WESTFIELD, MA - Federal health inspectors documented significant safety violations at Westfield Gardens Nursing and Rehab during a comprehensive survey, citing the facility for unsafe food temperatures, electrical hazards, and infection control failures that put residents at risk.
Food Safety and Temperature Violations
The most widespread issue involved food service failures affecting residents across the facility. During the January 15, 2025 inspection, surveyors documented hot meals being served at dangerously low temperatures that violated federal food safety standards.
When inspectors tested dinner trays, they discovered alarming temperature readings that fell far below safe levels. Ham was measured at just 103.6 degrees Fahrenheit, while elbow macaroni registered 104.0 degrees and mixed vegetables were served at 93.7 degrees. Federal regulations require hot foods to be maintained at 135 degrees Fahrenheit or higher to prevent bacterial growth and foodborne illness.
The temperature problems weren't limited to a single meal. Review of facility records revealed systematic failures, with no temperature documentation for numerous dinner meals throughout December 2024 and early January 2025. On multiple dates, including December 2-5 and January 2, 6-7, and 9, staff failed to record any food temperatures prior to serving meals to residents.
During a resident council meeting, eight of nine residents expressed concerns about food temperature, reporting that hot food was often cold when served. Multiple residents described receiving "terrible" food quality, with some noting that meals were "limp and could blow in the wind."
The facility's Food Service Director acknowledged that food carts used in the kitchen were old, had gaps, and lacked insulation, contributing to the temperature control problems. Kitchen staff admitted they hadn't conducted test trays "for a long time" and often failed to document temperatures even when measured.
Electrical Safety Hazards
Inspectors identified immediate electrical dangers in resident rooms. During a routine observation, surveyors discovered a bed remote control cord with frayed outer protective covering, exposing multicolored electrical wires. The damaged equipment remained in use by Resident #2, creating a serious electrocution and fire risk.
A Certified Nurses Aide familiar with the resident revealed the electrical hazard had existed for approximately one week without being reported to maintenance staff. This delay violated basic safety protocols and left the resident vulnerable to potential electrical injury.
The facility's Maintenance Director acknowledged the serious safety concern posed by the exposed wires but said he hadn't been notified of the problem until inspectors brought it to his attention during the survey.
Kitchen Sanitation and Equipment Failures
Beyond temperature control issues, inspectors found widespread sanitation problems throughout the kitchen operation. Multiple observations revealed unclean conditions that increased infection risks for residents.
Kitchen shelving containing clean pots, pans, and coffee pitchers showed visible dirt and debris. The toaster was "caked with dark, black colored crumbs covering the bottom," while air conditioners running over food preparation areas had visible dust accumulation on vents.
The facility's ice machine, used to provide ice for resident drinks, contained "black, brown discoloration on the internal parts." The machine was overdue for maintenance by approximately eight months, according to the maintenance director, who acknowledged the equipment shouldn't be used until properly cleaned.
Perhaps most concerning, the dishwashing machine consistently failed to reach proper sanitization temperatures. Records showed 16 occasions in January 2025 when wash temperatures never rose above 149 degrees Fahrenheit, falling short of the required 150-165 degree range. On some occasions, temperatures dropped as low as 142 degrees, compromising the sanitary cleaning of dishes and utensils used by residents.
Food storage violations included unlabeled and undated meat products in freezers, creating potential food safety risks. Staff were observed thawing food improperly at room temperature rather than following safe thawing protocols.
Infection Control Protocol Failures
The inspection revealed multiple failures in infection prevention measures designed to protect residents from communicable diseases. Staff repeatedly failed to follow established protocols for isolation precautions, particularly concerning a resident with COVID-19.
During observations of a resident on droplet precautions for COVID-19 infection, nursing staff entered the room without proper personal protective equipment. One aide entered wearing only a gown and surgical mask, lacking the required N95 mask, gloves, and eye protection specified by facility protocols.
Additional infection control failures included improper handling of medical equipment. A nurse was observed placing a contaminated blood glucose meter directly into a storage bin containing clean supplies without first cleaning and disinfecting the device.
During wound care for a resident on enhanced barrier precautions, nursing staff failed to change gloves between cleaning a wound and applying clean dressings. The same nurse also left the room while still wearing contaminated protective equipment, potentially spreading infectious materials to other areas of the facility.
Medical Record and Documentation Issues
Federal regulations require nursing homes to maintain complete and accurate medical records for resident care coordination. Inspectors found multiple documentation failures that compromised care quality and safety.
For residents requiring fluid restrictions due to kidney disease, the facility failed to maintain proper intake records. Despite physician orders requiring 24-hour fluid intake totals, nursing staff had no system to document actual consumption amounts, relying only on checkboxes indicating allowable limits weren't exceeded.
Critical medical documents were missing from resident files, including provider progress notes for residents who had been hospitalized and readmitted. In one case, Medical Orders for Life Sustaining Treatment forms lacked required physician signatures, making advance directive preferences legally invalid.
Vaccination and Immunization Gaps
The facility failed to ensure residents received recommended vaccinations in a timely manner. One resident who consented to COVID-19 vaccination in November 2024 had not received an updated vaccine by the time of inspection, despite having last been vaccinated in January 2022.
Another resident received a COVID-19 vaccination after their healthcare proxy was activated, but without proper consultation or consent from the designated decision-maker, violating resident rights and medical consent protocols.
Food Service and Dietary Management Problems
Beyond temperature issues, the facility struggled to accommodate resident dietary preferences and restrictions. Multiple residents reported receiving foods they were allergic to or had specifically refused, including eggs for residents with documented allergies and pork products for residents who had declined such items.
The facility's limited snack options consisted primarily of prepackaged peanut butter crackers and cookies, with staff acknowledging these items might not be appropriate for residents with chewing difficulties, diabetes, or other dietary restrictions.
Kitchen staff were observed reheating pureed food from lunch to serve as dinner without properly identifying what the meal contained or ensuring appropriate temperatures before serving to residents with special dietary needs.
Regulatory Response and Next Steps
These violations represent systematic failures across multiple aspects of resident care and safety. Federal regulations require nursing homes to provide safe, sanitary environments that protect residents from preventable harm.
The facility must develop comprehensive correction plans addressing each cited violation, including immediate equipment repairs, staff retraining, and implementation of proper monitoring systems. State and federal oversight agencies will conduct follow-up inspections to verify compliance with correction requirements.
Residents and families can access the complete inspection report through the Centers for Medicare & Medicaid Services nursing home database to review detailed findings and facility response plans.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Westfield Gardens Nursing and Rehab from 2025-01-15 including all violations, facility responses, and corrective action plans.
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