Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Westfield Rehabilitation And Health Center during CMS and state inspections, most recent first.
Surveyors found that the facility did not follow approved menus, failed to post accurate daily menus, and did not notify residents of menu substitutions. Residents on pureed diets were served leftover meals from previous days without being informed, and alternate menu options were inadequate. The Food Service Director and dietary staff did not document substitutions or maintain records of meals served, and residents expressed dissatisfaction with the food and lack of communication about menu changes.
Surveyors found the kitchen environment unsanitary, with dirty equipment, improper food thawing, unlabeled and undated food items, and inconsistent documentation of food and dishwashing temperatures. Staff failed to follow cleaning schedules and food safety protocols, and the ice machine was overdue for cleaning and visibly soiled.
Two residents with chronic medical conditions reported a broken bathroom sink handle in their shared room, which remained unrepaired for an extended period despite multiple reports to maintenance. Staff interviews confirmed the issue had persisted for months, and the Maintenance Director stated no work orders had been received to address the problem.
Staff did not follow physician orders for a Foley catheter with a 10cc balloon for a resident with urinary retention and chronic kidney disease, instead using a catheter with a 5cc balloon without notifying the provider or obtaining a new order. The correct catheter size was not available in the facility, and staff made independent decisions to substitute supplies, leading to complications such as catheter dislodgement and hematuria.
Two residents did not receive proper nutritional care and services: one with ESRD on dialysis was not accurately monitored for fluid intake as ordered, resulting in multiple days of exceeding fluid restrictions without proper documentation or notification to the medical team; another experienced significant weight loss without a required re-weight or timely notification to the physician or dietician, due to lapses in documentation and communication among staff.
The facility did not ensure that food was palatable or served at safe, appetizing temperatures, as evidenced by multiple resident complaints about cold and unappealing meals, insufficient portions, lack of menu variety, and untimely tray delivery. Staff interviews and food committee notes confirmed ongoing concerns, and a surveyor's test tray found hot food items below required temperatures. The Food Service Director acknowledged equipment issues and lack of recent test tray monitoring.
The facility did not maintain accurate and complete medical records for four residents, including failures to document 24-hour fluid intake for a resident on fluid restriction, incomplete MOLST forms lacking required clinician signatures, and missing or delayed provider progress notes in the clinical records. These deficiencies resulted in incomplete documentation of care and resident wishes.
Multiple failures in infection prevention and control were observed, including lack of surveillance for a resident with Shingles, improper disinfection of a glucometer, and staff not following Enhanced Barrier Precautions or droplet precautions for residents with communicable diseases. Staff did not consistently use required PPE during high-contact care and when entering isolation rooms, despite clear policies and signage.
A resident with renal failure and coronary heart disease, who was cognitively intact, was observed during a rehab therapy session lying in bed with their legs and incontinence brief exposed, visible from the hallway due to an open door and undrawn privacy curtain. Rehab staff was present, and both a nurse and the Director of Rehabilitation confirmed that privacy measures, such as closing the door or curtain, should have been used to protect the resident's dignity.
Five residents reported that their nightstand locked drawers were either nonfunctional or lacked keys, preventing them from securing personal belongings. Despite raising concerns with staff, no action was taken, and some residents resorted to purchasing their own lockboxes. Staff interviews revealed confusion about responsibility for providing keys and a lack of documentation or follow-through on maintenance requests for secure storage.
A resident with dementia and mobility impairments, who required substantial assistance with personal care, was found without access to a call light while waiting for staff help. The call light was discovered on the floor, out of reach, despite the care plan specifying it should be accessible. Staff interviews confirmed the resident's dependence on assistance and the inaccessibility of the call light at the time.
Three residents did not have their advanced directives properly documented or implemented, resulting in discrepancies between their expressed wishes and physician orders. In one case, a resident's MOLST form was not signed by a physician, making their DNI/DNV preferences invalid. Another resident's MOLST was not updated or reviewed as ordered, and a third resident's MOLST and physician orders conflicted, with staff acknowledging the inconsistency.
Staff did not notify the physician when a different sized Foley catheter was used for a resident than what was ordered. Nursing staff used a 16 Fr catheter with a 5cc balloon instead of the ordered 10cc balloon, and neither the physician nor the DON were informed of this change, contrary to facility policy.
A resident with ESRD, who was cognitively intact, reported missing clothing on two occasions. The facility did not resolve the grievance within the required 5 to 7 business days, failed to document resolution and resident satisfaction, and did not follow up with the resident until prompted by a surveyor.
A resident with dementia and other mental health diagnoses repeatedly requested a snack from two nurses, who acknowledged but did not fulfill the request. The resident became agitated, attempted to leave the facility, and wandered into other rooms, expressing frustration and hunger. Staff redirected the resident but did not provide the snack, resulting in emotional distress and behavioral issues.
A nurse was observed preparing and carrying multiple medication cups and drinks on a tray, some without proper labeling, and administering them to residents sequentially rather than one at a time. This practice did not follow professional standards, which require medications to be administered to one resident at a time to ensure accuracy and prevent errors. The expectation for single-resident medication administration was confirmed by another nurse covering for the DON.
