A list of the most recent deficiencies for Agawam East 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? |
|---|---|---|---|---|
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-11-01 | 2023-12-08 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2023-11-01 | 2023-12-08 | N |
| Develop a communication plan. | Fire Safety | 2023-11-01 | 2023-12-08 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-11-01 | 2023-12-08 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-11-01 | 2023-12-08 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-11-01 | 2023-12-08 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-11-01 | 2023-12-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-11-01 | 2023-12-08 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-10-17 | 2023-12-06 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-10-17 | 2023-12-06 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-10-17 | 2023-12-06 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-10-17 | 2023-12-06 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-10-17 | 2023-12-06 | N |
| Provide activities to meet all resident's needs. | Health | 2023-10-17 | 2023-12-06 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-10-17 | 2023-12-06 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-10-17 | 2023-12-06 | 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 | 2023-10-17 | 2023-12-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-25 | 2023-02-10 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-01-25 | 2023-02-10 | N |
| Perform COVID19 testing on residents and staff. | Health | 2023-01-25 | 2023-02-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-04-19 | 2022-05-27 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-04-19 | 2022-05-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-19 | 2022-05-27 | N |
| 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. | Health | 2022-04-19 | 2022-05-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-04-19 | 2022-05-27 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-04-26 | 2022-05-10 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-04-28 | 2021-06-12 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2021-04-28 | 2021-06-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-04-28 | 2021-06-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-04-28 | 2021-06-12 | 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 | 2021-04-21 | 2021-06-05 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-04-21 | 2021-06-05 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-04-21 | 2021-06-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-04-21 | 2021-06-05 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-04-21 | 2021-06-05 | 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 | 2021-04-21 | 2021-06-05 | 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 | 2021-04-21 | 2021-06-05 | 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 | 2021-04-21 | 2021-06-05 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-04-21 | 2021-06-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-21 | 2021-06-05 | N |
