Vantage at West Springfield LLC
42 Prospect Avenue, West Springfield, MA 01089 · For profit - Limited Liability company · 168 certified beds · (413) 733-3151 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited Oct 2024
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors recorded 2 serious findings as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (32) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $13,748 in federal fines (most recent 2023-10-12)
- its payroll-based staffing rating is low (2/5)
- its facility-reported quality-measure rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 32.4% | 16.4% | 15.4% | worse |
| Long-stay residents who lose too much weight | 7.3% | 5.1% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.4% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 3.4% | 1.8% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.8% | 15.5% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.2% | 3.4% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 23.3% | 15.4% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 16.4% | 19.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 99.1% | 94.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.2% | 4.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 10.0% | 21.2% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 20.4% | 21.4% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 1.7% | 1.4% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 75.7% | 77.7% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 30.3% | 25.7% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 9.3% | 11.9% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.08 | 1.88 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.66 | 1.50 | 1.80 | typical |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
43.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 99 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 47.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 40 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.20 therapist hours per resident per day in 2026Q1 — more than 21% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 28% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 43.6%CMS range 34.0–53.9 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 13.8%CMS range 10.4–16.5 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 47.5% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 37.5% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 42.5% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 95.2% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 3.2% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.3%CMS range 4.4–13.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.88 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 168 beds and averages 115.2 residents a day — about 69% occupied, or roughly 53 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.54 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.50 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.15 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.30 hrs/resident/day on weekends vs 3.63 on weekdays — 9% thinner on weekends. RN hours go from 0.49 to 0.51 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 53% is about the same as the national median of 45%. 3 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
32 citations, most serious first. The 12 most serious are shown; the remaining 20 are one tap away and print in full.
- Actual harm · Gcited before2023-10-12 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose Plan of Care indicated that he/she required physical assistance of two staff members for bed mobility, bathing and hygiene care ( which included incontinence care), the Facility failed to ensure nursing staff implemented and followed interventions identified in his/her Plan of Care while meeting his/her care needs. On 09/05/23, Certified Nurse Aide (CNA) #1 provided Resident #1 morning care, which included incontinence and hygiene care to Resident #1 without another staff member present to assist her. During care, after CNA #1 rolled Resident #1 onto his/her left side, CNA #1 stepped away from the bed and went to the doorway to call for the nurse, leaving Resident #1 unassisted, and he/she fell off the bed on to the floor, striking the right side of his/her head. Resident #1 was transferred to the Hospital Emergency Department for evaluation and diagnosed with contusions (region of injured tissue or skin in which…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · G2023-10-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was assessed by nursing to be at high risk for falls, and required physical assistance of two staff members for Activities of Daily Living (ADL) care, the Facility failed to ensure he/she was provided with the required level of staff assistance during care to maintain his/her safety, in an effort to prevent an accident resulting in an injury. On 09/05/23 at approximately 8:30 A.M., Certified Nurse Aide (CNA) #1 provided Resident #1 with morning care, which included assisting Resident #1 with bed mobility, as well as incontinence and hygiene care, and proceeded to do so without another staff member present to assist her. CNA #1 stepped away from the bed and out into the doorway, leaving Resident #1 in bed, which was in the raised position, on left his/her side, and unattended by a staff member. Resident #1 fell off the bed on to the floor, striking the right side of his/her head, was transferred to the Hospital…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-11 · tag F0637 — isolatedAssess the resident when there is a significant change in condition