A resident with severe cognitive impairment and dementia, who required staff assistance for personal hygiene, was repeatedly observed with significant facial hair growth. Despite being receptive to care and having a care plan indicating the need for staff support with grooming, staff did not provide the necessary assistance with facial hair removal, as confirmed by multiple staff interviews and observations.
Two residents did not receive timely and appropriate wound care due to the facility's failure to obtain and implement physician orders as recommended by hospital discharge instructions and a wound doctor. One resident with dementia did not receive Bacitracin for cellulitis as ordered at hospital discharge, and another with diabetes and chronic kidney disease did not receive zinc paste for a sacral wound, despite repeated recommendations. Nursing staff did not ensure the recommended treatments were initiated or properly documented.
A resident with a history of TIA, dysphagia, and aspiration pneumonia was not provided the required 1:1 supervision during meals, as ordered by the physician, and was repeatedly observed eating independently without staff present. Staff documentation and interviews showed inconsistent awareness and implementation of the supervision requirement. Additionally, a nurse left prepared medications unattended during a med pass, creating a risk of accidental ingestion by other residents.
A resident with COPD who required supplemental oxygen was observed receiving oxygen at a higher flow rate (2 LPM) than what was ordered by the physician (1.5 LPM) on multiple occasions. Staff were unaware of the reason for the incorrect setting, and the resident did not have access to adjust the equipment.
A resident with diabetic neuropathy experienced ongoing severe pain despite being prescribed scheduled and PRN pain medications. Staff documented frequent high pain scores but did not provide PRN medication or non-pharmacological interventions as ordered, nor did they notify the provider or act on recommendations for further pain management such as acupuncture. The DON and nursing staff were unaware of the resident's persistent pain and the lack of follow-up on pain management recommendations.
A resident with hemiplegia and moderate cognitive impairment experienced significant weight loss over several months, but the provider was not notified as required by facility policy. Weight changes were recorded by CNAs and entered into the medical record, but no documentation showed physician notification or intervention, and the nurse practitioner confirmed she was unaware of the weight loss.
The facility did not consistently obtain or implement resident food preferences, allergies, and intolerances, resulting in several residents receiving meals that did not meet their needs or requests. Residents reported issues with meal portions, lack of variety, and receiving inappropriate food items, while staff interviews revealed that preferences were not routinely updated or documented. Limited and unsuitable snack options further contributed to resident dissatisfaction.
A resident who was readmitted with a UTI and prescribed antibiotics did not have their infection or antibiotic use documented on the facility's antibiotic surveillance tracking form, as required by policy. The DON confirmed that the resident should have been included on the line listing for monitoring, but the documentation was incomplete and not updated as expected.
A resident was not screened for pneumococcal vaccine eligibility, and there was no documentation that the vaccine was offered or that education was provided about its benefits and side effects. Nursing staff confirmed that immunization history and consent or refusal should have been obtained at admission, but no such documentation was found in the medical record.
Two residents did not receive appropriate COVID-19 vaccine education, consent, and timely administration. In one case, a Health Care Proxy was not properly consulted or educated before vaccination, and in another, a resident did not receive the vaccine in a timely manner after consenting, with no documentation explaining the delay.
A resident was found using a bed remote control with a frayed cord and exposed wires, which had been in this condition for about a week. Staff familiar with the resident did not notify maintenance as required, and the Maintenance Director was unaware of the issue until the survey. The deficiency involved failure to ensure electrical equipment was kept in safe working order.
Failure to Follow and Communicate Resident Menus and Dietary Substitutions
Penalty
Summary
The facility failed to ensure that resident menus were followed, posted accurately, and updated as required. Surveyors observed that the meals served to residents did not match the approved facility menus on multiple occasions. For example, on several dates, the dinner and lunch meals provided to residents were different from those listed on the approved menus. Additionally, the daily menus posted for residents did not always reflect the actual meals served, and breakfast menus were not posted at all. Residents were not notified of menu substitutions, and there was no documentation of these changes. Residents requiring pureed diets were not informed about their meals and were served leftover food from previous meals, rather than receiving the same meal as other residents in a pureed form. The Food Service Director (FSD) and dietary staff confirmed that leftover meals were routinely pureed and served to residents on pureed diets, and that this practice was not documented or communicated to residents. The Registered Dietitian (RD) was unaware that this outdated practice was still occurring and stated that pureed meals should match the menu items served to other residents. The facility also failed to provide adequate alternate menu options and did not maintain records of what was actually served to residents. The FSD was unable to provide menus for previous weeks or months and did not use substitution logs. Residents and staff reported that menu changes were made based on food availability and resident preferences, but these changes were not communicated or documented. The facility's inventory and ordering practices were inconsistent, and the FSD relied on a single vendor, leading to frequent substitutions and omissions of menu items such as Lactaid milk. Residents expressed dissatisfaction with the food, and concerns were noted in Food Committee and Resident Council meetings regarding menu accuracy, portion sizes, and dietary accommodations.
