Westfield Rehabilitation And Health Center

the survey team that an audit had been completed to show all residents had been offered a padlock

225383 01/15/2025

Westfield Rehabilitation and Health Center 37 Feeding Hills Road Westfield, MA 01085

The surveyor walked around the Resident's room and was able to locate the Resident's call light on the opposite side of the bed from where he/she was positioned (between his/her bed and the roommate's bed).

The surveyor observed the call light was laying on the floor between the two beds and not accessible to the Resident. -the surveyor exited the Resident's room to request staff assistance for Resident #44 and located Certified Nurses Aide (CNA) #2 who said she would assist him/her.

During an interview on 1/8/25 at 4:56 P.M., CNA #2 said when she went in to assist Resident #44, she saw him/her seated in the wheelchair, unclothed from the waist up with a face cloth covering his/her chest. CNA #2 said she saw a wash basin positioned in front of the Resident, which was empty, and that the Resident's call light was far away from him/her and not accessible. CNA #2 said the Resident's assigned CNA had not yet provided care on that shift, so she was unsure how long the Resident was waiting for staff assistance.

During an interview on 1/8/25 at 5:12 P.M., CNA #3 said she was assigned to care for Resident #44 that evening. CNA #3 said the Resident required assist of one staff with all care, was able to make his/her needs known, and was able to and did utilize the call light. CNA #3 said she had not had a chance to work with the Resident when the surveyor observed him/her, and that the Resident's call light should have been accessible.

During an interview on 1/9/25 at 12:05 P.M., Nurse #3 (who was covering for the Director of Nursing) said she was notified of the surveyor's 1/8/25 observation (when the Resident's call light was not accessible to him/her to summon staff assistance) and that the Resident's call light should have been accessible to him/her.

225383 01/15/2025

Westfield Rehabilitation and Health Center 37 Feeding Hills Road Westfield, MA 01085

225383 01/15/2025

Westfield Rehabilitation and Health Center 37 Feeding Hills Road Westfield, MA 01085

During an interview on 1/14/25 at 5:06 P.M., the PA said that was unaware that a different sized Foley Catheter had been utilized for Resident #10, other than what she had ordered.

The PA said that Resident #10's Foley Catheter was changed monthly and she had never been notified that the facility did not have the correct sized Foley Cather in stock.

The PA further said that she would expect the facility staff to notify her about this concern.

The PA said that some concerns with using the wrong sized balloon could be urinary leakage, skin irritation/breakdown due to urinary leakage and possible discomfort.

Please Refer to F-F690

225383 01/15/2025

Westfield Rehabilitation and Health Center 37 Feeding Hills Road Westfield, MA 01085

Review of Resident #2's Minimum Data Set (MDS) assessment dated [DATE], indicated the following: -the Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of a possible score of 15. Resident #40 was admitted to the facility in October 2022, with diagnoses including End Stage Renal Disease (ESRD).

Review of Resident #40's MDS assessment dated [DATE], indicated the following: -the Resident was cognitively intact as evidenced by a BIMS score of 15 out of a possible score of 15.

During an interview on 1/9/25 at 11:12 A.M., Resident #40 said his/her bathroom sink had a broken handle and it had been that way for a long time. Resident #40 said he/she had informed maintenance multiple times but nothing was ever done about the broken sink.

During an observation and interview on 1/9/25 at 11:15 A.M., the surveyor and Resident #2 observed the bathroom sink.

The surveyor observed the hot water handle was broken off and difficult to turn. Resident #2 said the sink had been this way for some time and he/she had told maintenance many times but no one had fixed it.

During an interview on 1/9/25 at 11:32 A.M., the surveyor and Nurse #1 observed the bathroom sink.

Nurse #1 said the sink handle had been broken since she started working at the facility 6 months ago.

Nurse #1 further said the process to get the sink fixed would be to put in a work order for maintenance to fix the sink.

During an interview on 1/9/25 at 11:38 A.M., the surveyor and the Maintenance Director observed the bathroom sink.

The Maintenance Director said he had not received work orders to repair the bathroom sink.

