Vantage at West Springfield LLC

Inspectors wroteBased 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.

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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).

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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) [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.