Westfield Rehabilitation and Health Center

Inspectors wroteBased on observations, and interviews, the facility failed to ensure that food was prepared, distributed, and served in accordance with professional standards for food service safety in the facility's main kitchen. Specifically, the facility failed to ensure:1. that a fan in use in the main kitchen was clean and free from dust and debris.2. that an open window in the main kitchen had a screen to prevent outside elements including dust and insects from getting into the kitchen and contaminating food and food preparation surfaces.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by an interdisciplinary team and changes implemented as required for one Resident (#22), out of a total sample of 16 residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the facility menus were followed for resident meals. Specifically, the facility failed to: -ensure the daily menus posted reflected the actual meals provided and that breakfast meals were posted on the daily menus and match the approved menus. -notify residents when menu items were substituted. -ensure residents who required pureed meals were notified of what their meals were and not provided with leftover food items from previously served meals. -provide the residents with adequate alternate options for menu items.

Inspectors wroteBased on observations, interviews and record review, the facility failed to maintain a clean and sanitary environment in the facility's main kitchen increasing the potential risk of food related illnesses. Specifically, the facility failed to ensure that: -Kitchen surfaces and equipment were clean and free of dust and debris. -Temperatures were obtained prior to meal service to ensure food was safe to be served to residents. -Food was thawed appropriately to minimize risk of food related illness. -Food items were labeled and dated when stored. -The dish machine temperatures were within appropriate ranges for use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a homelike environment for two Residents (#2 and #40), out of a total sample of 20 residents. Specifically, for Resident #2 and #40, the facility failed to ensure that the bathroom sink in a shared room by both Residents was maintained in a safe and homelike manner.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide appropriate treatment and services relative to an indwelling urinary catheter (a thin, flexible tube inserted into the bladder to drain urine outside the body, for one Resident (#10) out of a total sample of 20 residents. Specifically for Resident #10, the facility staff failed to follow the Physician order's relative the Foley Catheter size (a type of indwelling urinary catheter), and ensure the proper size Foley Catheter was available in the facility, increasing the Resident's risk for indwelling urinary catheter complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide nutritional care and services, according to professional standards of practice for two Residents (#40 and #12) out of a total sample of 20 Residents. Specifically, the facility failed to: 1. For Resident #40, accurately monitor and assess the Resident's fluids intake amounts as ordered by the Physician. 2. For Resident #12, obtain a re-weight when the Resident experienced weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that food provided to residents was palatable and of appropriate temperatures on one unit (Willow) of two units observed.

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain complete and accurate medical records for four Residents (#40, #33, #118 and #12), out of a total sample of 20 Residents. Specifically, the facility failed to: 1. For Resident #40, accurately document the total 24 hour fluid measurements as ordered by the Physician when Resident #40 was identified as having a fluid restrictions order of 1200 milliliters (ml) per day. 2. For Resident #33, ensure the MOLST (Medical Order for Life Sustaining Treatment) form was accurate and completed to ensure that the Resident's wishes were honored. 3. For Resident #118, ensure the Medical Provider Progress Notes were located in the clinical record. 4. For Resident #12, ensure that Provider Progress Notes written by the Nurse Practitioner (NP) were included and accessible in the Resident's medical record.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement an infection control program that ensured residents in the facility were provided with a safe, sanitary, and comfortable environment aimed to prevent the development and transmission of communicable diseases and infection for three Residents (#48, #60, and #118) out of a total sample of 20 residents and on one Unit (Willow Unit) out of two units observed. Specifically, the facility failed to: 1. for Resident #48, conduct on going surveillance for a communicable disease when the Resident was diagnosed with Shingles (a viral infection the causes painful rash). 2. ensure a glucometer on the [NAME] Unit was disinfected appropriately after use and prior to storing. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one Resident (#48) out a total sample of 20 residents, was provided a dignified experience. Specifically, the facility failed to ensure that privacy was provided when the Resident was observed from the hallway with undergarments and legs exposed during a rehabilitation therapy session.

Inspectors wroteBased on resident and staff interview, the facility failed to ensure a secure space was provided for Residents' personal belongings for five of nine Residents who participated in the Resident Council Meeting.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodations to ensure that one Resident (#44) out of a total sample of 20 residents, had his/her call light accessible. Specifically, the facility failed to ensure that Resident #44's call light was within reach when he/she was indisposed and was unable to call for staff assistance for personal care.

