Cycle 1
Health 2025-09-15 · Fire 2025-09-15
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Agawam, MA
Agawam West Rehab And Nursing
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
61 Cooper Street, Agawam, MA
(413) 786-8000
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
164
Certified beds
Average residents
117
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Stern Consultants
Operator or chain grouping
Approved since
1976-05-01
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
0.57
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.87
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.25
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
3.69
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.43
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.13
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.36
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.54
CMS adjusted RN staffing hours
Adjusted total hours
3.54
CMS adjusted total nurse staffing hours
Case-mix index
1.43
Higher values indicate more complex resident acuity
RN turnover
44%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
35%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,475
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
32.71
Composite VBP score used to determine payment impact.
Payment multiplier
0.9873
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.84
Baseline 20.10% · Performance 18.72% · Measure score 5.84 · Achievement 5.84 · Improvement 3.99
Healthcare-associated infections
1.05
Baseline 5.55% · Performance 7.52% · Measure score 1.05 · Achievement 1.05 · Improvement 0
Total nurse turnover
5.30
Baseline 45.08% · Performance 42.03% · Measure score 5.30 · Achievement 5.30 · Improvement 1.01
Adjusted total nurse staffing
0.89
Baseline 3.23 hours · Performance 3.33 hours · Measure score 0.89 · Achievement 0.89 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.03% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 106 · Observed rate 11.32% · Lower 95% interval 8.24% |
| Discharge to community | 49.6% |
50.57%
1 pts worse
|
No Different than the National Rate · Eligible stays 70 · Observed rate 44.29% · Lower 95% interval 38.14% |
| Medicare spending per beneficiary | 0.81 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 73 · Denominator 73 |
| Falls with major injury | 2.74% |
0.77%
2 pts worse
|
Numerator 2 · Denominator 73 |
| Discharge self-care score | 25% |
53.69%
28.7 pts worse
|
Numerator 14 · Denominator 56 |
| Discharge mobility score | 32.14% |
50.94%
18.8 pts worse
|
Numerator 18 · Denominator 56 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 73 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.52% |
7.12%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 78 · Observed rate 7.69% · Lower 95% interval 4.72% |
| Staff COVID-19 vaccination coverage | 1.29% |
8.2%
6.9 pts worse
|
Numerator 2 · Denominator 155 |
| Staff flu vaccination coverage | 35.22% |
42%
6.8 pts worse
|
Numerator 56 · Denominator 159 |
| Discharge function score | 32.14% |
56.45%
24.3 pts worse
|
Numerator 18 · Denominator 56 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 38 · Denominator 38 |
| Resident COVID-19 vaccinations up to date | 25% |
25.2%
0.2 pts worse
|
Numerator 8 · Denominator 32 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.9
0.3 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.7 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.5
0.5 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.1 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.1% |
92.2%
4.9 pts better
|
93.4%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.0% · Q2 95.2% · Q3 97.2% · Q4 100.0% · 4Q avg 97.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.5% |
94.8%
0.3 pts worse
|
95.5%
1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.9% |
3.5%
1.6 pts better
|
3.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 1.9% · Q3 1.9% · Q4 2.9% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.4% |
12.0%
10.6 pts better
|
11.4%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 1.1% · Q3 2.1% · Q4 0.0% · 4Q avg 1.4% |
| Percentage of long-stay residents who lose too much weight | 9.2% |
5.2%
4 pts worse
|
5.4%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 12.9% · Q3 9.9% · Q4 3.9% · 4Q avg 9.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.7% |
19.2%
2.5 pts better
|
19.6%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.0% · Q2 13.6% · Q3 16.3% · Q4 18.1% · 4Q avg 16.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.7% |
22.5%
8.8 pts better
|
16.7%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.6% · Q2 15.6% · Q3 15.5% · Q4 12.2% · 4Q avg 13.7% · 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 | 13.2% |
17.7%
4.5 pts better
|
16.3%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 12.8% · 4Q avg 13.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.4% |
17.6%
6.2 pts better
|
14.9%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 18.3% · Q3 9.5% · Q4 14.7% · 4Q avg 11.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
1.0%
0.8 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
2.0%
1.5 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 0.0% · Q4 1.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.2% |
21.7%
9.5 pts worse
|
19.8%
11.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.9% · Q2 28.3% · Q3 38.9% · Q4 30.7% · 4Q avg 31.2% |
| Percentage of long-stay residents with pressure ulcers | 4.5% |
4.6%
0.1 pts better
|
5.1%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 2.8% · Q3 4.2% · Q4 4.6% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 35.5% |
77.1%
41.6 pts worse
|
81.7%