Failure to Maintain Kitchen Sanitation and Food Safety Standards
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in the main kitchen, as evidenced by multiple observations of unclean surfaces, equipment, and improper food handling practices. Surveyors observed visibly dirty shelves with clean pots, pans, coffee pots, and pitchers, as well as a toaster caked with dark crumbs and air conditioners with visible dust blowing over food preparation areas. An open box of wrapped turkey breasts was left out on a counter to thaw, and the ice machine in use had black and brown discoloration on internal parts. Additionally, large packages of uncooked meat in the freezer were found unlabeled and undated. Food safety procedures were not consistently followed. Dietary staff did not always obtain or document food temperatures prior to meal service, and some staff were unsure of the required cleaning frequency for equipment such as the toaster. Food was observed being reheated in the microwave and served to residents without temperature checks, and the staff member serving pureed food was unaware of the meal's contents. Review of temperature logs revealed multiple instances where food temperatures were not recorded for various meals, and the steam table was used with uncovered wells, allowing heat to escape. The dishwashing machine was also not maintained according to manufacturer guidelines, with multiple wash cycles failing to reach the required minimum temperature. Logs showed repeated instances of substandard wash temperatures, and staff did not consistently notify maintenance when issues occurred. The ice machine was overdue for contracted cleaning, and maintenance staff confirmed it was not clean and should not be used. Facility policies regarding cleaning schedules, equipment sanitation, and food labeling were not followed, and staff interviews revealed a lack of awareness and adherence to these protocols.
Failure to Repair Broken Bathroom Sink in Shared Resident Room
Penalty
Summary
The facility failed to maintain a safe and homelike environment for two residents who shared a room, as evidenced by a broken bathroom sink handle that was not repaired over an extended period. Both residents, who were cognitively intact and had significant medical diagnoses (Type 2 Diabetes and End Stage Renal Disease), reported the issue to maintenance multiple times without resolution. Observations confirmed that the hot water handle was broken off and difficult to turn, and both residents stated the sink had been in this condition for a long time. Interviews with staff revealed that the broken sink handle had been an ongoing issue, with a nurse stating it had been broken since she started working at the facility six months prior. The Maintenance Director indicated that he had not received any work orders to repair the sink, despite multiple reports from residents. Additional staff confirmed that the sink had not been repaired since it was first broken. These findings demonstrate a failure to address and resolve a maintenance issue that directly impacted the residents' environment.
Failure to Follow Physician Orders for Foley Catheter Size and Balloon Volume
Penalty
Summary
Facility staff failed to follow physician orders regarding the size of a Foley catheter and balloon for a resident with a history of urinary tract infection, urinary retention, and chronic kidney disease. The physician's order specified a 16 French Foley catheter with a 10cc balloon, but on multiple occasions, staff used a catheter with a 5cc balloon without notifying or consulting the physician or physician assistant. Documentation showed that the correct size catheter was not available in the facility, and staff made independent decisions to use a different size without obtaining a new order or documenting provider approval. Nursing notes indicated that the resident experienced issues such as the catheter being partially out of the bladder, the presence of blood clots, and hematuria. Despite these complications, there was no evidence that the physician or PA was informed about the use of a different catheter size or the unavailability of the ordered supplies. Interviews with nursing staff and the DON confirmed that the provider should have been notified and a new order obtained when a different catheter size was used, but this did not occur. The DON was unaware that the correct catheter size was not in stock and expressed surprise that this issue was not identified during a previous audit. The medical supplies coordinator stated that the facility's supplier did not carry the required catheter size and that she had not stocked the 16 Fr Foley catheter with a 10cc balloon during her tenure. The PA confirmed she was not informed about the substitution and would have expected to be notified. The lack of communication and failure to follow physician orders resulted in the resident receiving care that did not align with prescribed treatment, as well as the use of supplies not matching the physician's specifications.
Failure to Monitor Fluid Intake and Weight Loss in Two Residents
Penalty
Summary
The facility failed to provide nutritional care and services according to professional standards of practice for two residents. For one resident with end stage renal disease (ESRD) and on dialysis, the facility did not accurately monitor and assess fluid intake as ordered by the physician. The resident was on a strict 1200 ml fluid restriction, with specific amounts allocated per shift and a requirement to total and record 24-hour fluid intake. However, documentation showed that the resident exceeded the daily fluid limit on multiple occasions, and there was no evidence that 24-hour fluid totals were consistently obtained or assessed. Nursing staff acknowledged the fluid restriction in the Medication Administration Record (MAR) with check marks, but did not record actual intake amounts, and there was no communication to the medical team when the resident exceeded the prescribed limit. Staff interviews revealed confusion about documentation procedures and a lack of training on how to total and record fluid intake, despite facility policy requiring accurate measurement and reporting. For another resident, the facility failed to obtain a re-weight after a significant weight loss, as required by facility policy. The policy stated that any weight change of 5 pounds or more should be retaken for confirmation, and if verified, the physician and dietician should be notified. The resident experienced a weight loss of 15 pounds between two monthly weigh-ins, but there was no documentation of a re-weight or notification to the physician or dietician. The December weight was not initially entered into the electronic medical record (EMR), and staff interviews indicated that the dietician was unaware of the resident's weight loss and had repeatedly requested updated weights without receiving them. The nurse practitioner following the resident was also not informed of the weight loss. These deficiencies were identified through observation, interview, and record review, and involved failures to follow established facility policies and physician orders regarding fluid restriction monitoring and weight assessment. The lack of accurate documentation, communication, and adherence to professional standards contributed to the deficiencies in nutritional care and services for both residents.
