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The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Care One At Northampton during CMS and state inspections, most recent first.
A resident with a history of urinary retention and other conditions was not properly cared for due to the facility's failure to obtain a urine specimen as ordered by the NP. Despite multiple attempts, the specimen was not collected, and the NP was not notified of the issue. This lack of communication and documentation led to the resident's hospitalization with urosepsis and pneumonia.
A facility failed to maintain accurate medical records for a resident with an order to obtain a urine specimen for a suspected UTI. Despite the order, the specimen was never collected, and the Treatment Administration Record (TAR) showed inconsistencies and lack of documentation. Interviews revealed a lack of communication between shifts and insufficient documentation explaining why the specimen was not obtained.
A resident with severe cognitive impairment and non-weight bearing status was improperly transferred by CNAs without using a mechanical lift, as required by the care plan. This resulted in the resident sustaining a fracture to the left distal femur. The CNAs involved did not check the care card or care plan before performing the transfer, leading to the use of incorrect transfer techniques.
A resident who was non-weight bearing and required a mechanical lift for transfers was improperly transferred by a CNA using a stand/pivot method, resulting in a fracture to the resident's left distal femur. The CNA did not check the care plan or care card before the transfer, which required assistance from two staff members. The resident screamed in pain during the transfer, and the injury was confirmed by an X-ray.
A resident with severe cognitive impairment and multiple medical conditions sustained an injury of unknown origin, which was not reported to the DPH within the required two-hour timeframe. The facility's DON was informed of the injury but delayed the report submission by 48 hours, contrary to the facility's abuse policy.
The facility failed to adhere to infection control practices by not using proper PPE for a resident with a PICC and by allowing unsanitary smoking practices. A nurse did not wear a gown during high-contact care for a resident requiring Enhanced Barrier Precautions, and another nurse lit cigarettes for residents by placing them in her mouth, increasing infection risk.
A facility failed to obtain Physician's orders for the use and care of a TLSO brace for a resident with a spinal fracture. Despite recommendations to wear the brace, the facility lacked documented orders specifying its application and care, confirmed by the DON. This oversight risked inappropriate use and further injury.
The facility failed to provide necessary respiratory care for two residents. One resident did not receive humidified oxygen as ordered, while another received a higher oxygen flow rate than prescribed, leading to elevated blood oxygen saturation levels. These deficiencies were confirmed through observations and staff interviews, indicating a failure to adhere to physician orders and professional standards.
A resident at risk for weight loss, with diagnoses including Major Depressive Disorder and Dysphagia, experienced significant weight decline. Despite this, CNAs inaccurately documented the resident's meal intake, recording higher percentages than observed. Errors were attributed to rushed documentation and training issues, with the RD confirming the resident's poor appetite and low meal consumption.
Failure to Obtain and Communicate Urine Specimen Collection
Penalty
Summary
The facility failed to ensure proper communication and documentation regarding a urine specimen order for a resident suspected of having a urinary tract infection. The Nurse Practitioner (NP) ordered a urine specimen to be obtained on January 14, 2025, but the nursing staff did not successfully collect the specimen. Despite multiple shifts attempting to obtain the sample, there was no documentation of successful collection or notification to the NP about the inability to obtain the specimen. The resident, who had a history of urinary retention, stiff person syndrome, acute focal neurological deficit, and functional neurological system disorder, was not provided with the necessary follow-up care due to the lack of communication. The Treatment Administration Record (TAR) showed various codes indicating attempts and reasons for not obtaining the specimen, but there was no corresponding nursing note or documentation of notifying the NP or physician about the issue. Interviews with nursing staff and the Director of Nursing revealed that the expected protocol was not followed. The NP was aware that the specimen had not been obtained by January 15, 2025, but was not informed of the continued failure to collect it. Consequently, the resident experienced a significant decline in health and was admitted to the hospital with a diagnosis of urosepsis and pneumonia on January 18, 2025.
Failure to Maintain Accurate Medical Records for Urine Specimen Collection
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident who had a physician's order to obtain a urine specimen for a suspected urinary tract infection. The order, dated January 14, 2025, required nursing staff to collect the specimen every shift until it was obtained. However, the Treatment Administration Record (TAR) showed inconsistencies and lack of documentation regarding the collection of the specimen. Various codes were used in the TAR, such as checkmarks indicating acknowledgment of the order, but not the completion of the task, and other codes indicating resident refusal or that the resident was asleep. Despite these codes, there was no comprehensive documentation explaining why the specimen was not obtained, except for a single nursing note on January 18, 2025, stating an unsuccessful attempt. Interviews with nursing staff and management revealed that the urine specimen was never collected, and there was a lack of communication between shifts regarding the pending task. The Director of Nursing confirmed that the expectation was for nurses to communicate any uncompleted tasks at shift changes and to document reasons for not obtaining the specimen in the TAR or Nursing Progress Notes. The absence of such documentation and communication led to the failure in obtaining the required urine specimen, resulting in an incomplete medical record for the resident.
