Vantage at Worcester LLC

Inspectors wroteBased on records reviewed and interviews, for three of six sampled residents (Residents #1, #4, and #5), whose physician's orders included wound care and dressing changes, the facility failed to ensure professional standards of practice were maintained, when after completing dressing changes nursing staff did not document specific wound characteristics, as well as effectiveness of treatment, in accordance with nursing best practice and facility policy.

Inspectors wroteBased on records reviewed and interviews for one of six sampled residents (Resident #3), the Facility failed to ensure they protected his/her right to privacy, when a staff member took a screenshot of his/her facility face sheet image which included his/her personal and health information, without his/her knowledge or consent, and sent a copy of the screenshot to another person (who was subsequently identified as not being a facility employee).

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the main facility kitchen used to store, prepare and distribute resident food and beverages was maintained in a clean and sanitary manner and kept free from dust and debris increasing the risk for the potential of physical contamination.

Inspectors wroteBased on record review, and interview, the facility failed to provide care consistent with professional standards of practice relative to the administration of prescribed medication for one Resident (#2) out of a total sample of 22 Residents. Specifically, for Resident #2, the facility failed to ensure that a Physician ordered antihypotensive medication (Midodrine) was administered in accordance with the ordered blood pressure parameters (for Systolic Blood Pressure [SBP] less than 100 mmHg), when the medication was being administered for SBP's greater than 100 mmHg, placing the Resident at risk for adverse hemodynamic side effects.

Inspectors wroteBased on observations, interview, and record review, the facility failed to provide activities of daily living (ADL) care relative to personal hygiene and grooming for one Resident (#102), out of a total sample of 22 residents. Specifically, the facility failed to provide assistance with removal of unwanted facial hair when Resident #102 required assistance from staff for ADL care.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure one Resident (#2) out of a total sample of 22 residents received appropriate care and services for the use of an external urinary catheter. Specifically, for Resident #2, the facility failed to ensure that a Physician's order was obtained for the use and care of a non-invasive external urinary catheter when the Resident was observed with an External urinary catheter in use.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure professional standards to maintain adequate nutrition were implemented for one Resident (#92) of 4 applicable residents reviewed for nutrition, out of a total sample of 22 residents. Specifically, for Resident #92, the facility failed to ensure that nutritional supplements recommended by the Registered Dietician (RD) and ordered by the Physician were implemented after the Resident was re-admitted to the facility from a hospitalization, resulting in weight loss for two months.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide respiratory care and services consistent with professional standards of practice for one Resident (#8) of six applicable respiratory residents, out of a total sample of 22 residents. Specifically, for Resident #8, the facility failed to provide consistent care of an oxygen concentrator in accordance with manufacturer's instructions and recognized infection control practices.

Inspectors wroteBased on interviews and records reviewed, for one of three sampled residents (Resident #1) who reported an allegation of verbal abuse to a staff member, the Facility failed to ensure staff implemented and followed the Facility Abuse Prohibition Policy, when the staff member did not immediately report the allegations to the shift supervisor/charge nurse/manager or the Administrator/designee.

Inspectors wroteBased on interviews and records reviewed, for one of three sampled residents (Residents #1), the Facility failed to ensure that after being made aware on 6/02/25 of an allegation of verbal abuse by a staff member, that the incident was reported to the Department of Public Health (DPH), within two hours, as required.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1) who had a gastrostomy tube (G tube, placed through the abdomen into the stomach, for feedings, liquids and medications) in place to meet his/her nutritional and fluid intake needs, and whose physician's orders included formula feeds, water flushes and medication administration through the G tube, the Facility failed to ensure that Resident #1 was provided with appropriate treatment and services when his/her G tube was replaced by a Facility Nurse, and formula feeding and water flushes were administered into the incorrectly positioned G tube resulting in a change in Resident #1's condition, with subsequent need for transfer and admission to the Hospital.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1) who had a gastrostomy tube (G tube, placed through the abdomen into the stomach, for feedings, liquids and medications) in place to meet his/her nutritional and fluid intake needs, the Facility failed to ensure nursing staff were competent related to gastrostomy tubes (G tube) and appropriate actions to take when dislodged, when after Resident #1's G Tube became dislodged, nursing inserted a new G Tube and restarted his/her tube feeding without verifying tube placement, resulting in a change in Resident #1's condition, he/she subsequently required transfer and admission to the Hospital.