Failure to Provide Palatable and Properly Tempered Food
Penalty
Summary
The facility failed to ensure that food provided to residents was palatable and served at appropriate temperatures on one of its units. Multiple residents reported concerns regarding the quality and temperature of meals, including complaints about small breakfast portions, lack of menu variety, repetitive foods, and insufficient fruit. Several residents described the food as unappetizing, with some stating that hot food was served cold, vegetables were hard or overcooked, and desserts lacked variety or toppings. Residents also noted that beverages were not served at the correct temperatures and that meal trays were not distributed in a timely manner, resulting in further temperature issues. These concerns were echoed during a resident council meeting, where the majority of participants expressed dissatisfaction with the food's temperature and quality. Interviews with nursing staff confirmed that residents had made numerous complaints about the meals, but no changes had been observed. Review of food committee meeting notes from previous months revealed ongoing concerns about food temperature, portion sizes, repetitive menu items, and overcooked food. During a surveyor's test tray observation, hot food items were found to be served below the required temperature, and no dessert was provided. The Food Service Director acknowledged awareness of previous temperature concerns and attributed ongoing issues to old, poorly insulated food carts, but had not conducted test trays for an extended period.
Failure to Maintain Complete and Accurate Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for four residents, resulting in deficiencies related to documentation and safeguarding of resident-identifiable information. For one resident with end stage renal disease and chronic heart failure on a strict fluid restriction, the facility did not accurately document the total 24-hour fluid intake as ordered by the physician. Although staff recorded fluid intake per shift and signed off on the Medication Administration Record (MAR), there was no documentation of the actual amounts consumed in a 24-hour period, and staff expressed confusion about how to record this information in the electronic medical record. Another resident's Medical Order for Life Sustaining Treatment (MOLST) form was incomplete, as it lacked the required clinician signature and date, rendering the resident's wishes regarding resuscitation and intubation invalid. The clinical record contained conflicting information about the resident's code status, with discrepancies between the MOLST form, care plan, provider notes, and physician orders. The Director of Nursing acknowledged that the MOLST form should not have been filed in the record without the necessary signatures, and that the resident's wishes could not be honored as a result. For two additional residents, the facility failed to ensure that medical provider progress notes were present and accessible in the clinical record. In one case, there were no provider notes uploaded for a resident following admission and readmission, and the delay was attributed to staffing issues with uploading documents. In the other case, there were no physician progress notes in the record for over 120 days, despite the nurse practitioner having documentation for the missing months. These lapses resulted in incomplete medical records for the affected residents.
Infection Control Program Deficiencies and PPE Noncompliance
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, resulting in multiple deficiencies across several areas. For one resident diagnosed with Shingles, the facility did not conduct ongoing surveillance as required. The infection was not tracked on the facility’s infection line listing, and there was no documentation of monitoring for changes in the resident’s condition. The Director of Nursing acknowledged that the resident should have been followed on the line listing and that the documentation was incomplete. During medication administration, a nurse failed to properly disinfect a glucometer after use. The nurse placed the contaminated glucometer, with the used test strip still attached, into a storage bin containing clean supplies, and only disinfected it after this contamination occurred. The same glucometer and supplies were then prepared for use on another resident before the surveyor intervened. The nurse later confirmed that the glucometer should have been disinfected before being placed with clean supplies. Staff also failed to follow Enhanced Barrier Precautions (EBP) and droplet precautions in multiple instances. One nurse did not don a gown while administering medication and tube feeding to a resident on EBP, despite signage indicating this requirement. Another nurse did not change gloves or perform hand hygiene between cleaning a wound and applying a clean dressing, and exited the resident’s room without doffing gown and gloves, returning with soiled PPE still in place. Additionally, staff entering the room of a resident on droplet precautions for COVID-19 did not consistently wear the required PPE, such as N95 masks, gloves, gowns, and eye protection, despite clear signage and available supplies.
Failure to Provide Privacy and Dignity During Therapy Session
Penalty
Summary
A deficiency occurred when a resident was not provided with adequate privacy and dignity during a rehabilitation therapy session. The resident, who had diagnoses including renal failure and coronary heart disease and was cognitively intact, was observed lying in bed in a hospital gown with their legs and incontinence brief exposed. The door to the room was open, and the privacy curtain was not drawn, allowing the resident to be visible from the hallway. Rehabilitation staff was present at the bedside, providing verbal instructions for the resident to move from a lying to a seated position facing the doorway. A nurse, upon being asked to observe the session, confirmed that the resident was exposed and that the incontinence brief was visible. The nurse stated that the privacy curtain or the door should have been closed to maintain the resident's dignity and privacy. The Director of Rehabilitation also acknowledged that privacy measures should have been implemented during the treatment session. The facility's policy requires staff to promote, maintain, and protect resident privacy, including bodily privacy during care and treatment procedures.