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to determine that a significant change in status/ condition had occurred and ensure that a Significant Change in Status Minimum Data Set [MDS] Assessment (SCSA) was completed for two Residents (#105 and #52) out of a total sample of 23 residents. Specifically, the facility failed to identify and complete a SCSA:1. for Resident #105, when a significant change of functional decline in several ADL areas and bowel and bladder continence occurred for the Resident. 2. for Resident #52, when a significant change in mood, toileting, and activities of daily living (ADLs) occurred for the Resident. Findings include:Review of the facility policy titled Comprehensive Assessments, revised March 2022, indicated: -Comprehensive assessments are conducted to assist in developing person-centered care plans. -Comprehensive assessments are conducted in accordance with criteria and timeframes established in the Resident Assessment Instrument (RAI) User Manual. -Significant…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-11 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to review, revise and implement a person-centered care plan relative to assistance with Activities of Daily Living (ADLs-self-care tasks like bathing, dressing, eating, toileting, transferring and continence which are essential for independence) for one Resident (#52), out of a total sample of 23 residents. Specifically, for Resident #52, the facility failed to assess and implement the Resident's request for the use of a commode for toileting in accordance with the needs, goals of care, and preferences that addressed the identified limitations in his/her ability to perform ADL's. Findings Include: Review of the facility's policy, titled Activities of Daily Living, dated December 2020, included but was not limited to:To provide support, assistance, and encouragement to remain as independent as possible with activities of daily living, including hygiene, mobility, elimination, dining, and communication; and that the care and services…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-11 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure that one Resident (#23), out of total sample of 23 residents was provided assistance with personal hygiene. Specifically, for Resident #23, the facility failed to ensure that the Resident, who required ADL assistance was offered and/or provided with grooming assistance for the removal of unwanted facial hair. Findings include:Review of the facility's policy titled, Activities of Daily Living (ADLs), revised December 2022, indicated:-A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.-The facility will ensure a resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living.-The facility will provide care and services for the following activities of daily living:<hygiene, bathing, dressing, grooming and oral care. Resident #23 was admitted…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-11 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews and record reviews, the facility failed to ensure that controlled medication (medication that fall under the United States Drug Enforcement Administration (DEA) Schedules II-V, and have a potential for abuse) records were accurately maintained for a Controlled Substance Book on one unit (Unit Two) out of four units Controlled Substance Books reviewed.Specifically, the facility failed to accurately document the transfer, destruction, and removal of controlled substance medications (Oxycodone and Tramadol) for four residents in the Controlled Substance Book for Unit Two. Findings include:Review of the facility policy titled, Disposal of Medications and Medication-Related Supplies: Controlled Substance Disposal, effective January 2024, included but was not limited to:-Policy: Medications included in the DEA classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal and state laws and regulations.-Procedures:<Disposition is documented on the individual…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-11 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure that medications were labeled and stored in accordance with currently accepted professional principles on one unit medication cart (Unit 4) out of a total of four medication carts reviewed. Specifically, the facility failed to ensure that four pre-poured medication tablets observed in a plastic medication cup and stored in the top drawer of the medication cart on Unit 4 was appropriately labeled to prevent accidental administration of the medication. Findings include: Review of the facility policy titled Storage of Medications, undated, included but was not limited to:-Medications and biologicals are stored safely, securely, and properly, following manufacturers' recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. -The provider pharmacy dispenses medications in containers that meet regulatory requirements, medications are kept in these containers.-All medications dispensed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-11 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, and interview, the facility failed to adhere to infection control standards to prevent the transmission of communicable diseases and infections during two medication administration observations on one unit (Unit 4) out of four total units. Specifically, failed to adhere to infection control practices when:1. Nurse #4 was observed picking up a medication tablet that was dropped on the surface of an un-sanitized medication cart with a gloved hand and administered the medication to a resident during medication administration.2. Nurse #1 was observed picking up a medication that was dropped on an un-sanitized medication cart with his ungloved/un-sanitized hands and administering the medication to a resident during medication administration. Findings include: Review of the facility's policy titled Hand Hygiene, revised 2/23/22, indicated: -Use an alcohol-based hand rub before performing an aseptic task. -Before moving from work on a soiled body site to a clean body site. -After touching a patient's immediate environment. Review of the facility's policy titled,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-15 