46.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 33.8% · Q2 31.2% · Q3 35.0% · Q4 42.5% · 4Q avg 35.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.0% |
11.8%
4.2 pts worse
|
12.0%
4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.0% · Observed 15.3% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.3%
0.9 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 41.7% |
77.7%
36 pts worse
|
79.7%
38 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 41.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.9% |
25.8%
4.9 pts better
|
23.9%
3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.9% · Observed 22.0% · Expected 25.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-16 · Fire 2024-07-16
11 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Cycle 3
Health 2023-04-26 · Fire 2023-04-26
10 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-09-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-10-17
F · Potential for more than minimal harm
2025-09-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-10-10
D · Potential for more than minimal harm
2025-09-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-10-10
E · Potential for more than minimal harm
2024-07-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-10
D · Potential for more than minimal harm
2024-07-16
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-08-08
D · Potential for more than minimal harm
2024-07-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-08-08
D · Potential for more than minimal harm
2023-04-26
K379 · Smoke Deficiencies
Fire Safety
Have proper openings in smoke barrier doors.
Corrected 2023-06-15
D · Potential for more than minimal harm
2023-04-26
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-06-16
Inspection history
Recent health citations
G · Actual harm
2025-10-15
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 2025-09-26
F · Potential for more than minimal harm
2025-09-15
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2025-10-10
E · Potential for more than minimal harm
2025-09-15
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 2025-10-10
D · Potential for more than minimal harm
2025-09-15
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-10-10
D · Potential for more than minimal harm
2025-05-15
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-06-09
D · Potential for more than minimal harm
2025-05-15
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 2025-06-09
D · Potential for more than minimal harm
2025-05-15
F700 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2025-06-09
D · Potential for more than minimal harm
2025-05-15
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-06-09
D · Potential for more than minimal harm
2025-05-15
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 2025-06-09
D · Potential for more than minimal harm
2025-03-26
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 2025-04-21
D · Potential for more than minimal harm
2024-07-16
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2024-08-14
D · Potential for more than minimal harm
2024-07-16
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-08-14
D · Potential for more than minimal harm
2024-07-16
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2024-08-14
D · Potential for more than minimal harm
2024-07-16
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 2024-08-14
D · Potential for more than minimal harm
2024-07-16
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 2024-08-14
D · Potential for more than minimal harm
2024-07-16
F693 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2024-08-14
D · Potential for more than minimal harm
2024-07-16
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-08-14
D · Potential for more than minimal harm
2024-07-16
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2024-08-14
D · Potential for more than minimal harm
2024-07-16
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 2024-08-14
D · Potential for more than minimal harm
2024-07-16
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 2024-08-14
D · Potential for more than minimal harm
2024-07-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-14
E · Potential for more than minimal harm
2023-04-26
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-06-06
E · Potential for more than minimal harm
2023-04-26
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-06-06
D · Potential for more than minimal harm
2023-04-26
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-06-06
D · Potential for more than minimal harm
2023-04-26
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 2023-06-06
D · Potential for more than minimal harm
2023-04-26
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-06-06
D · Potential for more than minimal harm
2023-04-26
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 2023-06-06
D · Potential for more than minimal harm
2023-04-26
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-06-06
D · Potential for more than minimal harm
2023-04-26
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2023-06-06
D · Potential for more than minimal harm
2023-04-26
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 2023-06-06
D · Potential for more than minimal harm
2023-04-26
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 2023-06-06
Penalties and ownership
What sits behind the stars
$12,735
2025-09-15
Fine
Fine · fine $12,735
Fine
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
Ianacone, David
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
Tlco Holdings LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Agawam South Rehab And Nursing
Agawam, MA
4-star overall rating with 3-star inspections with 14 recent health deficiencies
#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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