Failure to Provide Secure Storage for Residents' Personal Belongings
Penalty
Summary
The facility failed to provide secure storage for residents' personal belongings as required by its own admission agreement, which states that each resident will be provided with a locked space and a key for their bedside table drawer. During a Resident Council meeting, five out of nine residents reported that their nightstand locked drawers either did not work or they did not have a key to secure their belongings. One resident expressed concern about other residents wandering into rooms and the inability to lock up personal items, while another stated they had to purchase their own lockbox because the facility did not provide one. All five residents indicated they had previously raised these concerns with staff, but no action had been taken to resolve the issue. Interviews with staff revealed a lack of clarity and follow-through regarding the provision of keys and secure storage. A nurse was unsure who was responsible for offering keys at admission, and the Maintenance Director acknowledged that not all drawers worked and that padlocks were provided only upon request, with no documentation maintained to track these requests. The Maintenance Director also confirmed that, despite receiving requests from two residents, padlocks had not been provided as of the survey date. The Director of Marketing and Admissions confirmed that keys should be available at admission, and the Administrator stated that an audit had been ordered to ensure compliance, but no documentation of such an audit was provided to the survey team.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
The facility failed to provide reasonable accommodations for a resident by not ensuring that the resident's call light was accessible when needed. The resident, who had a history of repeated falls, abnormal gait, mobility issues, and dementia, required substantial to maximum assistance with activities such as toileting, bathing, and dressing, and was dependent on staff for transfers. The resident's care plan specifically included interventions to anticipate needs and ensure the call light was within reach. However, during an observation, the resident was found seated in a wheelchair, unclothed from the waist up, and holding a face cloth over the chest, with the call light not visible or accessible. The call light was later found on the floor between two beds, out of the resident's reach. Interviews with staff confirmed that the resident required assistance with all care and was able to use the call light when it was accessible. The assigned CNA had not yet provided care during the shift, and another CNA confirmed the call light was not accessible when she entered the room. The nurse covering for the DON was also notified of the situation and acknowledged that the call light should have been accessible to the resident.
Failure to Ensure Residents' Advanced Directives Are Documented and Honored
Penalty
Summary
The facility failed to ensure that residents' wishes regarding advanced directives were properly documented, reviewed, and implemented, resulting in discrepancies between residents' expressed preferences and the medical orders in their records. For one resident with Type 2 Diabetes and Protein-Calorie Malnutrition, a MOLST form indicating a desire for Do Not Intubate (DNI) and Do Not Ventilate (DNV) was signed by the resident but not by a physician, rendering the form invalid. Despite the resident's wishes, the clinical record and physician orders listed the resident as full code, and the advanced directives care plan was not accurate. Another resident with Rheumatoid Arthritis and moderate cognitive impairment had an active physician order to obtain a new MOLST form reflecting Do Not Resuscitate (DNR), Do Not Hospitalize (DNH), and DNI status. However, the existing MOLST form indicated the opposite preferences, and there was no evidence that the new MOLST was obtained or reviewed with the resident, who confirmed in an interview that no one had discussed code status or advanced directives with them, despite their wish not to have CPR performed. A third resident, who was severely cognitively impaired and admitted to hospice, had a MOLST form completed by their activated healthcare proxy indicating DNR and DNI status, but the physician's order in the record still indicated CPR. Staff acknowledged that the physician order should match the MOLST form and that the process for updating orders after a MOLST is completed was not followed, creating the potential for care inconsistent with the resident's or proxy's wishes.
Failure to Notify Physician of Change in Foley Catheter Size
Penalty
Summary
Facility staff failed to notify or consult with the physician when a different sized Foley catheter was used for a resident than what was ordered. The physician's order specified a 16 French Foley catheter with a 10cc balloon, but nursing documentation showed that a 16 French catheter with a 5cc balloon was used instead. The nurse who inserted the catheter stated she filled the balloon to 5ccs to ensure the catheter was secure and comfortable for the resident, and there were no reported issues with the new catheter at that time. However, the facility's policy requires prompt notification of the physician and resident representative when there is a need to alter the resident's medical treatment significantly. Interviews with nursing staff and the Director of Nursing confirmed that the physician or physician assistant should have been notified and a new order obtained when a different sized catheter was used. The Director of Nursing was unaware that the correct size was not available and stated that the physician, PA, and herself should have been informed to further assess the issue. The physician assistant also confirmed she was not notified about the use of a different sized catheter and would have expected to be informed of such a change.