During a follow-up interview on 1/9/25 at 1:05 P.M., Resident #2 and Resident #40 said the bathroom sink had never been repaired since it first became broken.

During an interview on 1/9/25 at 5:34 P.M., Staff Member #6 said that since being broken, the sink had not been repaired.

225383 01/15/2025

Westfield Rehabilitation and Health Center 37 Feeding Hills Road Westfield, MA 01085

about his/her missing clothing until today. Resident #40 further said that he was told once that

The SW said that the facility policy is that a reasonable amount of time for a Resident to expect a grievance to be completed is 5 to 7 days.

The SW further said that the 12/6/24 grievance was not resolved in that timeframe.

225383 01/15/2025

Westfield Rehabilitation and Health Center 37 Feeding Hills Road Westfield, MA 01085

During an interview on 1/14/25 at 7:48 A.M., with CNA #4 and CNA #5, CNA #4 said if Resident #42 is asking for snacks in the morning after breakfast and before lunch they would get him/her something to eat as he/she does not have any food limitations. CNA #4 said that Resident #42 was able to make his/her basic needs known, was alert to him/herself, and will respond appropriately to basic questions. CNA #5 said that the Resident likes hot tea, root beer or crackers. CNA #5 said that the Resident's family usually brings him/her in snacks that are kept in his/her room.

During an interview on 1/14/25 at 9:30 A.M., the Administrator said that the staff could have provided Resident #42 a snack, and the staff are never supposed to eat in resident care areas.

The Administrator said that this situation was not only a resident right's concern but could be an infection control concern as well.

225383 01/15/2025

Westfield Rehabilitation and Health Center 37 Feeding Hills Road Westfield, MA 01085

Review of Lippincott Nursing Procedures 9th edition (2023), indicated the following: -Avoid distractions and interruptions when preparing and administering medication to prevent medication errors.

During an observation on 1/7/25 at 8:46 A.M., the surveyor observed Nurse #1 with medications on a small black tray.

The tray contained 3 medication cups and 3 drinks.

The medication cups had no visible labels on the cups to indicate the resident the medication would be administered to.

The surveyor observed Nurse #1 enter a room with the tray, administer one cup of medication and drink to a resident and then leave the room with 2 medication cups and 2 drinks remaining on the tray.

During an observation and interview on 1/7/25 at 5:09 P.M., the surveyor observed Nurse #1 with medications on a small black tray.

The tray contained 3 medication cups and 3 drinks.

Two medication cups had a first name written on the cups and one medication cup had no visible label to indicate who the medication was intended for.

Nurse #1 said the process for medication administration is to pour medications and then administer them to one resident at a time.

During an interview on 1/7/25 at 5:16 P.M., Nurse #3, who was covering for the Director of Nursing (DON) said that the expectation during medication administration is that the Nurse should pour and administer medications to one resident at a time to ensure accuracy of administration.

225383 01/15/2025

Westfield Rehabilitation and Health Center 37 Feeding Hills Road Westfield, MA 01085

During an interview on 1/14/25 at 2:33 P.M., Nurse #2 said if Resident #51 had facial hair, the staff should assist with removal.

During an interview on 1/14/25 at 3:10 P.M., the Director of Nursing (DON) said the facility had been working on ensuring unwanted facial hair was removed for residents.

The DON further said that Resident #51 was receptive to removing his/her facial hair, and staff should assist with this.

225383 01/15/2025

Westfield Rehabilitation and Health Center 37 Feeding Hills Road Westfield, MA 01085

Review of the Nursing Evaluation with [NAME] form dated 12/26/24, indicated Resident #56 was documented with a skin alteration to the sacrum.

Review of the Wound Doctor Progress notes indicated the following: -On 12/30/24 the Wound Doctor did an initial evaluation of Resident #56 and classified the area to the buttocks as MASD.

The Wound Doctor made a recommendation for zinc paste (a medicated ointment used to treat skin conditions such as MASD) to the wound base daily and as needed. -On 1/6/25 the Wound Doctor did a follow-up evaluation of Resident #56 and continued to recommend zinc paste to the wound base daily and as needed. -On 1/13/25 the Wound Doctor did a follow-up evaluation of Resident #56 and continued to recommend zinc paste to the wound base daily and as needed.

