Cycle 1
Health 2024-11-26 · Fire 2024-11-26
14 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Agawam, MA
Agawam South Rehab And Nursing
4-star overall rating with 3-star inspections with 14 recent health deficiencies
65 Cooper Street, Agawam, MA
(413) 786-8000
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
122
Certified beds
Average residents
85
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Stern Consultants
Operator or chain grouping
Approved since
1969-03-04
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
22 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.79
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.77
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.33
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
3.89
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.56
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.46
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.62
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.74
CMS adjusted RN staffing hours
Adjusted total hours
3.63
CMS adjusted total nurse staffing hours
Case-mix index
1.47
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,254
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
40.67
Composite VBP score used to determine payment impact.
Payment multiplier
0.9936
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.80
Baseline 20.24% · Performance 21.06% · Measure score 0.80 · Achievement 0.80 · Improvement 0
Healthcare-associated infections
8.79
Baseline 7.55% · Performance 5.21% · Measure score 8.79 · Achievement 8.79 · Improvement 8.66
Total nurse turnover
5.69
Baseline 54.41% · Performance 40.43% · Measure score 5.69 · Achievement 5.69 · Improvement 4.23
Adjusted total nurse staffing
0.99
Baseline 3.60 hours · Performance 3.36 hours · Measure score 0.99 · Achievement 0.99 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.99% |
10.72%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 182 · Observed rate 15.38% · Lower 95% interval 9.01% |
| Discharge to community | 51.11% |
50.57%
0.5 pts better
|
No Different than the National Rate · Eligible stays 177 · Observed rate 42.94% · Lower 95% interval 43.69% |
| Medicare spending per beneficiary | 0.93 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 99.12% |
95.27%
3.9 pts better
|
Numerator 112 · Denominator 113 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 113 |
| Discharge self-care score | 58.82% |
53.69%
5.1 pts better
|
Numerator 40 · Denominator 68 |
| Discharge mobility score | 54.41% |
50.94%
3.5 pts better
|
Numerator 37 · Denominator 68 |
| Pressure ulcers or injuries, new or worsened | 3.54% |
2.29%
1.2 pts worse
|
Numerator 4 · Denominator 113 · Adjusted rate 2.89% |
| Healthcare-associated infections requiring hospitalization | 5.21% |
7.12%
1.9 pts better
|
No Different than the National Rate · Eligible stays 134 · Observed rate 2.99% · Lower 95% interval 2.81% |
| Staff COVID-19 vaccination coverage | 2.65% |
8.2%
5.5 pts worse
|
Numerator 3 · Denominator 113 |
| Staff flu vaccination coverage | 83.81% |
42%
41.8 pts better
|
Numerator 88 · Denominator 105 |
| Discharge function score | 61.76% |
56.45%
5.3 pts better
|
Numerator 42 · Denominator 68 |
| Transfer of health information to provider | 97.62% |
95.95%
1.7 pts better
|
Numerator 41 · Denominator 42 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 47 · Denominator 47 |
| Resident COVID-19 vaccinations up to date | 9.38% |
25.2%
15.8 pts worse
|
Numerator 6 · Denominator 64 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.9
0.8 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.2 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.5
0.7 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.8 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.6% |
92.2%
1.4 pts better
|
93.4%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 83.6% · Q2 95.0% · Q3 100.0% · Q4 96.8% · 4Q avg 93.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.8%
5.2 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.5%
3.5 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.0% |
12.0%
7 pts better
|
11.4%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 6.0% · Q3 0.0% · Q4 4.3% · 4Q avg 5.0% |
| Percentage of long-stay residents who lose too much weight | 9.6% |
5.2%
4.4 pts worse
|
5.4%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 7.8% · Q3 12.7% · Q4 12.3% · 4Q avg 9.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.4% |
19.2%
8.8 pts better
|
19.6%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 7.7% · Q3 10.9% · Q4 13.8% · 4Q avg 10.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.9% |
22.5%
8.6 pts better
|
16.7%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.8% · Q2 13.2% · Q3 11.4% · Q4 12.8% · 4Q avg 13.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 15.7% |
17.7%
2 pts better
|
16.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 22.9% · Q3 18.7% · Q4 14.3% · 4Q avg 15.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.1% |
17.6%
4.5 pts better
|
14.9%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 17.4% · Q3 16.0% · Q4 11.3% · 4Q avg 13.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
1.0%
0.6 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.4% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
2.0%
1.6 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.7% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.4% |
21.7%
9.7 pts worse
|
19.8%
11.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.2% · Q2 25.6% · Q3 31.6% · Q4 42.1% · 4Q avg 31.4% |
| Percentage of long-stay residents with pressure ulcers | 5.0% |
4.6%
0.4 pts worse
|
5.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 2.7% · Q3 5.4% · Q4 7.3% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 76.0% |
77.1%
1.1 pts worse
|
81.7%
5.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 71.6% · Q2 82.2% · Q3 82.7% · Q4 66.9% · 4Q avg 76.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.7% |
11.8%
6.1 pts better
|
12.0%
6.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.7% · Observed 6.1% · Expected 11.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.3%
0.4 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.8% · Q3 0.8% · Q4 0.9% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 84.6% |
77.7%
6.9 pts better
|
79.7%
4.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 84.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.9% |
25.8%
3.9 pts better
|
23.9%
2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.9% · Observed 26.3% · Expected 28.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-10 · Fire 2023-10-10