Failure to Resolve Resident Grievance Regarding Missing Clothing in a Timely Manner
Penalty
Summary
The facility failed to resolve a resident's grievance regarding missing clothing within the timeframe specified by its own grievance policy. The policy states that grievances should be reviewed and completed within 5 to 7 business days, and that the grievance official is responsible for tracking grievances through completion. A resident, who was cognitively intact and admitted with End Stage Renal Disease, reported missing clothing, including a Led Zeppelin shirt, on two separate occasions. The grievance forms related to these reports were either incomplete or not resolved within the required timeframe, with one form missing resolution and satisfaction documentation and another indicating a resolution date well beyond the policy's timeframe. Interviews revealed that the resident had not been informed of any resolution or received the missing items back, despite being told at one point that the items had been found. The administrator acknowledged that there was no evidence or log to support the completion date or resident satisfaction as indicated on the grievance form. The social worker confirmed that the grievance was not resolved within the policy's 5 to 7 day timeframe, and the resident stated that no follow-up had occurred until the day of the surveyor's inquiry.
Failure to Provide Requested Snack Leads to Resident Distress and Neglect
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect by not providing requested goods and services, specifically a snack, despite multiple requests from the resident. The resident, who had diagnoses of Major Depressive Disorder, Dementia, and Generalized Anxiety Disorder, was observed making repeated verbal requests for a snack to two nurses, both of whom acknowledged the requests but did not provide the snack. The resident became increasingly agitated, restless, and attempted to exit the facility, wandered into other residents' rooms, and expressed frustration and hunger. Staff were observed redirecting the resident but still did not fulfill the request for a snack during the observation period. The resident's care plans indicated a need to monitor snacks and provide extra fluids, and noted a preference for soda and sweets. Interviews with CNAs confirmed that the resident was able to communicate basic needs and had no food limitations. The administrator acknowledged that staff could have provided a snack and noted that staff are not permitted to eat in resident care areas, referencing an additional concern about infection control. The failure to provide the requested snack resulted in the resident experiencing emotional distress and behavioral disturbances.
Failure to Administer Medications to One Resident at a Time
Penalty
Summary
The facility failed to ensure that medications were administered according to professional standards of practice on one unit, specifically by not administering medications to one resident at a time. During observations, a nurse was seen carrying a tray with multiple medication cups and drinks, some of which were unlabeled or only partially labeled, into resident rooms and administering medications to residents sequentially from the same tray. The nurse acknowledged that the process was to pour and administer medications to one resident at a time, but this was not followed. Another nurse, covering for the Director of Nursing, confirmed that the expectation is to administer medications to one resident at a time to ensure accuracy. These actions did not align with professional standards outlined in the Lippincott Nursing Procedures, which emphasize avoiding distractions and administering medications individually to prevent errors.
Failure to Provide Grooming Assistance for Resident with Cognitive Impairment
Penalty
Summary
The facility failed to provide necessary grooming assistance to a resident with severe cognitive impairment and dementia, who required staff support for personal hygiene tasks, including facial hair removal. The resident was observed on multiple occasions to have significant facial hair growth, measuring approximately one to one and a half inches on the upper lip and chin, despite being out of bed and dressed for the day. The resident's care plan indicated a need for one staff member to assist with personal hygiene, and the Minimum Data Set assessment confirmed the requirement for supervision with grooming and facial hair removal. Interviews with facility staff, including a CNA and a nurse, confirmed that the resident was receptive to assistance and that staff were responsible for helping with facial hair removal. The CNA noted that the resident's facial hair appeared to have not been removed for some time and required staff intervention with a razor. The Director of Nursing acknowledged that staff should assist with unwanted facial hair removal and that the resident was cooperative with this care. Despite these requirements and staff awareness, the resident was not provided with the necessary grooming assistance, resulting in the deficiency.
Failure to Obtain and Implement Physician Orders for Wound Treatments
Penalty
Summary
The facility failed to obtain and implement physician orders for wound treatments in accordance with professional standards of practice for two residents. For one resident with dementia, hospital discharge instructions recommended Bacitracin ointment for cellulitis of the left hand. However, upon admission, no treatment order for Bacitracin was entered into the physician orders, and the recommendation was not addressed with a physician. Nursing staff observed the resident’s bandaged hand but did not ensure the recommended treatment was initiated, and there was confusion among staff regarding the process for obtaining and documenting verbal orders. For another resident with type 2 diabetes and chronic kidney disease, the wound doctor recommended zinc paste for a sacral wound identified as moisture-associated skin damage (MASD). Despite repeated recommendations documented in the wound doctor’s progress notes, no physician order for zinc paste was obtained, and the recommendation was not communicated to the provider. Nursing staff and CNAs applied barrier cream, but this was not the treatment specified by the wound doctor. In both cases, the facility’s failure to obtain and implement appropriate wound treatment orders as recommended by hospital discharge instructions and the wound doctor resulted in the residents not receiving timely and appropriate care for their skin conditions. The facility’s policy required interventions and treatments to be implemented for residents with skin impairments, but this was not followed for these two residents.