Review of Resident #56's Physician orders indicated no evidence of an order for zinc paste.

Review of Resident #56's Progress Notes indicated no evidence the Wound Doctor's recommendation was addressed with the Provider.

During an observation and interview on 1/14/25 at 3:30 P.M., the surveyor observed Resident #56 lying in bed. Resident #56 said he/she had cream applied to his/her bottom by the Certified Nurses Aides (CNAs) during care but never by the Nurse.

During a wound observation and interview on 1/14/15 at 3:35 P.M., the surveyor and Nurse #16 observed Resident #56's buttocks.

Nurse #16 said there was an open area to the right buttock.

Nurse #16 further said there was no order for treatment to the Resident's buttocks.

During an interview on 1/15/25 at 8:08 A.M., the surveyor and Nurse #9 reviewed the wound consults and Physician orders.

Nurse #9 said that there should have been an order in place for zinc paste based on the Wound Doctor recommendations but there was not.

During an interview on 1/15/25 at 8:16 A.M., the Assistant Director of Nursing (ADON) said that there had not been an order for zinc paste in place until he reviewed the 1/13/25 Wound Doctor note on 1/14/25 and obtained the order.

The ADON further said that the CNAs had been applying barrier cream but that this was not the same as zinc paste.

225383 01/15/2025

Westfield Rehabilitation and Health Center 37 Feeding Hills Road Westfield, MA 01085

During an interview on 1/8/25 at 4:40 P.M., Nurse #10 said she should not have left medications unattended because there was a risk that another resident could have taken them placing residents at risk for accident.

225383 01/15/2025

Westfield Rehabilitation and Health Center 37 Feeding Hills Road Westfield, MA 01085

During an interview on 1/14/25 at 2:01 P.M., the Medical Supplies Coordinator said that the supplier she is required to use does not have 16 Fr Foley Catheter with a 10cc balloon available only 16 Fr with a 5cc balloon.

The Medical Supplies Coordinator said she put a medical supply order in weekly and is not able to place orders outside of the weekly window.

The Medical Supplies Coordinator said that if there is something that the facility requires emergently, she can use the corporate card and go to the local store to purchase the required item.

The Medical Supplies Coordinator further said that since she had been working in this role (about one year), she could not recall keeping the 16 Fr Foley Catheter with a 10cc balloon in stock.

During an interview on 1/14/25 at 5:06 P.M., the PA said that she was unaware that a different sized Foley Catheter other than what she had ordered had been utilized for Resident #10.

The PA said that Resident #10's Foley Catheter was changed monthly and that she had never been notified that the facility did not have the correct sized Foley Catheter in stock.

The PA further said that she would expect the facility staff to notify her about this concern.

The PA said that some concerns with using the wrong sized balloon could be urinary leakage, skin irritation/breakdown due to urinary leakage and possible discomfort.

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Westfield Rehabilitation and Health Center 37 Feeding Hills Road Westfield, MA 01085

entered into the EMR by staff.

The Dietician said she was not aware of Resident #12 having a weight

Resident #12 and is very familiar with him/her. NP #1 said she was not made aware by the facility the Resident had weight loss.

225383 01/15/2025

Westfield Rehabilitation and Health Center 37 Feeding Hills Road Westfield, MA 01085

Review of the facility policy titled Oxygen Administration, revised October 2010, indicated the following in part: -Verify that there is a physician's order for this procedure. -Review the physician's orders or facility protocol for oxygen administration. -Review the residents care plan to assess for any special needs of the resident -Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered period. Resident #4 was admitted to the facility in March 2023 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD) and dependence on supplemental oxygen.

Review of Resident #4's January 2025 Physician orders indicated the following: -Oxygen at 1.5 LPM (liters per minute- flow rate of oxygen delivery) per nasal cannula every shift for shortness of breath, start date 11/7/24.