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-04-14 · Fire 2022-04-14
13 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2022-04-14
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2022-05-06
E · Potential for more than minimal harm
2022-04-14
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2022-05-06
E · Potential for more than minimal harm
2022-04-14
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-05-06
E · Potential for more than minimal harm
2022-04-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-05-06
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-04-23
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-04-23
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-05-16
E · Potential for more than minimal harm
2024-11-26
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-12-16
E · Potential for more than minimal harm
2024-11-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-16
D · Potential for more than minimal harm
2024-11-26
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2024-12-16
D · Potential for more than minimal harm
2024-11-26
F646 · Resident Assessment and Care Planning Deficiencies
Health
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Corrected 2024-12-16
D · Potential for more than minimal harm
2024-11-26
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-12-16
D · Potential for more than minimal harm
2024-11-26
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-12-16
D · Potential for more than minimal harm
2024-11-26
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-12-16
D · Potential for more than minimal harm
2024-11-26
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-12-16
D · Potential for more than minimal harm
2024-11-26
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-12-16
D · Potential for more than minimal harm
2024-11-26
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-12-16
D · Potential for more than minimal harm
2024-11-26
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2024-12-16
D · Potential for more than minimal harm
2024-11-26
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2024-12-16
F · Potential for more than minimal harm
2023-10-10
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-11-24
D · Potential for more than minimal harm
2023-10-10
F559 · Resident Rights Deficiencies
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2023-11-24
D · Potential for more than minimal harm
2023-10-10
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-11-24
D · Potential for more than minimal harm
2023-10-10
F691 · Quality of Life and Care Deficiencies
Health
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Corrected 2023-11-24
D · Potential for more than minimal harm
2023-10-10
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-11-24
D · Potential for more than minimal harm
2023-10-10
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-11-24
D · Potential for more than minimal harm
2023-10-10
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-11-24
D · Potential for more than minimal harm
2023-10-10
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2023-11-24
E · Potential for more than minimal harm
2022-04-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-06-17
D · Potential for more than minimal harm
2022-04-14
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2022-06-17
D · Potential for more than minimal harm
2022-04-14
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2022-06-17
D · Potential for more than minimal harm
2022-04-14
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-06-17
D · Potential for more than minimal harm
2022-04-14
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2022-06-17
D · Potential for more than minimal harm
2022-04-14
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-06-17
D · Potential for more than minimal harm
2022-04-14
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2022-06-17
D · Potential for more than minimal harm
2022-04-14
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-06-17
D · Potential for more than minimal harm
2022-04-14
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-06-17
D · Potential for more than minimal harm
2022-04-14
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-06-17
D · Potential for more than minimal harm
2022-04-14
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2022-06-17
D · Potential for more than minimal harm
2022-04-14
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-06-17
D · Potential for more than minimal harm
2022-04-14
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2022-06-17
Penalties and ownership
What sits behind the stars
Ownership
Etn Family Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Tlco Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Sheps, Boruch
5% Or Greater Direct Ownership Interest · Individual
Erblich, Avraham
5% Or Greater Direct Ownership Interest · Individual
Friedman, Shana
5% Or Greater Direct Ownership Interest · Individual
Com Family Trust
5% Or Greater Indirect Ownership Interest · Organization
E Newhouse Family Trust
5% Or Greater Indirect Ownership Interest · Organization
T Newhouse Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Tlm Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Stern, Bezalel
5% Or Greater Direct Ownership Interest · Individual
Ashkar, Rami
Operational/Managerial Control · Individual
Beatty, Brittany
Operational/Managerial Control · Individual
Erblich, Avraham
Operational/Managerial Control · Individual
Etn Family Holdings LLC
Operational/Managerial Control · Organization
Friedman, Benjamin
Operational/Managerial Control · Individual
Millman, Chaim
Operational/Managerial Control · Individual
Millman, Chaim
Corporate Officer · Individual
Newhouse, Eric
Operational/Managerial Control · Individual
Plew, Andrea
Operational/Managerial Control · Individual
Sheps, Boruch
Operational/Managerial Control · Individual
Stern Therapy Consultants LLC
Operational/Managerial Control · Organization
Subira, Marta
Operational/Managerial Control · Individual
Tlco Holdings LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Agawam West Rehab And Nursing
Agawam, MA
2-star overall rating with 2-star inspections with $12,735 in total fines with 10 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Agawam North Rehab And Nursing
Agawam, MA
2-star overall rating with 1-star inspections with $86,130 in total fines with 16 recent health deficiencies
#3
Agawam East Rehab And Nursing
Agawam, MA
3-star overall rating with 3-star inspections with 8 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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