Failure to Provide Required Supervision During Meals and Unsafe Medication Handling
Penalty
Summary
The facility failed to ensure that a resident with a history of Transient Cerebral Ischemic Attack (TIA), dysphagia, and recent aspiration pneumonia received the required one-to-one (1:1) direct supervision during oral intake as ordered by the physician. Despite clear physician orders and care plans specifying the need for 1:1 supervision, mechanical soft/ground meat diet, and aspiration precautions, the resident was repeatedly observed eating independently in their room without staff present. Certified Nurses Aide (CNA) documentation inconsistently recorded the level of assistance provided, with the resident marked as independent for most meals, and staff interviews revealed a lack of awareness regarding the resident's supervision needs. During multiple meal observations, the resident was found eating alone with the privacy curtain pulled, making them unobservable from the hallway. The resident had access to food items such as applesauce, bananas, cookies, and peanut butter crackers without staff supervision. Staff interviews confirmed that the resident was not always provided the required supervision, and some CNAs were unaware of the physician's order for 1:1 assistance during meals, despite the resident's increased risk for choking and aspiration. Additionally, the facility failed to maintain safe medication administration practices on one unit. During a medication pass, a nurse prepared medications and left them unattended on a window sill while exiting the room to obtain water for flushing a G-tube. This action left the medications accessible and unmonitored, creating a risk that another resident could have accessed and ingested the medications not intended for them. The nurse acknowledged that medications should not have been left unattended.
Failure to Administer Oxygen at Ordered Flow Rate
Penalty
Summary
The facility failed to provide respiratory care and services consistent with professional standards of practice for one resident with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) who was dependent on supplemental oxygen. The resident had a physician's order for oxygen at 1.5 liters per minute (LPM) via nasal cannula, as documented in both the physician's orders and the resident's care plan. However, observations by the surveyor on two separate occasions found that the resident was receiving oxygen at a flow rate of 2 LPM, which was higher than the ordered amount. During one observation, the oxygen concentrator was set at 2 LPM, and during another, the portable oxygen tank was also set at 2 LPM. A nurse later confirmed that she adjusted the flow rate from 2 LPM to the ordered 1.5 LPM and stated she was unaware of why the flow rate had been set incorrectly. The resident did not have access to adjust the oxygen equipment, indicating the incorrect setting was due to staff action or oversight.
Failure to Provide Appropriate Pain Management Interventions
Penalty
Summary
A deficiency occurred when a resident with a history of diabetes and diabetic neuropathy, who was cognitively intact, did not receive pain management interventions as ordered. The resident was prescribed scheduled and PRN Tylenol, as well as Lyrica, for pain control. Despite frequent reports of significant pain, with pain scores of 7 or 8 out of 10 documented multiple times, there was no evidence that PRN pain medication or non-pharmacological interventions were provided as ordered. The resident consistently reported to staff that the pain medication was ineffective and that pain was persistent and severe. Nursing documentation showed that pain assessments were conducted regularly, and high pain scores were recorded on numerous occasions. However, there was no documentation indicating that the physician was notified of the resident's ongoing severe pain, nor that any adjustments to the pain management plan were made in response to these assessments. Additionally, recommendations from the psychiatrist for further evaluation and for non-pharmacological interventions such as acupuncture were not acted upon, and referrals were not made in a timely manner. Interviews with staff revealed a lack of awareness regarding the resident's pain status and the psychiatrist's recommendations. The DON stated that significant pain should prompt provider notification and intervention, but was unaware of the resident's ongoing pain issues and the lack of follow-up on recommended interventions. The resident continued to experience high levels of pain, reported decreased mobility, and expressed dissatisfaction with the effectiveness of current pain management strategies.
Failure to Notify Provider of Significant Weight Loss
Penalty
Summary
The facility failed to provide appropriate medical care and physician supervision for one resident by not ensuring that the provider was informed of significant weight loss and the management of the resident's nutritional status. According to facility policy, any weight change of 5 pounds or more should be retaken for confirmation, and if verified, the physician and dietician must be notified. The resident, who had a history of hemiplegia and hemiparesis following a cerebral infarction and moderate cognitive impairment, experienced a notable weight loss over several months. Weight records showed a decrease from 122.2 lbs to 106 lbs between October and January, with a December weight of 109.1 lbs noted on the CNA flowsheet but not entered into the medical record. There was no documentation in the medical record that the physician was notified of the resident's weight loss, nor were any interventions documented in response to the weight change. During interviews, a nurse practitioner confirmed she was not made aware of the resident's weight changes, and stated that she would have ordered a nutritional supplement if she had been informed. The process for communicating weights from CNAs to nurses and then into the medical record was described, but the required notification to the provider did not occur.