Review of Resident #4's COPD Care Plan, initiated 3/13/23, indicated to give oxygen therapy as ordered by the Physician.

On 1/7/25 at 10:51 A.M., the surveyor observed Resident #4 was receiving oxygen via nasal cannula.

The oxygen concentrator (device that concentrates oxygen from environmental air and delivers it to a patient in need of supplemental oxygen) was set at 2 LPM.

On 1/13/25 at 3:39 P.M., the surveyor and Certified Nurses Aide (CNA) #6 observed Resident #4 who was seated in a wheelchair and receiving oxygen via a portable oxygen tank. CNA #6 said that the oxygen was set to 2 LPM.

During an interview on 1/13/25 at 4:03 P.M., Nurse #5 said that she just went in to check the oxygen and adjusted it from 2 LPM to 1.5 LPM per the Physician order.

Nurse #5 said that she was not aware of why the liter flow was set to 2 LPM, that she set it to 1.5 LPM.

Nurse #5 said the Resident does not touch the portable tank or the oxygen concentrator.

225383 01/15/2025

Westfield Rehabilitation and Health Center 37 Feeding Hills Road Westfield, MA 01085

Psychiatrist's documentation and usually agree with and implement all of the recommendations, not

225383 01/15/2025

Westfield Rehabilitation and Health Center 37 Feeding Hills Road Westfield, MA 01085

Review of the facility policy titled Weight Assessment and Intervention, revised March 2019, indicated the following: -weights will be recorded in each individual's medical record. -any weight change of 5 pounds (lbs) or more since the last weight assessment will be retaken for confirmation. If the weight is verified, nursing will notify the physician and dietician. Resident #12 was admitted to the facility in March 2023 with diagnoses including Hemiplegia and Hemiparesis following a Cerebral Infarction affecting the right dominant side.

Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #12 had moderate cognitive impairment as evidenced by a BIMS score of 12 out of a possible score of 15.

Review of Resident #12's weight documentation in the Electronic Medical Record (EMR) indicated: -10/1/24: weight of 122.2 lbs -11/1/24: 121 lbs -no December 2024 weight -1/1/25: 106 lbs -1/2/25: 106 lbs Review of Resident #12's Medical Record indicated no documentation of Physician notification or interventions for a weight loss greater than 5 lbs.

During an interview on 1/9/25 at 10:51 A.M., Certified Nurses Aide (CNA) #4 showed the surveyor a weight book on the unit used by the CNAs to communicate weights to the Nurses.

The Nurses then enter the weights into the medical record.

The surveyor and CNA #4 reviewed the December 2024 weight flowsheet and CNA #4 said the December 2024 weight for Resident #12 indicated on the flowsheet was 109.1 lbs.

During a telephone interview on 1/9/25 at 11:05 A.M., Nurse Practitioner (NP) #1 said she was not made aware of the December 2024 and January 2025 weights of 109 lbs and 106 lbs, but had she been informed she would have ordered something like Ensure (nutrition supplement).

225383 01/15/2025

Westfield Rehabilitation and Health Center 37 Feeding Hills Road Westfield, MA 01085

Review of the facility approved menu indicated the following lunch menu for 1/14/25: -Meatloaf, mashed potatoes, broccoli cuts, dinner roll and mandarin oranges.

On 1/14/25 at 12:32 P.M., the surveyor observed the following lunch meal served to the residents: -kielbasa, mashed potatoes, sauerkraut and applesauce.

Review of the facility approved menu indicated the following breakfast and lunch menu for 1/15/25: -Breakfast: cold cereal of choice, hard cooked eggs, white toast, fresh banana -Lunch: chicken and biscuits, marinated green bean salad, chocolate chip bar On 1/15/25 at 8:11 A.M., the surveyor observed the following breakfast served to the residents: -french toast, scrambled eggs and cold cereal On 1/15/25 at 10:37 A.M., Dietary Aide #2, who was also a regular cook, said the lunch today was chicken parmesan, noodles, green beans and pineapple.

Dietary Aide #2 said he goes by the menus posted on the cook's book, looks in the refrigerators to see what was available and makes a plan for breakfast and lunch.

