 2019-07-20 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2019-06-06 | 2019-07-20 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2019-06-06 | 2019-07-20 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-06-06 | 2019-07-20 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-06-06 | 2019-07-20 | N |
| Provide or obtain dental services for each resident. | Health | 2019-06-06 | 2019-07-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-06-06 | 2019-07-20 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-06-06 | 2019-07-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-06-06 | 2019-07-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-19 | 2019-07-05 | N |