Failure to Follow Care Plan Leads to Resident Injury
Penalty
Summary
The facility failed to ensure that staff consistently implemented and followed the care plan interventions for a resident who required assistance of two staff members and a mechanical lift for transfers due to non-weight bearing status. On a specific date, a Certified Nurse Aide (CNA) transferred the resident using a stand/pivot technique without assistance from another staff member or a mechanical lift, contrary to the care plan. During this transfer, the resident screamed, and it was later determined that the resident sustained a fracture to the left distal femur. The resident, who was admitted to the facility with diagnoses including unspecified dementia, osteopenia, anemia, and macular degeneration, was severely cognitively impaired and dependent on staff for various activities of daily living. The care plan and care card clearly indicated the need for a mechanical lift and assistance from two staff members for transfers. However, the CNA did not check the care card or care plan before transferring the resident, leading to the improper transfer method being used. Further investigation revealed that other CNAs also failed to follow the care plan, as they transferred the resident without using a mechanical lift. The Director of Nurses (DON) confirmed that multiple CNAs did not adhere to the care plan, and it was concluded that the fracture likely occurred during the improper transfer. The facility's internal investigation highlighted the failure to follow established care protocols, resulting in harm to the resident.
Improper Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to ensure the safety of a resident who was non-weight bearing and required the assistance of two staff members and a mechanical lift for all transfers. On a specific date, a Certified Nurse Aide (CNA) transferred the resident alone from a wheelchair to a bed using a stand/pivot transfer instead of the required mechanical lift. During this transfer, the resident screamed out in pain, and it was later determined that the resident sustained a fracture to the left distal femur. The facility's policy on safe lifting and movement of residents, revised in July 2017, mandates the use of appropriate techniques and devices to lift and move residents, eliminating manual lifting when feasible. The resident's care plan, updated with the Annual Minimum Data Set (MDS) Assessment, indicated a severe cognitive impairment and dependence on staff for various activities of daily living, including transfers. The care plan specifically required the assistance of two staff members with a mechanical lift due to the resident's non-weight bearing status. The CNA involved in the incident had not previously cared for or transferred the resident and did not check the care plan or care card before performing the transfer. The CNA admitted to transferring the resident alone and without the mechanical lift, despite the resident's care plan requirements. The Director of Nurses (DON) confirmed that the fracture likely occurred during this improper transfer, as the resident was non-weight bearing and the transfer was not conducted according to the care plan.
Delayed Reporting of Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident to the Department of Public Health (DPH) within the required two-hour timeframe. The resident, who was admitted in December 2020, had a medical history including dementia, macular degeneration, osteopenia, and iron deficiency anemia. The resident was severely cognitively impaired and dependent on staff for activities of daily living and transfers. On January 13, 2025, the resident complained of left lower extremity pain, and an X-ray was performed, which initially showed no fracture. However, further X-rays on January 14, 2025, revealed an acute impacted distal femur supracondylar fracture. The resident was unable to describe how the injury occurred, and there were no witnesses. The Director of Nurses (DON) was informed of the fracture on January 14, 2025, and determined it to be an injury of unknown source, initiating an investigation per the facility's abuse policy. Despite the policy requiring immediate reporting within two hours for such injuries, the report was not submitted to the DPH until January 16, 2025, 48 hours after the injury was identified. The delay in reporting was acknowledged by the DON, who intended to report the injury immediately but failed to do so in the required timeframe.