Dietary Aide #2 said he knows what the residents like, sees what's available and makes menus that way.

Dietary Aide #2 said he knows the meals provided to residents have to have a meat source, starch and a vegetable.

Dietary Aide #2 showed the surveyor the menu he said they were using at the time which was titled Spring/Summer Menu with dates listed from May to September 2023 (and not the weekly Fall/Winter 2024-2025 menus provided to the survey team during entrance).

Dietary Aide #2 said that the Spring/Summer Menu was the menu to be used, but breakfast listed for yesterday (1/14/25) and today (1/15/25) was not what was served.

Dietary Aide #2 further said pancakes were served on 1/14/25 (Spring/Summer Menu indicated: cream of wheat, scrambled eggs with ham, wheat toast) and French toast and scrambled eggs was served on 1/15/25 (Spring/Summer Menu indicated: cheese grits, pancakes, banana).

Dietary Aide #2 further said tomorrow (1/16/25), he would be serving waffles (Spring/Summer Menu indicated: oatmeal, scrambled eggs and muffin).

During an interview on 1/15/25 at 11:21 A.M., the surveyor and the FSD reviewed the concerns relative to the resident menus and the FSD said he understood the concerns.

Please Refer to F-F804

225383 01/15/2025

Westfield Rehabilitation and Health Center 37 Feeding Hills Road Westfield, MA 01085

During an interview on 1/9/25 at 3:50 P.M. with Nurse #1, Nurse #5 and Nurse #6 the following was discussed: -the residents have expressed they do not like the meals. -there have been numerous resident complaints about the food and nothing changes.

Review of the Food Committee Meeting Notes, from October 2024 and November 2024 (no notes were provided for December 2024) indicated the following: -some reports of food temperature concerns -concerns about the orange juice being watery -concerns that portions provided were not enough or not what was on diet plan (large portions) -concerns about receiving broccoli stalks -receiving repetitive foods like apples multiple days in a row -concerns about food being too overcooked On 1/9/25 at 4:15 P.M., the surveyor requested test trays for the dinner meal to be placed on the [NAME] and Oak meal trucks for the dinner meal.

On 1/9/25 at 5:18 P.M., the surveyor obtained one of the two test trays and the following was observed: -thickly sliced ham - 103.6 degrees Fahrenheit (F): not hot and did not contain much flavor -elbow macaroni - 104.0 degrees F: room temperature, no flavor -mixed vegetables - 93.7 degrees F: cool to taste -no dessert was provided During a follow-up interview on 1/9/25 at 5:59 P.M., the FSD said the hot food should be 135 degrees or higher and the cold food should be 40 degrees or less, and had not done tests trays for a long time.

During a follow-up interview on 1/15/25 at 11:21 A.M., the FSD said he was aware that residents had temperature concerns about the meals previously and was hoping it was resolved.

The FSD said the food carts they utilize in the kitchen were old, have gaps and no insulation and thought this could be contributing to the temperature issues with the meals.

225383 01/15/2025

Westfield Rehabilitation and Health Center 37 Feeding Hills Road Westfield, MA 01085

During an interview on 1/15/25 at 11:12 A.M., the FSD said Resident #117 was recently admitted and preferences should have been obtained by the RD.

The FSD said when the RD obtains resident preferences, she typically writes them on a sticky note, he enters the information into the computer for the meal tickets and then the notes made for resident preferences were discard.

The FSD said he was made aware of what occurred with Resident #20's breakfast meal.

225383 01/15/2025

Westfield Rehabilitation and Health Center 37 Feeding Hills Road Westfield, MA 01085

During an interview on 1/15/25 at 9:41 A.M., the Director of Maintenance (DOM) said that he had not been made aware that the wash temperatures had not been coming up to the expected wash temperature and would expect that the staff would notify him when they were not, so that he could call the company to come in and service the dishwashing machine.

The surveyor and the DOM reviewed the January 2025 wash temperature log.

The DOM said that the temps were not high enough and the wash temperature usually goes up to 160 degrees Fahrenheit.