Inspectors wroteBased on observations, interviews, and record reviews, for five out of ten sampled residents (Resident #3, #4, #5, #6, and #7), on one of four nursing units (Unit #2), all of whom were either on Enhanced Barrier Precautions (EBP) or Contact Precautions, both of which required staff to use Personal Protective Equipment (PPE) during the provision of care, the Facility failed to ensure they implemented and maintained an infection control program that helped prevent the development and spread of infections, when staff were observed not following infection control practices in accordance with performing hand hygiene at appropriate intervals and not adhering to posted Precaution Signs.

Inspectors wroteBased on observations, records reviewed and interviews, on one of four nursing units (Unit #1) that specialized in the care and treatment of residents who were dependent on a tracheostomy and/or ventilator for breathing, whose residents all required Enhanced Barrier Precaution (EBP) to be utilized by nursing staff during the provision of care, and where there was on-going spread of Candida Auris (C. [...]

Inspectors wroteBased on observations, records reviewed and interviews, for one of four nursing units (Unit #1), that specialized in the care and treatment of residents with a tracheostomy and/or ventilator, the facility failed to ensure it provided appropriate administrative oversight of Infection Control Practices when resident cases of Candida Auris (C. Auris- a type of yeast that can cause severe illness and spreads easily among patients in healthcare facilities, which can cause a range of infections from superficial (skin) infections to more severe, life-threatening infections, such as bloodstream infections) on Unit #1 continued to spread. Although Administration was aware of the on-going spread of this infection, the facility failed to ensure that resources available to the facility were used in an effort to prevent the spread of C. [...]

Inspectors wroteBased on records reviewed, policy reviews and interviews, the Facility which had a known area of concern related to the continued spread of Candida Auris (C. Auris, a type of yeast that can cause severe illness and spreads easily among patients in healthcare facilities, which can cause a range of infections from superficial (skin) infections to more severe, life-threatening infections) an infectious disease on Unit #1, which specializes in care and treatment of residents' requiring a tracheostomy and/or ventilator to breathe, with new cases of the infection identified in December 2024 and several more new cases identified in January 2025, the Facility failed to ensure they developed, implemented and maintained a Quality Assurance and Performance Improvement (QAPI) program that was comprehensive, ensured the residents' received care in accordance with their Infection Control Program, and [...]

Inspectors wroteBased on observations, interviews, and record reviews, for one of four nursing units (Unit #1) that specialized in the care and treatment of residents with a tracheostomy and/or ventilator, with an average daily census of 27 residents all of whom were on Enhanced Barrier Precautions (EBP) which required staff to use Personal Protective Equipment (PPE) during the provision of care, and had a known issue with the spread of Candida Auris (C. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services, relative to enteral feeding (nutrients provided directly into the stomach), for two Residents (#114 and #86) out of a total sample of 26 residents. Specifically, the facility failed to: 1. Ensure interventions were implemented in a timely manner to determine Resident #114's abilities for restoring oral eating skills, as recommended by the Ear Nose and Throat (ENT) Clinic Specialist and as requested by the Resident. 2. Adequately monitor Resident #86's gastric residual volume (amount of liquid drained from the stomach following enteral feeding), as ordered by the Physician, increasing the Resident's risk for aspiration (when food or liquid enters your airway or lungs by accident which may cause serious health problems such as Pneumonia [infection of the lungs]).

Inspectors wroteBased on observation, and interview, the facility failed to ensure all medications used in the facility were stored and labeled in accordance with currently accepted professional principles of practice. Specifically, the facility failed to: 1. Ensure that staff properly labeled all medications stored in one of four medication carts reviewed. 2. Ensure that staff removed four expired medications from one medication room refrigerator of two refrigerators reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to preserve the dignity of one Resident (#55) out of a total sample size of 26 residents. Specifically, the facility failed to provide Resident #55 with a wheelchair that was properly maintained and repaired as required.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide care and services according to professional standards of practice for an indwelling urinary/Foley catheter (a flexible tube that passes through the urethra and into the bladder to drain urine outside the body) for two Residents (#86 and #286) out of a total sample of 26 residents. Specifically, the facility staff failed to ensure that the correct size indwelling urinary catheter, as ordered by the Physician, was in place for both Resident #86 and Resident #286, placing the Residents at risk for infection, discomfort, and potential damage to the urinary system.

Inspectors wroteBased on observation, interview, and National Standards reviewed, the facility failed to provide a safe, and sanitary environment for all residents, staff, and visitors, on one Unit (Fourth Floor) out of four total units observed. Specifically, the facility failed to implement cleaning techniques to manage and eliminate rodent droppings according to National Standards in order to control the source of potential infection for all individuals on the Unit.