Inspectors wroteBased on interview, and record review, the facility failed to ensure three Residents (#33, #60, and #22) of five applicable residents reviewed, out of a total sample of 20 residents, had the opportunity to formulate advanced directives and/or ensure that their wishes relative to advances directives were implemented. Specifically, the facility failed to: 1. For Resident #33, ensure his/her wishes relative to advanced directives were ordered by the Physician putting the Resident at risk for medical treatment that he/she did not want. 2. For Resident #22, ensure that Advanced Directives were reviewed with the Resident to allow his/her wishes to executed. 3. For Resident #60, ensure that the completed MOLST form and Physician orders matched, creating the potential for Cardiopulmonary Resuscitation (CPR) to be performed when it was not the Resident's wishes.

Inspectors wroteBased on record review, and interview, the facility failed to notify or consult with the Physician when staff did not follow the Physician's orders for one Resident (#10) out of a total sample of 20 residents. Specifically, for Resident #10, the facility staff failed to notify or consult the Physician when staff utilized a different sized Foley Catheter (a type of indwelling urinary catheter -a thin, flexible tube inserted into the bladder to drain urine outside the body) than what the Physician ordered.

Inspectors wroteBased on record review, and interview, the facility failed to resolve a grievance timely for one Resident (#40) out of a total sample of 20 residents. Specifically, the facility failed to ensure for Resident #40 that a reported grievance of missing clothing was resolved in a reasonable time period.

Inspectors wroteBased on observation, record review, and interview, the facility failed to protect one Resident's (#42) right to be free from neglect, out of a total sample of 20 residents. Specifically, the facility failed to provide goods and services to Resident #42 relative to his/her request for a snack, resulting in Resident #42 attempting to exit the facility, wandering into other resident rooms, and displaying restlessness and agitation.

Inspectors wroteBased on observation, and interview, the facility failed to ensure medications were administered according to professional standards of practice on one unit (Willow) out of a total of two units. Specifically, the facility failed to ensure that medications were administered to one resident at a time to mitigate the risk for medication errors.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide grooming assistance for one Resident (#51), out of a total sample of 20 residents. Specifically, the facility failed to ensure that Resident #51 was assisted with facial hair removal when he/she required assistance from staff with personal hygiene.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain orders for wound treatments in accordance with professional standards of practice for two Residents (#49 and #56) out of a total sample of 20 residents. Specifically, the facility failed to: 1. For Resident #49, ensure that hospital discharge recommendations for treatment of the Resident's skin condition were appropriately implemented placing the Resident at risk for worsening of the skin conditions. 2. For Resident #56, obtain a Physician order for wound treatments recommended by the Wound Doctor resulting in the Resident's sacral wound not being treated timely.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one Resident (#117) out of a total sample of 20 residents, was free from potential accidents/hazards. The facility also failed to minimize risk of accident/hazards during medication pass on one of two units observed. Specifically, 1. For Resident #117, the facility failed to ensure one to one (1:1) direct supervision was provided during oral intake as ordered by the Physician, increasing the potential risk of choking and aspiration (food/fluids that enters the lungs). 2. On the [NAME] Unit, the facility failed to ensure that poured medications were maintained in a safe manner to prevent access to and accidental ingestion by residents for whom the poured medication was not intended to be administered.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide respiratory care and services consistent with professional standards of practice for one Resident (#4) out of a total sample of 20 residents. Specifically, the facility failed to ensure that the correct oxygen flow rate was administered to Resident #4 as ordered by the Physician.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that care and services for pain management consistent with professional standards of practice were provided for one Resident (#9) out of a total sample of 20 residents. Specifically, the facility failed to provide pain management interventions as ordered for Resident #9 when the Resident reported pain and was dependent on staff to receive as needed and scheduled pain medication and non-pharmacological measures to treat his/her pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate medical care and Physician supervision for one Resident (#12) out of a total sample of 20 Residents. Specifically, for Resident #12, the facility failed to ensure that the Provider was aware of the Resident's weight loss and management of his/her nutritional status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that resident preferences were obtained and implemented by the facility kitchen for four Residents (#1, #56, #117 and #20) and resident council participants. Specifically, the facility failed to: -For Resident #1, provide food that accommodated the Resident's preferences. -For Resident #56, provide food and drink that accommodated the Resident's preferences. -For Resident #117, provide food that accommodated the Resident's preferences. -For Resident #20, provide food that accommodated the Resident's preferences. -provide food items that were appropriate and accommodated resident allergies, intolerances and preferences. -provide appealing substitutes of similar nutritive value.