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and records reviewed, for one of three sampled residents (Resident #1), who was cognitively intact and had the potential to be verbally aggressive, the Facility failed to ensure he/she was free from physical abuse by a staff member, when on 10/02/24 at approximately 12:30 P.M. (exact time unknown), Nurse #1 engaged in a verbal altercation with Resident #1 during which she grabbed his/her chin and reprimanded him/her for his/her behavior. Nurse #1 admitted to physically touching Resident #1 during the altercation. Findings include: Review of the Facility's policy titled Abuse Prohibition, dated as revised 02/20/23, indicated residents will not be subject to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers, and staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. The Policy indicated that physical abuse included hitting, slapping, pinching, scratching, spitting, holding roughly, kicking etc. The Policy indicated that physical abuse also included…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-08-06 · tag F0657 — failed to keep the care plan current — patternDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record and policy review, and interview, the facility failed to conduct interdisciplinary care plan meetings after the Minimum Data Set (MDS) assessments were completed, and involve the Resident and/or Resident Representative in the care planning process for six Residents (#11, #1, #2, #23, #54, and #8), out of a total sample of 26 residents. Specifically, the facility failed to provide evidence of a care plan meeting being held, or that the Resident and/or Resident Representative had participated in the care planning process following the MDS assessments completed: 1. For Resident #11 on 5/20/24. 2. For Resident #1 on 3/25/24 and 6/25/24. 3. For Resident #2 on 12/22/23, 3/21/24 and 6/20/24. 4. For Resident #23 on 9/8/23, 12/1/23, 2/23/24, and 5/25/24. 5. For Resident #54 on 5/20/24 6. For Resident #8 on 8/10/23 and 2/28/24. Findings include: Review of the policy titled Comprehensive Care Plan, undated, included the following: --Our facility's Care Planning/Interdisciplinary Team (IDT) in coordination…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-08-06 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and policy review, the facility failed to adhere to infection control standards to prevent the potential transmission of communicable diseases and infections within the facility on two units (Unit One and Unit Four) out of a total of four units. Specially, the facility failed to ensure: 1. On Unit One, that staff wore required Personal Protective Equipment (PPE-clothing and equipment that is worn or used in order to provide protection against hazardous substances or environments) while caring for a resident on Enhanced Barrier Precautions (EBP), placing him/her at increased risk of infection. 2. On Unit Four, that a staff member wore a fit tested N95 mask appropriately. 3. On Unit Four, that staff correctly utilized and/or discarded/ disinfected the required PPE while caring for residents diagnosed with COVID-19 (a highly contagious respiratory infection) placing residents at risk of contracting the disease. 4. On Unit Four, that staff wore the required and appropriate PPE when assisting a COVID-19 positive resident. Findings include: Review of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-08-06 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure a care plan was developed to address the medical needs for one Resident (#52) out of a total sample of 26 residents. Specifically, for Resident #52, the facility failed to ensure a care plan was developed that included necessary interventions and goals relative to the care of a pressure wound (injury to the skin and underlying tissue resulting from prolonged pressure or friction). Findings include: Resident #52 was admitted to the facility in February 2022, and had a diagnosis of a Stage Two (2) pressure wound (partial thickness wound with loss of skin presenting as an open shallow ulcer) to his/her coccyx (tail bone area). Review of the Nursing Admission/readmission Nursing Assessment, Skin Integrity, dated 5/8/24, indicated Resident #52 had been readmitted to the facility following a hospitalization and he/she had a pressure wound to his/her coccyx. Review of the most recent comprehensive MDS Assessment, dated 6/20/24, indicated that Resident #52 had an unhealed pressure wound. Review of the corresponding Care…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 20 citations
- Potential for harm · D2024-08-06 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, and policy review the facility failed to maintain professional standards of practice to prevent the development and promote healing of pressure ulcers/skin injuries for one Resident (#83) out of a total sample of 26 residents. Specifically, for Resident #83 the facility failed to ensure: 1. that Physician's orders for care and treatment were in place to prevent worsening of a pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) identified at the time the Resident was admitted to the facility. 2. the completion of weekly wound assessments to monitor for improvement and/or deterioration of the wound. 