Westfield Rehabilitation and Health Center

In the surveyor’s words

From the most serious findings on record at Westfield Rehabilitation and Health Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF880Jan 5, 2021

  Based on record review, observation, review of facility infection control policy and procedure, and interviews with staff, the facility failed to implement the facility's COVID-19 Preparation and Response policy when the facility failed to ensure 1 of 2 COVID-19 negative residents( #2) did not share a room with a COVID-19 positive resident (#1) which increased the risk of spreading COVID19 to another resident. On 12/22/2020 the facility reported 52 of its 54 residents had tested positive for COVID-19. Immediate Jeopardy began on 12/20/2020 when the facility became aware a COVID-19 positive resident and a COVID-19 negative resident were residing in the same room. These two residents remained in the same room for two days after the positive result was reported to the facility. […]

• Actual harm, isolatedF689Aug 21, 2025

  Based on observations, record review, and resident interview and staff interviews, the facility failed to perform a transfer from the bed to wheelchair in a safe manner for 1 of 3 residents reviewed for accidents (Resident #26). Resident #26 had pain and sustained a skin tear (laceration) to midline shin (the front of the leg below the knee) with significant depth to left lower leg which required a visit to the emergency department and sutures. Findings included: Resident #26 was admitted to the facility on [DATE] with the diagnoses that included hypertension, hyperlipidemia, polyneuropathy and anemia. […]

• No harm, potential for more than minimal, patternF641Mar 9, 2023

  Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessments in the areas of medications (Residents # 22, #4 & #1), accidents (Resident #4 & #26), diagnoses (Resident #4) and urinary status (Resident # 54) for 5 of 20 sampled residents whose MDS were reviewed. Findings included: 1 a. Resident # 4 was admitted to the facility on [DATE] with multiple diagnoses including congestive heart failure (CHF). Resident #4 had a physician's order dated 12/14/22 for Bumetanide (a diuretic drug) 1 milligram (mg.) by mouth twice a day for CHF. Review of the January 2023 Medication Administration Records (MARs) revealed that Resident #4 had received Bumetanide from January 1 through January 31, 2023. […]

• No harm, potential for more than minimal, patternF686Mar 9, 2023

  Based on record review, observation, and interviews with the Physician, Wound Physician and staff, the facility failed to obtain an order for treatment to the left buttock pressure ulcer (Resident #4) and failed to ensure the alternating air mattress was functioning resulting in a deflated air mattress (Resident #29) for 2 of 3 sampled residents reviewed for pressure ulcers (Residents #4 & #29). Findings included: 1. Resident # 4 was admitted to the facility on [DATE] with multiple diagnoses including diabetes mellitus, thoracic, thoracolumbar, lumbosacral, and intervertebral disk disorder, stage 4 chronic kidney disease, and congestive heart failure (CHF). […]

• No harm, potential for more than minimal, patternF757Mar 9, 2023

  Based on record reviews, Nurse Practitioner, Medical Director and staff interviews, the facility failed to hold diabetic medications (Residents #18 and #42) and blood pressure medications (Residents #42 and #22) as ordered by the physician for 3 of 6 residents whose medications were reviewed. The findings included: 1. Resident #18 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes. A Significant Change in Status Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #18 was cognitively intact. Review of Resident #18's February 2023 and March 2023 physician orders included an order for Levemir Solution (a diabetic medication) 100 unit per milliliter. Inject 5 units subcutaneously in the morning for diabetes. […]