Inspectors wroteBased on interview, and record review, the facility failed to implement antibiotic monitoring system for one Resident (#118) out of a total sample of 20 residents. Specifically, for Resident #118, who was diagnosed with a urinary tract infection (UTI) and started on antibiotics, the facility failed to ensure their antibiotic surveillance tracking form was updated and maintained to include all pertinent information relative to monitoring Resident #118's infection and use of antibiotics.

Inspectors wroteBased on record review, and interview, the facility failed to ensure that one Resident (#60) out of a total sample of five residents reviewed for immunization, was screened for eligibility to receive the recommended pneumococcal vaccination, that the Resident and/or his/her Resident Representative was educated on the benefits and potential side effects of the vaccine, and were offered and administered (if applicable) the vaccine in a timely manner. Specifically, the facility failed to ensure that Resident #60 was offered the Pneumococcal Conjugate Vaccine (PCV-a vaccine that helps protect against diseases caused by pneumococcal bacteria) at the time of admission or shortly thereafter, putting the Resident at risk for developing facility acquired Pneumonia.

Inspectors wroteBased on record review, and interview, the facility failed to ensure screening for eligibility to receive the recommended COVID-19 vaccination, education on the benefits and potential side effects of the vaccine was provided to the Resident and/or Resident Representative, and COVID-19 vaccines were offered and administered (if applicable) in a timely manner, for two Residents (#4 and #60) out of a total sample of five Residents reviewed for immunizations. Specifically, the facility failed to ensure that: 1. [...]

Inspectors wroteBased on observation, and interview, the facility failed to ensure that electrical bed equipment was maintained in a safe operating condition for one Resident (#2) out of a total sample of 20 residents. Specifically, for Resident #2, the facility failed to ensure that the bed remote control remained in safe working condition when the Resident's bed remote control cord that was currently in use was identified to be frayed with exposed electrical wires.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), whose Health Care Proxy had been activated in October of 2023, the Facility failed to maintain Resident #1's rights related to obtaining copies of medical record information, when his/her Health Care Agent (HCA) requested copies of documentation from his/her medical record, and did not receive those copies, in accordance with the regulation.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain a safe, clean, homelike environment on two units (Orchard Unit and [NAME] Unit) out of two units observed. Specifically, the facility failed to: 1. Ensure the carpet was clean and in good repair throughout the main hallway and the resident care area. 2. Ensure mattresses used by the residents were in good condition. 3. Ensure a toilet in one resident room was adequately maintained for resident use. 1. On 11/5/23 at 8:30 A.M., the surveyor observed the wall-to-wall carpet that connected the [NAME] Unit to the Orchard Unit to have numerous black stains which continued throughout the Orchard Unit where residents resided. The black stained areas covered large areas of the carpeting and were too numerous to count. [...]

Inspectors wroteBased on record review and interview, the facility failed to notify the Office of the State Long Term Care Ombudsman when a resident was transferred from the facility for five Residents (#6, #40, #36, #50, and #57) out of a total sample of 20 residents.

Inspectors wroteBased on records reviewed and interviews the facility failed to: 1. Ensure the Consultant Pharmacist recommendations were addressed timely for one Resident (#14) out of five applicable residents, from a total sample of 20 residents. 2. Develop a comprehensive Medication Regimen Review (MRR) policy.

Inspectors wroteBased on observations, interviews and policy review, the facility failed to the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the main kitchen. Specifically, the facility failed to: 1. maintain the main kitchen in a clean and sanitary manner to prevent contamination and food-borne infections. 2. ensure that staff wore hair/beard restraints and used gloves appropriately in the food service area to prevent contamination.

Inspectors wroteBased on interviews and record reviews, the facility failed to include effective communications as mandatory training for four out of four direct care staff. Specifically, the facility did not offer any communications training for staff that included using visual aids, body language communications and making adjustments to communication methods as required.

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to ensure resident meals were palatable and served at appropriate temperatures on one Unit (Willow) out of two units observed.