3. that recommended lab work was obtained. Findings include: Review of the facility policy titled Pressure Ulcer Prevention, revised 12/22/22, indicated the following: -Wounds will have weekly assessment and documentation on each area until healed. Review of the facility policy titled Wound Care, undated, indicated the following: -Verify that there is…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-06 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record and policy review, the facility failed to provide care and services for the administration of supplemental Oxygen (O2), consistent with professional standards of practice for one Resident #272, out of a total sample of 26 residents. Specifically, for Resident #272, the facility failed to ensure that Physician orders were in place for the use of Oxygen and the care and services of oxygen equipment when the Resident had pulmonary diagnoses that required safe and appropriate Oxygen administration to prevent the occurrence of adverse events. Findings include: Review of the facility policy titled Oxygen Administration Policy and Procedure, reviewed 12/6/22, indicated the following: -Oxygen is administered by Licensed Nurses with a Physician's order. -Orders should specify the oxygen equipment and flow rate or concentration required as routine or as needed (PRN). Review of the AARC (American Association for Respiratory Care) Clinical Practice Guideline, updated 2014: https://www.aarc.org/wp-content/uploads/2014/08/08.07.1063.pdf indicates: -All…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-08-06 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record and policy review, the facility failed to ensure that recommendations made by the Consultant Pharmacist during a monthly Medication Regimen Review (MRR) were acted upon as required for one Resident (#23), of five applicable residents reviewed for unnecessary medications, out of a total sample of 26 residents. Specifically, the facility staff failed to act upon the Consultant Pharmacist recommendation dated 5/4/24, to include an evaluation date for a PRN (as needed) psychotropic (medication that affects how the brain works and causes changes in mood, awareness, thoughts, feelings or behavior) medication. Findings include: Review of the facility policy titled Medication Regimen Review, undated, indicated the following: -The Consultant Pharmacist reviews the medication regimen of each resident at least monthly. -The findings are phoned, faxed, or e-mailed within (24 hours) to the Director of Nurses (DON) or designee and are documented and stored with the other Consultant Pharmacist recommendation in the resident's active record. -Recommendations are acted…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-06 · tag F0773 — isolatedProvide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, and interview, the facility failed to ensure that Physician orders were in place prior to laboratory testing being conducted for two Residents (#52 and #59), out of a total applicable sample of three residents. Specifically, for Residents #52 and #59, the facility failed to ensure that a Physician's order for COVID-19 testing was in place prior to the Residents being tested for COVID-19. Findings include: Review of the facility policy titled Policy and Procedure: Testing for COVID-19, updated 3/31/23, indicated the following: -Resident testing will be performed per Medical Doctor (MD) order. 1. Resident #52 was admitted to the facility in February 2022, with a diagnosis of Alzheimer's Disease (a progressive disease beginning with mild memory loss and leading to the loss of the ability to carry on a conversation and respond to the environment, involves parts of the brain that control thought, memory, and language). Review of the facility's testing for COVID-19 line listing, undated, indicated Resident #52 was tested for COVID-19 every other day starting on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-06 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews, for one of four sampled residents (Resident #3), who's physician orders included the administration of an anticoagulant (prevents blood clots) medication and the administration of intravenous (IV) antibiotics which required the review of laboratory results to determine dosage amounts, the facility failed to ensure Resident #3's provider was notified when 1) the anticoagulant was unavailable and not administered, placing him/her at risk for the development of a blood clot and 2) despite being instructed by the provider to obtain Resident #3's laboratory results related to his/her IV antibiotic, nursing had not done so, which resulted in Resident #3 missing a dose of his/her IV antibiotic. Findings include: Review of the Facility's policy, Change In Resident's Condition or Status and Notification, reviewed June 2022, indicated the following: -Purpose: To ensure that the resident and/or his/her representative, and his/her attending physician/physician extender are notified…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-06 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on records reviewed and interviews, for one of four sampled residents (Resident #1), the Facility failed to ensure that staff implemented and followed their Abuse Policy related to the need to immediately report an allegation of neglect to the Administrator or Director of Nurses (DON). On 10/22/23, at the start of the day (7:00 A.M. - 3:00 P.M.) shift Nurse #3 was made aware of an allegation of possible resident neglect made against Certified Nurse Aide (CNA) #1, however, Facility administration was not made aware of the allegation until approximately 2:00 P.M. (several hours later), when CNA #2 reported the incident directly to the DON via telephone. Findings include: Review of the Facility's policy titled Abuse Prohibition, updated 02/20/23, indicated the following: -Allegations of abuse will be reported promptly and thoroughly investigated. -Any employee who has reasonable cause to believe a resident has been abused, mistreated, or neglected shall immediately report alleged incidents to their Supervisor, Director of Nursing Services, or Administrator. -The Shift…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-06 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on records reviewed and interviews, for one of four sampled residents (Resident #1), the Facility failed to ensure that after being made aware of an allegation of neglect on 10/22/23, that they reported the allegation to the Department of Public Health (DPH) within two hours, as required. On 