Failure to Accommodate Resident Food Preferences and Dietary Needs
Penalty
Summary
The facility failed to ensure that resident food preferences, allergies, and intolerances were consistently obtained and implemented, resulting in multiple residents receiving meals that did not accommodate their needs or requests. Several residents reported concerns about meal portions, lack of variety, and receiving food items they disliked or were allergic to, such as eggs and pork products. Observations and interviews revealed that residents often did not have their preferences documented or updated, and that alternate meal options were limited and sometimes inappropriate for residents with specific dietary needs. During resident council and food committee meetings, residents expressed dissatisfaction with the quality, temperature, and variety of food, as well as the lack of appealing substitutes and snacks. Some residents reported not receiving beverages during meals, repetitive food items, and insufficient portions. The available snacks were limited to prepackaged items like peanut butter crackers, cookies, and pudding, which were not suitable for all residents, especially those with chewing, swallowing difficulties, or diabetes. Additionally, residents indicated that their preferences had not been revisited for an extended period, and that staff did not routinely offer snacks at bedtime unless specifically requested. Interviews with facility staff, including the Food Service Director and Registered Dietitian, confirmed that resident preferences were typically obtained only at admission and not regularly updated. Documentation of when preferences were obtained was lacking, and the process relied on informal notes that were later discarded. Meal tickets often did not reflect current preferences or allergies, leading to residents receiving inappropriate meals. Staff acknowledged the limitations in snack options and the lack of formal involvement of dietary staff in care plan meetings, contributing to the ongoing issues with meal service and resident satisfaction.
Failure to Monitor and Document Antibiotic Use for Resident with UTI
Penalty
Summary
The facility failed to implement its antibiotic monitoring system for one resident who was diagnosed with a urinary tract infection (UTI) and prescribed antibiotics following a hospital readmission. According to the facility's policy, all antibiotic regimens and related outcome data are to be documented on an approved antibiotic surveillance tracking form. However, review of the January 2025 physician's orders and medication administration record confirmed that the resident received Cefdinir as ordered, but there was no corresponding documentation on the facility's antibiotic surveillance tracking form or line listing for this resident's infection or antibiotic use. During an interview, the Director of Nursing (DON), who was substituting for the Infection Preventionist (IP), acknowledged that the IP is responsible for tracking infections and antibiotic use using a line listing that should include details such as infection onset, antibiotic use, and relevant labs. Upon review, the DON confirmed that the resident's UTI and antibiotic treatment were not documented on the January 2025 line listing, and that the listing was incomplete. The DON stated that the resident should have been included and monitored, and that the line listing should have been updated twice weekly.
Failure to Screen and Offer Pneumococcal Vaccination at Admission
Penalty
Summary
The facility failed to ensure that a resident was properly screened for eligibility to receive the recommended pneumococcal vaccination upon admission. Record review showed that there was no documentation indicating the resident or their representative was educated about the benefits and potential side effects of the pneumococcal vaccine, nor was there evidence that the vaccine was offered or administered in a timely manner. The facility's policy required that each resident be offered the pneumococcal immunization unless medically contraindicated or previously immunized, and that education and consent or refusal be documented in the medical record. Interviews with nursing staff confirmed that the resident's immunization history should have been obtained at admission and that a consent or refusal form should have been completed. However, staff were unable to find any documentation that the resident or their representative was offered the pneumococcal vaccine or provided with information about it at the time of admission or shortly thereafter. This lapse was identified during a review of the resident's medical record and staff interviews.
Failure to Ensure Proper COVID-19 Vaccine Consent and Timely Administration
Penalty
Summary
The facility failed to ensure proper procedures were followed regarding COVID-19 vaccination education, consent, and timely administration for two residents. For one resident, after the activation of a Health Care Proxy (HCP) due to the resident's inability to make medical decisions, there was no documentation that the HCP was provided with education about the risks and benefits of the COVID-19 vaccine or that the HCP consented to or declined the vaccination. Despite the HCP being activated, the resident's own consent form was completed, and the vaccine was administered without the required involvement of the HCP. For another resident, although consent to receive the COVID-19 vaccine was documented, there was no evidence in the medical record that the resident received the most recent recommended COVID-19 vaccination in a timely manner. Additionally, staff were unable to provide documentation or explanation for the delay or omission of the vaccine administration after consent was obtained. These findings indicate lapses in both the consent process and timely vaccine administration as required by facility policy.
Failure to Maintain Safe Bed Equipment Due to Frayed Remote Cord
Penalty
Summary
The facility failed to maintain electrical bed equipment in a safe operating condition for one resident. During observations, the resident was found using a bed remote control with a frayed cord, exposing multicolored wires where the outer protective layer had separated. The issue was present during multiple observations throughout the day, both when the resident was in bed and when the bed was unoccupied. A CNA, familiar with the resident, acknowledged that the cord had been in this condition for about a week and admitted that maintenance had not been notified, despite facility protocol requiring immediate notification for such issues. The Maintenance Director confirmed he was unaware of the problem until it was brought to his attention during the survey and expressed concern about the exposed wires.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 369 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Westfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Vantage At Westfield Llc | 1.8 mi | — | 1 | 0 |
| Agawam South Rehab And Nursing | 4.8 mi | — | 8 | 0 |
| Agawam West Rehab And Nursing | 4.8 mi | — | 10 | 0 |
| Agawam North Rehab And Nursing | 4.9 mi | — | 0 | 0 |
| Agawam East Rehab And Nursing | 5.1 mi | — | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.