The DOM said that he was told by the dishwasher's company representative that if the wash temperature did not come up to the expected temperature, but the final rinse did, that the facility staff should not worry because it is the final rinse where the sanitation occurs.

On 1/15/25 at 10:21 A.M., the DOM provided the manufacturer's specification (guidelines) and said that the wash temperature is expected to be from 150-165 degrees Fahrenheit.

The surveyor and the DOM reviewed the January 2025 wash temperature log again and found 16 wash temperatures in January 2025 did not come up to 150 degrees Fahrenheit.

The DOM said that he would have expected staff to let him know when the wash temperature did not come up to at least 150 degrees Fahrenheit and they did not.

During a follow-up kitchen walk through on 1/15/25 at 10:37 A.M., the surveyor observed the following: -shelves with clean pots/pans, coffee pots, pitchers were visibly dirty and had debris present. -ice machine (that was in use) had black, brown discoloration on the internal parts. -in the reach-in freezer: >two large unopened clear packages of uncooked meat ribs, unlabeled and undated. >two large unlabeled and undated uncooked beef wrapped in clear plastic wrap.

During an interview on 1/15/25 at 11:06 A.M., the FSD said the ice machine did not look clean inside.

The FSD said maintenance does the internal cleaning.

The FSD said the unlabeled and undated meat items in the reach-in freezer were spare ribs and pork butt and they were not labeled and dated.

During an interview on 1/15/25 at 12:41 P.M., the DOM said the ice machine was part of a preventative maintenance program and was supposed to be cleaned by a contract company every six months.

The DOM said the last time the ice machine received preventative maintenance was approximately eight months ago and it was overdue.

The DOM said he looked at the inside of the ice machine, and it was not clean and should not be used until it was cleaned.

225383 01/15/2025

Westfield Rehabilitation and Health Center 37 Feeding Hills Road Westfield, MA 01085

During a telephone interview on 1/9/25 at 11:05 A.M., Nurse Practitioner (NP) #1 said she had progress notes for October 2024, November 2024 and December 2024 in her records.

225383 01/15/2025

Westfield Rehabilitation and Health Center 37 Feeding Hills Road Westfield, MA 01085

During an interview at the time, CNA #8 said she entered the Resident's room to respond to the call light. CNA #8 said she did not put on eye protection because she was not providing care. CNA #8 said Resident #118 was requesting medication when she went in to attend to the call light. CNA #8 said she was familiar with the Droplet Precautions signage and that it indicated to put on a gown, gloves, mask and eye protection. CNA #8 said Resident #118 was on Droplet Precautions because he/she was positive for COVID-19 infection.

On 1/9/25 at 10:07 A.M. through 10:15 A.M., the surveyor observed the following: -Resident #118's call light was initiated. -at 10:13 A.M., CNA #1 was observed donning a gown and surgical mask and entered the Resident's room. CNA #1 did not have an N95 mask, gloves or eye protection in place. -at 10:15 A.M., CNA #1 opened the door to the Resident's room with gown and surgical mask on.

Nurse #14 was observed outside of the Resident's room.

During an interview at the time, when the surveyor indicated the Droplet Precaution signage posted outside of the Resident's room, CNA #1 said he answered the Resident's call light and that he/she was requesting water and medications. At this time, Nurse #14 provided verbal education to CNA #1 about the PPE requirements prior to entering Resident #118's room which included gown, gloves, N95 mask and eye protection.

225383 01/15/2025

Westfield Rehabilitation and Health Center 37 Feeding Hills Road Westfield, MA 01085

Review of the facility policy titled Antibiotic Stewardship-Review and Surveillance of Antibiotic Use and Outcomes, revised 12/2016, indicated the following: -Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. -All resident antibiotic regimens will be documented on the facility approved antibiotic surveillance tracking form. Resident #118 was re-admitted to the facility post hospitalization in January 2025 with a diagnosis of UTI.

Review of Resident #118's January 2025 Physician's orders indicated: -Cefdinir (an antibiotic) one capsule by mouth twice daily for 10 days, start date 1/4/25.