10/22/23, the Director of Nurses (DON) was made aware of an allegation of neglect involving Resident #1 and Certified Nurse Aide (CNA) #1, the facility's report was not submitted to DPH by the facility until 10/26/23, four days after first being made aware of the allegation. Findings include: Review of the Facility's policy titled Abuse Prohibition, updated 02/20/23, indicated the Administrator and Director of Nurses are responsible for investigation and reporting. The Policy indicated that the Administrator is responsible for ensuring that there has been notification of local law enforcement and the State Survey Agency within two hours of the allegation after identification of the alleged/suspected incident. The Policy indicated that all alleged violations involving abuse, neglect,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-06 · tag F0694 — isolatedProvide for the safe, appropriate administration of IV fluids for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews, for one of four sampled residents (Resident #3) who had a peripherally inserted central catheter (PICC-catheter that enters through the body through the skin and extends into the superior vena cava, to deliver medications for extended periods of time), the Facility failed to ensure physician orders for necessary care and treatment of the PICC were obtained and entered onto the Medication Administration Record (MAR) and/or Treatment Administration Record (TAR), and as a result Resident #3 went twenty-four hours without being administered flushes to the PICC line port (s) to prevent occlusion (blockage), there was no documentation to support the PICC insertion site was assessed and monitored by nursing for signs of infection, and the PICC line catheter was not measured upon admission or thereafter to ensure the catheter had not migrated (moved) out of place. Findings include: Review of the Facility policy titled PICC, dated May 1, 2022, indicated physician's orders would…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-12-06 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on records reviewed and interviews, for one of four sampled residents (Resident #3), who had a recent partial hip replacement and was at risk for the development of a blood clot, and had physician's orders for the administration of an injectable anticoagulant medication that had to be ordered and delivered from the pharmacy, but was available in the Facility's emergency medication storage unit, the Facility failed to ensure all nurses (including agency nurses) had access to the Emergency medications, as a result Resident #3 missed one dose of his/her anticoagulation medication, therefore placing him/her at increased risk for the development of blood clots. Findings include: Review of the Facility policy, Medication Ordering and Receiving from Pharmacy, dated 10/01/19, indicated that emergency pharmacy service is available on a 24-hour basis. Emergency needs for medication are met by using the facility's approved emergency medication supply or by special order from the provider pharmacy. Review of the list of Emergency Medications available in the Facility's emergency…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-12-06 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interview, for one out of four sampled residents (Resident #3) who was admitted to the Facility with a surgical incision from a recent left hip hemiarthroplasty (partial replacement) and a chronic ulcerated wound on his/her left lower extremity, the Facility failed to ensure they maintained a complete and accurate medical record related to the assessment of his/her wounds by nursing upon admission, which included measurements and descriptions of wounds Findings include: Review of the undated Facility policy, titled Wound Care, indicated the following: -the purpose of the procedure is to give guidelines for the care of wounds to promote wound healing. -the following information should be recorded in the resident's medical record: type of wound care given, the date and time the wound care was given, all assessment data (i.e., wound bed color, size, drainage, etc.), obtained when inspecting the wound. Review of the undated Facility policy, titled Charting Errors and/or Omissions,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-05-31 · tag F0756 — failed to review each resident's drug regimen — patternEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to respond timely to the Consultant Pharmacist recommendations for four Residents (#56, #72, #41 and #1), out of a total sample of 24 residents. Specifically, the facility failed to communicate the Consultant Pharmacist recommendations to the Physician. Findings include: Review of the facility policy titled Consultant Pharmacist Services Provider Requirements, undated, included the following under the specific activities that the consultant pharmacist performs, includes but is not limited to: -reviewing the medication regimen (medication regimen review or MRR) for each resident at least monthly . incorporating federally mandated standards of care in addition to other applicable standards as outlined in the procedure medication regimen review, and for documenting the review and findings in the residents medical record or in a readily retreivable format if utilizating electronic documentation -communicating with responsible prescriber and the facility…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-05-31 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and policy review, the facility failed to ensure secure storage of medications on one of four units. Specifically, the facility staff failed to ensure: a) Nurses (#2 and #4) securely locked the medication cart when left unattended. b) Resident medications/treatments were secured when not being administered by the nurse for two sampled Residents (#53 and #72). Findings include: Review of the facility policy titled Storage of Medications, undated, indicated: -medications and biologicals are stored safely, securely, and properly, -the medication supply is accessible only to licensed nursing personnel, pharmacy personnel or staff members lawfully authorized to administer medications, and -:medication rooms, carts and medication supplies are locked when not attended by persons with authorized access . a) On 5/24/23 from 10:55 A.M., through 11:08 A.M., the surveyor observed Nurse #2, who was working on the back hallway of Unit One leave the medication cart, which was unlocked and out…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-05-31 · tag F0637 — isolatedAssess the resident when there is a significant change in condition
