GOVERNORS CENTER

Nursing Home Inspector

66 BROAD STREET
WESTFIELD, MA 01085
Hampden County
Phone: 413-562-5464
Provider Number: 225313
Last Inspection: 12/28/2016

About the Nursing Home

Number of Beds: 100
Number of Residents: 88
Beds Available: 12
Percent Occupancy: 88%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: Non profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

8

Facility
16

County
16

MA
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

8

2016
22

2015
15

2014

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

12/28/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Actual 4 1/26/2017
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Actual 4 1/26/2017
 

11/2/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Isolated : Minimal 3 12/16/2015
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 12/16/2015
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 12/16/2015
 
Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Isolated : Minimal 3 12/16/2015
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Actual 4 12/16/2015
 
Failed To: Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. Isolated : Minimal 3 12/16/2015
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 12/16/2015
 

10/28/2014 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 12/4/2014
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 12/4/2014
 
Failed To: Ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion. Isolated : Minimal 3 12/4/2014
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 12/4/2014
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Isolated : Minimal 3 12/4/2014
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

1/4/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Isolated : Minimal 3 3/3/2016
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg MA State Avg
Number of Residents 88 94.77 96.79
Registered Nurses 0.91 0.90 0.89
Licensed Practical / Vocational Nurses 0.46 0.74 0.84
Certified Nursing Assistants 1.94 2.25 2.30
Total Staff Hours 3.31 3.89 4.03

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% MA State Avg%
of high risk long-stay residents with pressure ulcers 4 3 4
of long-stay residents assessed and appropriately given the pneumococcal vaccine 96 93 92
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 93 95 95
of long-stay residents experiencing one or more falls with major injury 5 3 3
of long-stay residents who have depressive symptoms 9 2 2
of long-stay residents who lose too much weight 5 6 5
of long-stay residents who received an antianxiety or hypnotic medication 32 21 20
of long-stay residents who received an antipsychotic medication 22 20 18
of long-stay residents who self-report moderate to severe pain 13 5 4
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 17 18 18
of long-stay residents whose need for help with daily activities has increased 18 15 14
of long-stay residents with a catheter inserted and left in their bladder 1 1 1
of long-stay residents with a urinary tract infection 2 3 3
of low risk long-stay residents who lose control of their bowels or bladder 65 59 54
of short-stay residents assessed and appropriately given the pneumococcal vaccine 96 80 79
of short-stay residents who had an outpatient emergency department visit 12 10 11
of short-stay residents who made improvements in function 71 61 60
of short-stay residents who newly received an antipsychotic medication 2 2 1
of short-stay residents who self-report moderate to severe pain 24 13 14
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 96 83 82
of short-stay residents who were rehospitalized after a nursing home admission 18 21 22
of short-stay residents who were successfully discharged to the community 54 57 56
of short-stay residents with pressure ulcers that are new or worsened 1 0 0