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Health Inspection

Westfield Rehabilitation And Health Center

January 15, 2025 · Westfield, MA · 37 Feeding Hills Road
Citations 3
CMS Rating 1/5
Beds 80
Provider ID 225383
Healthcare Facility
Westfield Rehabilitation And Health Center
Westfield, MA  ·  View full profile →
Inspection Summary

Westfield Rehabilitation and Health Center in WESTFIELD, MA — inspection on January 15, 2025.

Found 3 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF690
Minimal harm or Some Based on observation, interview, and record review, the facility failed to provide a homelike environment for affected

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

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in WESTFIELD, MA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Westfield Rehabilitation and Health Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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