Vantage at Westfield LLC

Based on interviews and records reviewed, the facility failed to ensure grievances and concerns reported during the Resident Council meetings in February and March 2026 were addressed timely and that a response/rationale by the facility was provided to the Council to address the concerns.Specifically, the facility failed to ensure that:-The facility provided a response to the concerns brought forth during Resident Council about timeliness of call bell response on the A-wing in February 2026.-The response by the facility relative to the repeated concerns about the timeliness of call bell response in March 2026 were relayed to the Resident Council. Findings include:Review of the facility policy titled Resident Council, created January 2017, indicated the Resident Council is mandated by law and is the recognized forum established for the residents to voice their ideas and/or concerns regarding their environment and care. This governing body works closely with the administration of the facility and other staffs to possible [sic] affect changes and resolve problems within 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.

Based on records reviewed and interviews for four of four sampled residents (Resident #1, Resident #2, Resident #3, and Resident #4), who all had a diagnosis of Diabetes (a condition when a hormone called insulin does not work properly or there is not enough of it which causes the level of glucose (sugar) in the blood to become too high), the facility failed to ensure they maintained a complete and accurate medical record when Certified Nurse Aide (CNA) Activity of Daily Living (ADL) Flow Sheets related to meal intake were not consistently completed and often left blank.Findings include:Review of the Facility Policy titled, Charting and Documentation, dated as last revised July 2017, included but was not limited to: -All services provided to the resident, progress toward care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. Review of the Facility Policy titled, Nursing Care of the Resident with Diabetes Mellitus, dated as last revised in 2015, included but was not limited to:…

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.

Based on records reviewed and interviews for one of four sampled residents (Resident #1), who had a change in condition requiring a transfer to the Hospital Emergency Department (ED), the facility failed to ensure they communicated pertinent clinical information to the ED when there was no clinical, medical, or contact information sent with the resident or communicated to the ED at the time of transfer. Findings include: Resident #1 was admitted to the facility in June 2025, diagnoses included Type 2 Diabetes Mellitus, osteomyelitis (a bone infection) to his/her left ankle and foot, as well as a diabetic ulcer on his/her left heel. During a telephone interview on 07/25/25 at 1:15 P.M., the Emergency Department (ED) Nurse said on the morning of 06/16/25, Resident #1 was transported to the ED via Ambulance from the Facility. The ED Nurse said when Resident #1 arrived, she received verbal and written report of his/her condition from the paramedics, however the only documentation she received from the Facility was a Face Sheet (which includes demographic information such as 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.

Based on record review, and interview, the facility failed to complete a performance review at least once every 12 months for five Certified Nurses Aides ([CNA's] #1, #2, #3, #4 and #5) out of five employee records reviewed. Specifically, the facility failed to complete annual performance evaluations for CNA's #1, #2, #3, #4 and #5 as required, to address areas of weakness identified in the evaluation and the special needs of the facility residents. Findings include: Review of the facility employee records indicated that: -CNA #1 was hired on 1/21/22 -CNA #2 was hired on 5/15/18 -CNA #3 was hired on 10/16/23 -CNA #4 was hired on 12/19/17 -CNA #5 was hired on 11/27/18 Further review of the employee records did not indicate that performance evaluations had been completed for the employees for the past 12 months. During an interview on 1/7/25 at 11:22 A.M., CNA #1 said that she had worked at the facility for over a year and had never received an employee performance evaluation since being employed at the facility. During an interview on 1/7/25 at 2:28 P.M., the Director of Nursing…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care consistent with professional standards of practice relative to the use of compression stockings for one Resident (#51) out of a total sample of 17 residents. Specifically, the facility failed to: -Assess Resident #51 for the proper use of compression stockings for the Resident's lower extremities when the Resident had lower extremity swelling and staff applied improperly fitted compression stockings, which increased the Resident's risk for impaired skin integrity and blood circulation. Findings include: Review of the Cardinal Health document titled T.E.D. (thrombo-embolic-deterrent: type of hosiery used to prevent blood clots) Anti-Embolism (obstruction of an artery, typically by a clot of blood or an air bubble) Stockings, dated 2020 and located at https://www.cardinalhealth.com/content/dam/corp/web/documents/brochure/cardinal-health-ted-anti-embolism-stockings-for-acute-care-brochure.pdf indicated: -T.E.D. Anti-Embolism…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care according to professional standards of practice for one Resident (#14) out of a total sample of 17 Residents, relative to nutrition interventions and weight monitoring when the Resident was identified as being at nutritional risk and had severe weight loss. Specifically, for Resident #14, the facility failed to: -Implement Provider recommendations in a timely manner for a nutrition consult. -Implement weekly weight monitoring, as recommended by the Physician Assistant (PA) when the Resident was identified with greater than 20 pounds weight loss over a period of two weeks. -Accurately monitor and record the Resident's meal intake percentage. -Accurately assess the Resident for weight loss when the Resident had a severe weight loss of greater than 10% in less than six months. Findings Include: Review of the facility's Policy titled, Weight Assessment and Intervention, dated 2001 and last reviewed March 2022, indicated:…