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure its staff completed a Significant Change in Status Assessment (SCSA) for two Residents (#100 and #37) out of a total sample of 24 residents, following a significant decline in functional status. Specifically, 1. For Resident #100, the facility failed to ensure a SCSA was completed after the Resident sustained a hip fracture, that resulted in a significant decline in functional status. 2. For Resident #37, the facility failed to ensure its staff completed a SCSA following a significant functional decline. Findings include: 1. Resident #100 was admitted to the facility in May 2022. Review of the Minimum Data Set (MDS) assessment, with Assessment Reference Date (ARD) of 3/2/23, indicated the Resident required the following assistance for each task: -Bed mobility/Locomotion on and off the unit: supervision with no set up or physical help -Transfers/Walk in room/Walk in corridor/Eating: supervision with set up only -Dressing/Toilet…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-05-31 · tag F0660 — isolatedPlan the resident's discharge to meet the resident's goals and needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review and interview, the facility failed to provide discharge planning services with respect for one Resident's (#18) wishes, out of a total sample of 24 residents. Specifically, the facility staff failed to provide referrals, information and education based on Resident #18's expressed desire to transfer to another skilled nursing facility closer to their relative's home. Findings include: Review of the facility policy for Discharge Planning Process, last revised 12/6/21, indicated that the Social Services Director or designee shall compile available data on other post-acute care options to present to the resident including but not limited to: -data on providers within the resident's desired geographical area, where available. -the facility will present provider information to the resident and resident representative, if applicable, in an accessible and understandable format, and will answer any questions to assist in the resident/representative's understanding. Resident #18 was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-05-31 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews the facility failed to provide Activities of Daily Living (ADLs - basic self-care tasks that an individual does on a day-to-day basis, such as eating, bathing, dressing, and mobility) care for one Resident (#83) out of 24 sampled residents, who required extensive assistance. Specifically, the facility failed to provide adequate grooming for the Resident resulting in dirty nails and facial hair on his/her chin and upper lip. Findings include: Review of the facility policy for Activities of Daily Living (ADL), last reviewed 12/2022), indicated that a resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming and personal and oral hygiene. Resident #83 was admitted to the facility in May 2020 with diagnoses including Dementia (group of symptoms that affects memory, thinking and interferes with daily life) and Adult Failure to Thrive. Review of Resident #83's Minimum Data Set (MDS)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-05-31 · tag F0687 — failed to care for feet properly — isolatedProvide appropriate foot care.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on policy review, record review, and interview, the facility failed to ensure routine diabetic foot care was provided for one Resident (#68) out of a total sample of 24 residents, to maintain good foot health. Findings include: Review of the facility's undated policy for Nursing Care of the Resident with Diabetes Mellitus (DM), indicated the following: Purpose: -Review the most common and serious conditions and complications associated with DM -Recognize, manage, and document the treatment of complications commonly associated with DM Complications Associated with Diabetes: -Foot complications- neuropathy (damage to nerves that can cause a prickly, numbing sensation), dry skin, calluses, poor circulation, ulcers. Skin and Foot Care: -Skin should be kept as clean and dry as possible -Bathe feet in warm (not hot) water as necessary to keep them clean -Keep feet dry, especially between toes Resident #68 was admitted to the facility in February 2022 with diagnosis including DM. Review of the care plan for DM, with goal date 8/9/23, indicated an intervention to inspect feet daily…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-05-31 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure its staff provided care and services consistent with professional standards of practice for two applicable Residents (#54 and #65) out of a total sample of 24 residents receiving Dialysis (process of removing excess water, solutes and toxins from the blood from individuals whose kidneys can no longer perform these functions naturally. Dialysis is necessary to maintain the life of an individual with end stage renal disease). Specifically, 1. For Resident #54, the facility failed to ensure orders were in place for management of the Dialysis catheter, that emergency equipment was available at the resident's bedside and communication documentation with the dialysis center was completed. 