Infection Control Deficiencies in PPE Use and Smoking Practices
Penalty
Summary
The facility failed to implement proper infection control practices concerning the use of Personal Protective Equipment (PPE) for a resident with a peripheral inserted central catheter (PICC). The resident, admitted with diagnoses including septic thrombophlebitis and a Methicillin Susceptible Staphylococcus Aureus (MSSA) infection, required Enhanced Barrier Precautions (EBP) during high-contact care activities. Despite the facility's policy and signage indicating the need for gown and glove use, Nurse #3 only donned gloves and a mask while performing PICC care, neglecting to wear a gown. This oversight occurred because Nurse #3 did not notice the EBP sign on the resident's closet door and was unaware of the facility's system of using an orange circle sticker on the nameplate to identify residents on EBP. Additionally, the facility did not maintain a sanitary smoking environment for four resident smokers. During a smoking observation, Nurse #4 was seen lighting cigarettes for residents by placing each cigarette in her mouth before handing it to the residents. This practice was acknowledged by Nurse #4 as a poor infection control practice, as it increased the risk of germ transmission among the residents. The Director of Nursing (DON) confirmed the facility's system for identifying residents on EBP and acknowledged that Nurse #3 should have worn a gown during the PICC care to minimize infection risk. Similarly, the DON stated that Nurse #4 should not have lit the residents' cigarettes by placing them in her mouth, recognizing it as an inappropriate infection control practice.
Failure to Obtain Physician's Orders for TLSO Brace
Penalty
Summary
The facility failed to meet professional standards of practice by not obtaining Physician's orders for the use, management, and care of a Thoracic Lumbar Sacral Orthosis (TLSO) brace for a resident who suffered a fall resulting in a spinal fracture. The resident, admitted with a diagnosis of a wedge compression fracture of the third lumbar vertebrae, was recommended by neurosurgery to wear a TLSO brace at all times except when lying flat. Despite this recommendation, the facility did not have any documented Physician's orders specifying the application, frequency of use, duration of therapy, or care instructions for the TLSO brace. The deficiency was identified through a review of the resident's medical records, which lacked any Physician's orders for the TLSO brace, and was confirmed during interviews with the Director of Nursing (DON). The DON acknowledged the absence of a Physician's order and stated that such an order should have been in place to ensure proper documentation and monitoring of the brace's use, including checking for potential skin issues. This oversight placed the resident at risk for inappropriate use of the TLSO brace and further spinal injury.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory care and services in accordance with professional standards of practice for two residents. For one resident, who was admitted with chronic respiratory failure and shortness of breath, the facility did not ensure that humidified oxygen was administered as ordered by the physician. Observations revealed that the oxygen concentrator was set to the correct flow rate but lacked a humidifier bottle, which was a requirement per the physician's order. The resident confirmed that a humidifier bottle had never been attached, and the unit manager acknowledged that it was the nurses' responsibility to ensure compliance with the order. Another resident, diagnosed with chronic obstructive pulmonary disease and chronic respiratory failure, was found to have been administered oxygen at a higher flow rate than prescribed. The physician's order specified a continuous flow of one liter per minute to maintain blood oxygen saturation between 88% and 92%. However, observations showed the oxygen concentrator set at two liters per minute, resulting in blood oxygen saturation levels above the ordered parameters. The resident confirmed the incorrect setting, and the unit manager and assistant director of nursing acknowledged the error, noting that the staff failed to follow the physician's order and did not notify the physician when the saturation levels exceeded the prescribed range. These deficiencies highlight the facility's failure to adhere to physician orders and professional standards for oxygen administration, potentially putting residents at risk. The lack of proper equipment and incorrect oxygen flow rates were observed and confirmed by both residents and facility staff, indicating a systemic issue in the management of respiratory care within the facility.
Inaccurate Documentation of Meal Intake for At-Risk Resident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident identified as being at risk for weight loss. The resident, who was admitted with diagnoses including Major Depressive Disorder, Dysphagia, and Altered Mental Status, showed significant weight decline over several months. Despite the resident's poor oral intake and documented weight warnings, the Certified Nurses Aides (CNAs) inaccurately recorded the resident's meal intake percentages. On multiple occasions, the CNAs documented that the resident consumed 75% to 100% of meals, while observations and interviews revealed the resident ate significantly less. The inaccuracies in documentation were attributed to errors made by the CNAs, including one instance where a CNA admitted to documenting in error due to a rushed shift change. Another CNA in training also recorded incorrect meal intake percentages, which were later identified as errors. The Registered Dietician confirmed that the resident had a poor appetite and typically consumed less than 25% of meals, further highlighting the discrepancies in the CNAs' documentation. These documentation errors failed to accurately reflect the resident's nutritional intake, which is critical for monitoring and addressing the resident's risk for weight loss.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Northampton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Linda Manor Extended Care Facility | 2.9 mi | — | 4 | 0 |
| Highview Of Northampton | 3.4 mi | — | 0 | 0 |
| Hadley Pointe Nursing Rehab & Care | 6 mi | — | 9 | 0 |
| Center For Extended Care At Amherst | 6.9 mi | — | 2 | 0 |
| Care One At Holyoke | 7 mi | — | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.