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.

Based on observation, interview, and record review, the facility failed to ensure that staff competencies were assessed for three employees (Certified Nurses Aides [CNAs #7 and #8], and Activities Assistant [AA #1]) out of three employees reviewed and relative to meal monitoring and documentation for one Resident (#14). Specifically, the facility failed to: -Assess competency for Activities Assistant (AA) #1 relative to accurately monitoring meal percentage intakes when AA #1 was tasked with monitoring and recording resident meal percentage intakes in the facility's main dining room and AA #1 monitored and recorded an inaccurate meal intake for Resident #14. -Assess nursing assistant competencies, identified by the facility for assessment, for CNAs #7 and #8 upon hire, and since working at the facility, when CNAs #7 and #8 were working in the facility and providing direct care to residents. Findings include: Review of the Facility Assessment Work Document, dated 8/5/24, indicated the following: -The facility provided care for residents with cognitive impairments. -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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that one Resident (#366) out of a total sample of 17 residents, was free from unnecessary medication administration. Specifically, for Resident #366, the facility failed to ensure that the Resident had adequate indication for the use of an antibiotic medication (Clarithromycin - used to treat chest and skin infections) that was ordered by the Physician to be administered for twenty-nine days. Findings include: Review of the facility policy titled Medication Monitoring and Management, dated 1/1/21, indicated: >When a resident receives a new medication, the medication order is evaluated for the following: -The dose, route of administration, duration, and monitoring are in agreement with current clinical practice, clinical guidelines, and/or manufacturer's specifications for use. -A written diagnosis, an indication, and/or documented objective findings support each medication. -The prescriber documents the clinical rationale in the resident's…

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.

Based on observation, record review, and interview, the facility failed to ensure that it was free of a medication error rate of five percent (5%), or greater when one Nurse (#1) out of three Nurses observed during the medication pass procedure, made two errors in 27 total opportunities, for a medication error rate of 7.41%, impacting one Resident (#45) out of five residents observed, out of a total sample of 19 residents. Specifically, for Resident #45, the facility failed to ensure that: -Nurse #1 did not crush medications that were not ordered to be crushed. -Nurse #1 properly administered two Extended Release (ER) medications. Findings include: Review of the facility policy titled Medication Administration-General Guidelines, dated 1/1/21, indicated: -Tablet Crushing/Capsule Opening: Crushing tablets may require a Physician's order, per facility policy. -Long acting or enteric coated dosage forms should not be crushed, an alternative should be sought. -Consult with the Pharmacist for an alternative medication. -The Pharmacist should be contacted to review all medications being…

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.