Review of Resident #118's January 2025 Medication Administration Record (MAR) indicated that the Cefdinir medication was administered for Resident #118 as ordered from 1/4/25 through 1/14/25.

During an interview on 1/15/25 at 9:59 A.M., the Director of Nursing (DON) who was filling in for the Infection Preventionist (IP) who was not available during the survey said the IP tracks any infections in the facility to look for trends to make sure infections are contained and are not spreading.

The DON also said that the IP tracks antibiotic use to ensure treatments are working or if other alternatives need to be explored for treatment.

The DON further said the IP utilizes a line listing (form used that includes but is not limited to date of infection onset, use of antibiotics, pertinent labs/x-rays, changes in treatment) information to track infections and antibiotic use.

The surveyor and the DON reviewed the January 2025 line listing which indicated no documentation for Resident #118's UTI or that antibiotic use was being monitored for the Resident.

The DON said Resident #118 should have been included on the line listing so he/she could be monitored for changes in his/her condition and the line listing should have been updated twice weekly when the IP was in the building, and it did not appear the January 2025 line listing was complete.

225383 01/15/2025

Westfield Rehabilitation and Health Center 37 Feeding Hills Road Westfield, MA 01085

information about Pneumococcal Vaccination at the time Resident #60 was admitted to the facility or

225383 01/15/2025

Westfield Rehabilitation and Health Center 37 Feeding Hills Road Westfield, MA 01085

Review of Resident #4's COVID-19 Vaccine Consent/Refusal dated 12/20/23, indicated Resident #4 completed the COVID-19 Vaccine Consent/Refusal form.

Further review of the COVID-19 Vaccine Consent/Refusal form indicated no documentation Resident #4's HCP had been provided with education related to the benefits and potential side effects of the vaccine or that he/she consented or declined vaccination for Resident #4.

Review of Resident #4's Immunization Audit Report, indicated Resident #4 was administered his/her most recent COVID-19 vaccination on 12/27/23.

• Resident #60 was admitted to the facility in November 2024.

Review of Resident #60's COVID-19 Vaccine Consent/Refusal form dated 11/8/24 indicated he/she consented to receiving COVID-19 vaccinations.

Review of Resident #60's Massachusetts Immunization Information System Report (MIIS-system used to track vaccinations) indicated Resident #60 had last received a COVID-19 vaccination on 1/3/22.

Further review of the Resident's medical record indicated no documentation that the Resident had received an updated COVID-19 vaccination after consenting to receive COVID-19 vaccinations.

During an interview on 1/8/25 at 3:26 P.M., Nurse #3 said she was unable to find any documentation on why Resident #60 did not receive a COVID-19 vaccination timely after he/she consented to a COVID-19 vaccination.

During an interview on 1/8/25 at 5:02 P.M., Nurse #3 said Resident #4's HCP was activated prior to Resident #4 receiving his/her most recent dose of the COVID-19 vaccination.

Nurse #3 further said Resident #4's HCP should have been consulted for consent and to provide education prior to administering a COVID-19 vaccination to Resident #4.

225383 01/15/2025

Westfield Rehabilitation and Health Center 37 Feeding Hills Road Westfield, MA 01085

During an observation on 1/7/25 at 8:37 A.M., the surveyor observed Resident #2 lying in bed with the bed remote control in his/her hand.

The cord to the bed remote control was observed to be frayed with multicolored wires visible where the outer protective portion of the cord had separated.

During on observation on 1/7/25 at 2:05 P.M., the surveyor observed Resident #2's bed.

The Resident was not in the bed.

The bed remote control was laying at the foot of the bed and the cord to the remote control remained with a frayed outer protective layer with visible multicolored wires.

During an interview on 1/7/25 at 2:17 P.M., CNA #1 said he was a regular staff member and was familiar with Resident #2.

The surveyor and CNA #1 observed Resident #2's bed remote control cord.

CNA #1 said that the cord had been that way for about a week. CNA #1 further said that the process was to notify maintenance immediately if this type of issue is identified but that he had not notified maintenance.

During an interview on 1/7/25 at 2:25 P.M., the surveyor and the Maintenance Director observed Resident #2's bed remote control cord.