2. For Resident #65, the facility failed to ensure clamps and a pressure dressing were at the bedside in case of an emergency related to a central venous catheter (a thin, flexible tube placed into a large vein for on-going treatments, including…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-05-31 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and policy review, the facility failed to ensure that its staff maintained a clean and sanitary environment in the main kitchen, and adhered to safe food practices relative to labeling/dating and removal of expired food. Specifically, the facility failed to ensure: 1) that staff wore hair restraints while working in the main kitchen. 2) that all food stored in the main kitchen walk-in refrigerator and freezer were labeled/dated and the expired food removed. Findings include: Review of the facility policy titled, Hair Restraint, dated 1/20/2017, included: -posted and available dietary policy and protocol to define the facilities guidelines for hair restraint including facial hair. -Compliance to local and federal foodservice code requires that anyone within the kitchen, who will have close contact with the preparation or service of food, food storage areas, equipment will keep hair effectively/appropriately restrained to include facial hair. -Allowable hair restraints - Hairnets, [NAME] Guards, Chef Caps/Beanies/Chef Hats, Ball Caps. -The Food Service…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-05-31 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure complete and accurate clinical records for three Residents (#69 and #24), out of a total sample of 24 residents. Specifically, the facility failed: 1. For Resident #69, ensure an accurate clinical record relative to advanced directives (written statement of a person's wishes regarding medical treatment). 2. For Resident #24, consistently record the meal intake for a resident with a documented weight loss. Findings include: 1. Resident #69 was admitted to the facility in February 2023 with a diagnoses including Cerebral Infarction (or Stroke which occurs when there is an interruption of blood supply to the brain causing damage) and Dementia. Review of the May 2023 Physician's Orders included the following related to the Resident's advanced directives: Do Not Use Non-Invasive Ventilation (NIV), Transfer to Hospital, No artificial hydration, initiated 1/21/20 Review of the Resident's clinical record indicated a Massachusetts Orders for Life…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2024-08-06 · tag F0641 — patternEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure that the Minimum Data Set (MDS) Assessments were accurately coded for two Residents (#35, and #54) out of a total sample of 26 residents. Specifically, the facility failed to: 1. Accurately code that Resident #35 was no longer receiving an antibiotic (medication used to treat bacterial infections) medication. 2. Accurately code that Resident #54: -received Hospice (a program that gives special care to people who are near the end of life and have stopped treatment to cure or control their disease) services. -utilized eyeglasses. Findings include: 1. Resident #35 was admitted to the facility in March 2024 with a diagnosis of Cellulitis (potentially serious bacterial infection of the skin) of the left lower limb. Review of the most recent MDS assessment dated [DATE], indicated that the Resident was currently taking an antibiotic. Review of the March 2024 through August 2024 Physician's orders indicated the Resident was prescribed the following…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$13,748 in federal fines across 1 penalty.
- $13,748 — penalty dated 2023-10-12
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to VANTAGE CARE — 10 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 2.4 | +0.6 vs chain |
| Health inspection | 3 of 5 | 2.7 | +0.3 vs chain |
| Staffing | 2 of 5 | 2.8 | -0.8 vs chain |
| Quality measures | 2 of 5 | 2.3 | -0.3 vs chain |
The other 9 homes this chain runs (chain average 2.4★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| AREM, CHERYL | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 25% | since 12/29/2025 |
| BROWN, YOSSI | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 25% | since 12/29/2025 |
| HERSKOVITZ, MIRIAM | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 25% | since 12/29/2025 |
| YUROWITZ, SAM | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 25% | since 12/29/2025 |
| VANTAGE WEST SPRINGFIELD REALTY LLC | Organization | 5% OR GREATER SECURITY INTEREST; ADP OF THE SNF | — | since 12/29/2025 |
| JOHNSON, JERI | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/29/2025 |
| INNOVATIONS HEALTHCARE, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/20/2026 |
| BUTT, JENNIFER | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/29/2025 |
| FINN, LISA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/29/2025 |
| GREEN, MORRIS | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/29/2025 |
| PELTIER, ALEXANDRIA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/29/2025 |
| PETERSON, DAVID | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/29/2025 |
| IM FAMILY HOLDINGS LLC | Organization | ADP OF THE SNF | — | since 12/29/2025 |
| JCA CAPITAL ASSOCIATES LLC | Organization | ADP OF THE SNF | — | since 12/29/2025 |
| LTC CONSULTING SERVICES LLC | Organization | ADP OF THE SNF | — | since 12/29/2025 |
CMS files one row per role, so the 34 rows in the source record cover these 15 parties — each is shown once here with every role it holds. Nothing is omitted.
5 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $602K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Massachusetts Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 225262. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-11, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.