Based on observation, interview, and record review, the facility failed to ensure that one Resident (#45) out of a total sample of 19 residents were free from significant medication errors. Specifically, the facility failed to ensure the proper administration of Isorbide Mononitrate ER (an extended release [ER] medication used to prevent chest pain) and Metoprolol Succinate ER (an extended-release medication used to treat chest pain and high blood pressure) when the manufacturer's specifications regarding the preparation and administration of both medications were not followed, putting the resident at risk for worsening cardiac symptoms. Findings include: Review of the facility policy titled Medication Administration-General Guidelines, dated 1/1/21, indicated: -Tablet Crushing/Capsule Opening: Crushing tablets may require a Physician's order, per facility policy. -Long acting or enteric coated dosage forms should not be crushed, an alternative should be sought. -Consult with the Pharmacist for an alternative medication. -The Pharmacist should be contacted to review all medications…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to adhere to infection control standards of practice for one Resident (#25) out of a total sample of 18 residents, increasing the risk of contamination and the spread of infections to the Resident and other residents within the facility. Specifically, for Resident #25, the facility staff failed to appropriately follow Enhanced Barrier Precautions (EBP's: the use of protective gowns and gloves during high contact care activities that may provide opportunity for transmission of medication resistant organisms through staff hands and/or clothing), while providing: -high contact care to the Resident when performing ADLs (Activities of Daily Living such as bathing, dressing, grooming, personal hygiene). -administration of an Intravenous (IV- method of delivering medication through the vein) medication to the Resident. Finding include: Review of the facility policy titled Enhanced Barrier Precautions, revised March 2024, indicated: -Enhanced…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record and policy review, the facility failed to provide Activities of Daily Living (ADLs - tasks such as bathing, grooming, maintaining dental hygiene, nail and hair care) assistance for one Resident (#12) out of a total sample of 15 residents. Specifically, the facility failed to ensure that the Resident's nails were trimmed, when the Resident was dependent for care. Findings include: Resident #12 was admitted to the facility in February 2013 with diagnoses including hemiplegia (one-sided muscle paralysis) and hemiparesis (partial weakness or the inability to move on one side of the body) following cerebral vascular disease affecting right dominant side (paralyzed on his/her right side due to a stroke). Review of the facility policy titled, Activities of Daily Living (ADLs), revised 5/1/23 indicated the following: -Based on the comprehensive assessment of a patient and consistent with the patient's needs and choices, the Center must provide the necessary care and services to…

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.

Based on interview, policy and record review, the facility failed to ensure that routine dental services were provided for one Resident (#38), out of a total sample of 15 residents. Specifically, the facility staff failed to ensure that an annual dental exam and prophylactic (preventative) cleaning every six months were completed as recommended. Findings include: Review of the facility policy titled Dental Services, revised 9/1/22, indicated the following: -Centers will provide or obtain from an outside resource routine and emergency dental services, including 24-hour emergency dental care, to meet the needs of each patient. -Routine dental services means an annual inspection of the oral cavity for signs of disease .dental cleaning . Resident #38 was admitted to the facility in December 2021. Review of the most recent Minimum Data Set (MDS) Assessment, dated 9/12/23, indicated the Resident scored a 9 out of 15 in the Brief Interview of Mental Status (BIMS) indicating the Resident was moderately cognitively impaired and was usually able to make him/herself understood. During an…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to maintain complete medical records for one Resident (#57) out of a total sample of 15 residents. Specifically, for Resident #57, who was being monitored for weight loss, the Certified Nurses Aides (CNAs) failed to consistently monitor and document meal intake percentages as required, per the Resident's Nutritional Risk care plan. Findings include: Resident #57 was admitted to the facility in August 2023 with a diagnoses including left tibia (bone in the leg) fracture, left fibular (bone in the leg) fracture, and Dementia with behavioral disturbance (a condition that impairs memory and is accompanied by behavioral or psychological disturbances such as agitation, depression, and psychosis). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident had a 5% or more weight loss in the last month and was not on a Physician prescribed weight loss regimen. Review of the Dietitian's Nutritional assessment dated [DATE], indicated 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.