The Maintenance Director said he had not been made aware of this issue before this afternoon.

The Maintenance Director further said that there is concern with this bed remote control cord because of the exposed wires.

Review of Resident #2's Minimum Data Set (MDS) assessment dated [DATE], indicated the following:

-the Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of a possible score of 15.

Resident #40 was admitted to the facility in October 2022, with diagnoses including End Stage Renal Disease (ESRD).

Review of Resident #40's MDS assessment dated [DATE], indicated the following:

-the Resident was cognitively intact as evidenced by a BIMS score of 15 out of a possible score of 15.

During an interview on 1/9/25 at 11:12 A.M., Resident #40 said his/her bathroom sink had a broken handle and it had been that way for a long time. Resident #40 said he/she had informed maintenance multiple times but nothing was ever done about the broken sink.

During an observation and interview on 1/9/25 at 11:15 A.M., the surveyor and Resident #2 observed the bathroom sink.

The surveyor observed the hot water handle was broken off and difficult to turn. Resident #2 said the sink had been this way for some time and he/she had told maintenance many times but no one had fixed it.

During an interview on 1/9/25 at 11:32 A.M., the surveyor and Nurse #1 observed the bathroom sink.

Nurse #1 said the sink handle had been broken since she started working at the facility 6 months ago.

Nurse #1 further said the process to get the sink fixed would be to put in a work order for maintenance to fix the sink.

During an interview on 1/9/25 at 11:38 A.M., the surveyor and the Maintenance Director observed the bathroom sink.

The Maintenance Director said he had not received work orders to repair the bathroom sink.

During a follow-up interview on 1/9/25 at 1:05 P.M., Resident #2 and Resident #40 said the bathroom sink had never been repaired since it first became broken.

225383

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 225383 B.

Wing 01/15/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Westfield Gardens Nursing and Rehab 37 Feeding Hills Road Westfield, MA 01085

During an interview on 1/7/25 at 7:38 A.M., the Food Service Director (FSD) said he had not had any concerns about food and had received no grievances for about eight months.

The FSD said they have a food committee that meets monthly and any concerns that are brought up in food committee were addressed.

On 1/9/25 from 1:30 P.M. to approximately 3:00 P.M., the survey team conducted a resident council meeting with nine residents and the following was discussed:

-staff stand around when the meal carts are delivered to the units and the food trays are not passed timely.

-eight of the residents said temperature of the food was a concern.

-hot food was often cold.

-they were provided fruit and pudding for dessert for most meals, do not get whipped topping on desserts and would like to.

-some of the food was burnt when served.

225383

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 225383 B.

Wing 01/15/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Westfield Gardens Nursing and Rehab 37 Feeding Hills Road Westfield, MA 01085

Review of January 2025 Physician orders indicated the following:

-16 Fr (French -size) Foley Catheter with 10cc (cubic centimeters) balloon to straight drainage for urinary retention.

-May change as needed for leakage, dislodgement or occlusion, initiated 6/9/22.

Review of a Nursing Note dated 1/1/25, indicated the following in part:

-Resident had Foley Catheter changed #16 Fr with 5cc balloon.

During an interview on 1/13/25 at 9:53 A.M., Nurse #5 and Nurse #7, Nurse #7 said that she was the Nurse that inserted the Foley Catheter on 1/1/25.

Nurse #7 said that she filled the balloon to 5cc's because she filled it until she felt that the catheter was secure (where it would not dislodge) as she did not want it to be uncomfortable for Resident #10.

Nurse #7 said that there had been no issues with the new Foley Catheter.

The surveyor, Nurse #5, and Nurse #7 reviewed the different sized catheters located in a plastic bin and noted there were 16 Fr Foley Catheters, however the Foley Catheters in the bin all had 30cc balloons.

Nurse #5 said that a 30cc balloon would be too big and most likely uncomfortable for the Resident.

225383

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 225383 B.

Wing 01/15/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Westfield Gardens Nursing and Rehab 37 Feeding Hills Road Westfield, MA 01085