The broken hot water handle at Westfield Gardens Nursing and Rehab was "difficult to turn" when federal inspectors examined it in January. One resident said the sink "had been this way for a long time" and he had "informed maintenance multiple times but nothing was ever done."
His roommate gave inspectors the same account. Both residents were cognitively intact, with mental status scores of 13 and 15 out of a possible 15 points.
A nurse who had worked at the facility for six months told inspectors the sink handle "had been broken since she started working" there. When she explained the process for repairs, she said staff would "put in a work order for maintenance to fix the sink."
But the maintenance director said he "had not received work orders to repair the bathroom sink."
The broken fixture violated federal requirements for nursing homes to provide a "safe, clean, comfortable and homelike environment." Inspectors found the facility failed this standard for both residents who used the shared bathroom.
The sink represented just one of multiple care failures inspectors documented during their January visit to the 37 Feeding Hills Road facility.
Hungry Resident Ignored During 53-Minute Ordeal
In the most disturbing incident, staff repeatedly promised food to a dementia patient but forgot to provide it, leading to nearly an hour of escalating agitation and dangerous wandering.
The resident, who has major depressive disorder and generalized anxiety disorder, asked for snacks at 10:39 AM on January 13. A nurse said she would get him something to eat, then "resumed working and did not provide" any food.
Ten minutes later, the hungry resident tried to push through an alarmed door leading outside. Staff redirected him back inside.
By 10:51 AM, he came out of the day room "asking for a snack, became frustrated stating he was hungry and there was no food." Another nurse promised to bring snacks but also forgot.
The resident told an inspector: "it's terrible... I'm hungry and there's nothing!"
He became "agitated and restless," standing at the nurses' station and mumbling. At 10:54 AM, both nurses acknowledged they had forgotten to get him food. Neither provided any.
Left alone in the day room with no television or music, the resident began talking to himself and making statements like "let's go" and "this is enough." At 11:03 AM, he still had received no food.
A nursing aide then entered the room eating a bag of Doritos in front of the hungry resident.
By 11:11 AM, the resident was saying "I'm getting out of here, that's it, let's go, I'm gone." He wandered the hallway, tried to enter a closet, and walked into another resident's room before staff intervened.
The ordeal continued until 11:31 AM, when staff finally brought him to lunch. As he walked to the dining room, he said: "I can't wait to eat I am so hungry."
The administrator later acknowledged that "staff could have provided" the resident a snack, calling the situation both a resident rights concern and potential infection control issue.
Medication Safety Lapses Put Residents at Risk
Nurses routinely prepared medications for multiple residents simultaneously, violating professional standards designed to prevent dangerous errors.
Inspectors observed one nurse carrying a tray with three medication cups and three drinks. Two cups had first names written on them, but one cup "had no visible label to indicate who the medication was intended for."
The nurse said her process was "to pour medications and then administer them to one resident at a time." But inspectors watched her enter a room, give medicine to one resident, then leave with medications for two other residents still on her tray.
Professional nursing standards require avoiding distractions during medication preparation to prevent errors. The acting director of nursing confirmed that nurses "should pour and administer medications to one resident at a time to ensure accuracy."
In another incident, a nurse left three cups of prepared medications "unattended on the window sill" while she left a resident's room to get water for tube feeding. The nurse acknowledged she "should not have left medications unattended because there was a risk that another resident could have taken them."
Wrong Catheter Size Used for Months
Staff used the wrong size urinary catheter on a resident for months without telling his doctor, potentially increasing infection and discomfort risks.
The resident's physician had ordered a catheter with a 10cc balloon, but the facility only stocked catheters with 30cc balloons. Nurses used 5cc balloons instead, filling them based on their own judgment rather than medical orders.
One nurse said she "used her judgment and filled it until she felt that the catheter had been secured" because she "did not want the catheter to be uncomfortable." She never contacted the physician about the deviation from his orders.
The medical supplies coordinator said she had worked there about a year and "could not recall keeping" the correct catheter size in stock. The facility's supplier "does not have 16 Fr Foley Catheter with a 10cc balloon available."
The physician assistant said she was "unaware that a different sized Foley Catheter other than what she had ordered had been utilized." She noted that using the wrong size balloon could cause "urinary leakage, skin irritation/breakdown due to urinary leakage and possible discomfort."
Severe Pain Ignored Despite Daily Documentation
A diabetic resident with neuropathy consistently reported severe pain but received no additional pain medication or alternative treatments, despite staff documenting pain levels of 7 and 8 out of 10 nearly every day.
The resident told inspectors he was "in constant pain" in his hands and feet, rating it usually an 8 on the 0-10 scale. "The pain medication doesn't help," he said, explaining that he had available as-needed Tylenol "but it doesn't help so I don't ask for it."
Records showed staff documented his pain 93 times in December 2024. He rated his pain as 7 or higher on 25 of those occasions. In January, he reported pain levels of 7 nine times out of 40 documented assessments.
Despite these consistent reports of severe pain, he received no as-needed pain medication during January. Staff also failed to provide ordered non-pharmacological interventions like "relaxation, light touch, exercise, music."
His psychiatrist twice recommended additional treatments. In October, the psychiatrist suggested referring him to the medical team for "worsening numbness/weakness hands and painful feet." No referral was made until December.
In December, the psychiatrist recommended acupuncture for "painful neuropathy," noting the resident had previously benefited from acupuncture for chronic fatigue. No acupuncture referral was arranged.
The director of nursing said she was unaware of the resident's severe pain levels and hadn't seen him walking in hallways recently. She called pain levels of 7 or 8 "significant" and said she would expect nurses to contact providers and intervene.
Food Service Chaos Leaves Residents Guessing
The facility's food service operated without consistent menus, served leftovers to residents requiring pureed food, and failed to notify residents about meal substitutions.
The food service director admitted he couldn't provide menus showing what residents had actually been served in previous weeks or months. He said he had "no set menu" and didn't use substitution logs when changing planned meals.
Residents on pureed diets received reheated leftovers from previous meals rather than pureed versions of current menu items. The food service director said this was "the way it had always been done" to avoid "wasting food."
When asked if residents receiving pureed food would know what they were eating, he said "they would not."
During one dinner service, inspectors observed him removing covered plates from refrigerators and reheating them in microwaves. He said this was "the pureed food from lunch that I was serving as the pureed meal for dinner" but couldn't identify what the original meal had been.
Menu substitutions happened frequently without resident notification. Posted daily menus rarely matched either the approved corporate menus or what was actually served. Breakfast menus weren't posted at all.
A registered dietitian said the facility "should not be using leftover food from a previous meal to provide to the residents on a pureed diet" and called the practice inappropriate.
The violations resulted in citations affecting the facility's federal compliance ratings, though specific penalties weren't disclosed in the January 15 inspection report.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Westfield Rehabilitation and Health Center from 2025-01-15 including all violations, facility responses, and corrective action plans.
Additional Resources
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