Inspectors wroteBased on record review, and interview, the facility failed to electronically submit complete and accurate direct care staffing data based on payroll to Centers for Medicare and Medicaid Services (CMS) for the entire reporting period, Fiscal Year (FY) Quarter 3 2024 (April 1 - June 30) as required by CMS.

Inspectors wroteBased on records reviewed and interviews, for three of three sampled residents, (Resident #1, Resident #2 and Resident #3), the Facility failed to ensure they maintained complete and accurate medical records, when 1) physician's orders were not obtained related to isolation precautions when each resident was Covid-19 positive, and 2) nursing and respiratory therapy documentation for Resident #1 related to the administration of a medication was incomplete.

Inspectors wroteBased on observations, records reviewed and interviews, for one of three sampled residents (Resident #1), who was identified upon admission to the Facility as being at risk for potential alteration in nutrition, required all nutrients to be administered via gastrostomy tube (tube inserted into the stomach to deliver nutrients and fluids), had non-healing pressure injuries, and had experienced an undesired weight loss, the Facility failed to ensure nursing transcribed and put into effect a physician's order to increase the rate of his/her continuous supplemental nutritional tube feed formula, resulting in Resident #1 being at further risk for continued weight loss and poor wound healing.

Inspectors wroteBased on interviews and records reviewed, for two of three sampled residents (Residents #1 and #2) the Facility failed to ensure that, after being made aware on 10/30/23 that Resident #2 alleged he/she had been raped by Resident #1, that they reported the allegation to the Department of Public Health (DPH) within two hours as required, when they did not submit their report to the DPH until the following day.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure reasonable accommodations were maintained for one Resident (#110) out of a total sample of 26 residents. Specifically, -for Resident #110, the facility staff failed to ensure that his/her call light was within reach resulting in the Resident not being able to call for staff when needed.

Inspectors wroteBased on policy review, observation and interview, the facility failed to provide privacy during observation of a medication pass for one Resident (#18), out of seven applicable residents, in a total sample of 26 residents.

Inspectors wroteBased on observations and interviews, for one resident (Resident #107) out of a sample of 26 residents, the facility failed to provide a safe, clean, homelike environment. Specifically, the facility staff failed to address a strong odor coming from the Resident's room.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the plan of care for two Residents (#123 and #42), out of a total sample of 26 residents. Specifically, the facility staff failed to: 1. For Resident #123, administer enteral (passing through the intestine) feedings as ordered resulting in a decrease in daily nutrients and fluids intake. 2. For Resident # 42, reassess quarterly for the continued use of a restraint.

Inspectors wroteBased on observation, record review and interview, the facility failed to follow professional standards of quality during the administration of medication through an enteral tube (a tube inserted surgically in the abdominal wall for allowing liquid food to enter the stomach, also referred to as a Gastrostomy tube[G-tube]), for one Resident (#18), out of a total sample of 26 residents. Specifically, the facility staff failed to flush the Resident's G-tube with water prior to administering medications and also failed to allow administered medications to flow by gravity as required.

Inspectors wroteBased on observations, interviews, and records reviewed for one Resident (#34) out of a total sample of 26 residents, the facility failed to provide urinary catheter (a flexible tube inserted into the bladder to drain urine to the outside of the body) care consistent with professional standards for the Resident who was already deemed at risk for Urinary Tract Infections (UTIs). Specifically, the facility staff failed to ensure: 1) that the urinary catheter was properly secured with a catheter securement device, used to prevent trauma to the urethra (the tube that connects the bladder to the outside of the body). 2) that hospital discharge recommendations for the Resident to visit a Urologist (a doctor who specializes in conditions related to the urinary system) were implemented.

Inspectors wroteBased on observation, record review and interview, the facility failed to maintain a medication pass error rate of less than five percent (%). Specifically, the medication error rate was observed to be 20%, for two Residents (#4 and #18), out of seven applicable residents, out of 25 opportunities.

Inspectors wroteBased on observation, record review and interview, the facility failed to maintain accurate medical records for one Resident (#18), out of a total sample of 26 residents. Specifically, the facility staff failed to obtain a Physician order to indicate the correct route of medication administration.

Inspectors wroteBased on policy review, observation and interview, the facility failed to ensure its staff followed infection control guidelines relative to hand washing during the observation of the medication administration pass, for two out of seven opportunities, out of seven residents, in a total sample of 26 residents.