Inspectors wroteBased on observations and interviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for the residents and staff in the facility laundry room.

Inspectors wroteBased on observation, interviews, and records reviewed for one Resident (#36) out of a total sample of 20 residents, the facility failed to ensure that the physical environment met the Resident's needs. Specifically, the facility failed to ensure that the Resident who was deemed at risk for falls, and with a history of falls, had access to his/her call bell at all times.

Inspectors wroteBased on interview and record review the facility failed to re-submit a Level 1 Preadmission Screening and Resident Review (PASARR- is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. PASARR requires that: 1) all applicants to a Medicaid-certified nursing facility be evaluated for serious mental disorder and/or intellectual disability, 2) be offered the most appropriate setting for their needs [in the community, a nursing facility, or acute care setting], and 3) receive the services they need in those settings) when it was identified that one Resident (#41) out of a total sample of 20 residents, had a serious mental illness.

Inspectors wroteBased on observations, interviews and records reviewed for one Resident (#116) out of a total sample of 20 residents, the facility failed to initiate baseline care plans within 48 hours, as required. Specifically, the facility failed to initiate a baseline care plan relative to the Resident's inability to speak or understand English.

Inspectors wroteBased on observations, interviews, and records reviewed for one Resident (#50) out of a total sample of 20 residents, the facility failed to develop a person-centered care plan. Specifically, the facility failed to develop a care plan relative to the Resident seeking of food and beverages that would be detrimental to his/her health, putting him/her at risk for aspiration (when something, such as food or liquid enters the airway or lungs by accident).

Inspectors wroteBased on record review and interview, the facility failed to ensure a final discharge summary included, but not limited to, course of illness/treatment, reconciliation of medication, and any follow-up care arrangements/services, for one Resident (#63) out of two closed records reviewed.

Inspectors wroteBased on observations, interviews and records reviewed for one Resident (#116) out of a total sample of 20 residents, the facility failed to ensure that the necessary interventions were in place to meet the Resident's communication needs. Specifically, the facility failed to provide the Resident, who did not speak or understand English, a functional communication system to meet his/her needs.

Inspectors wroteBased on observation, record review, and interview, the facility staff failed to provide assistance for one Resident (#12), out of a total sample of 20 residents. Specifically, the facility staff failed to provide shower and grooming/ maintaining facial hair for a Resident who was unable to carry out activities of daily living (ADLs).

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an environment that was free from possible hazards for two Residents (#44 and #50) out of a total sample of 20 residents. Specifically, 1. For Resident #44, the facility failed to ensure the Resident's bed remained free from gaps between the footboard and the mattress to reduce the risk for possible entrapment (when a person becomes trapped between the mattress and headboard, footboard, or bed rails on a bed) 2. For Resident #50, the facility failed to ensure his/her environment was free from easily accessible thin liquids when he/she was on a thickened liquid diet.

Inspectors wroteBased on observations, interviews, and records reviewed for one Resident (#14) out of a total sample of 20 residents, the facility failed to ensure that the oxygen concentrator (a device that pulls air from the room, and filters it into purified oxygen for breathing) was maintained in a clean and sanitary manner per professional standards. Specifically, the facility failed to ensure that the Resident's oxygen concentrator was maintained in a clean and sanitary manner for the Resident's use and to prevent equipment contamination.

Inspectors wroteBased on record review and interviews, for one Resident (#17) of five applicable residents, out of a total sample of 20 residents, the facility failed to ensure a gradual dose reduction (GDR) was attempted by the Physician for the Resident receiving a psychotropic medication.

Inspectors wroteBased on interview, policy and record review, the facility failed to ensure that complete and accurate medical records were maintained for two Residents (#40 and #44) out of a total sample of 20 residents. Specifically, 1. For Resident #40, the facility failed to ensure documentation for care plan meetings were completed. 2. For Resident #44, the facility failed to ensure documentation in the Resident's Care Plan and Physician's orders accurately matched the Resident's Massachusetts Medical Orders for Life Sustaining Treatment (MOLST-a medical order form that relays instruction between health professionals about a patient's care).

Inspectors wroteBased on record reviews, policy reviews and interviews, the facility failed to ensure that two Resident's (#14 and #17) out of five sampled residents, was offered and administered the Pneumococcal Vaccine.