Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Vantage At West Springfield Llc during CMS and state inspections, most recent first.
Failure to complete SCSA MDS assessments for two residents after major declines in ADLs, continence, and mood. One resident with vascular dementia declined from needing limited assistance to dependence for multiple ADLs with new bladder and bowel incontinence, while another resident with cerebral palsy and anxiety had worsening depressive symptoms and became dependent for hygiene and toileting with new total urinary and bowel incontinence. Staff acknowledged both residents had declined and that SCSA assessments should have been completed.
A resident with cerebral palsy, psychotic disorder, and a recent BKA amputation repeatedly stated a desire to use a commode, but staff continued to provide a bedpan and incontinent care instead. OT documented that toilet transfer was not attempted and that toileting should be at bed level with mechanical lift transfers, yet the care plan still referenced commode use and was not updated after the resident’s change in function. Interviews showed the IDT, therapy, and MDS staff had not fully assessed or revised the resident’s toileting plan to match current needs and preferences.
A resident with dementia and moderate cognitive impairment required help with personal hygiene and grooming, including removal of unwanted facial hair. Surveyors observed facial hair on the resident’s upper lip and chin on separate occasions, with the hair becoming denser and longer, while CNA staff said they had not noticed it and one CNA reported only providing bathing and dressing. The UM said CNAs were expected to provide grooming, including facial hair removal, and the DON stated the resident should have been assisted but was not.
Controlled substance records on one unit were not accurately maintained. During review of the Controlled Substance Book, several Oxycodone and Tramadol entries showed tablets remaining, but an RN could not locate the medications in the cart lock box. An LPN stated that some had been destroyed or likely transferred to another book, yet the designated pages lacked the required documentation, including the removal or destruction details and two nurse signatures.
Surveyors observed a plastic medication cup with four unlabeled tablets in the top drawer of a Unit 4 med cart. An LPN said the meds had been refused by a resident and were kept in the locked cart for later re-administration, while the UM and DON stated the meds should have been destroyed and not left pre-poured in the cart.
Infection control practices were not followed during medication administration on one unit when two nurses handled medications that fell onto unsanitized medication cart surfaces. One nurse picked up a dropped tablet with gloved hands and gave it to a resident, while another used a portable BP machine without disinfecting it, then picked up a dropped medication with bare, unsanitized hands and administered it. The DON and UM stated the dropped medications should not have been given after contact with the contaminated cart surfaces.
A resident with a history of verbal aggression was physically abused by a nurse during a verbal altercation. The nurse grabbed the resident's chin, violating the facility's abuse prohibition policy. The resident had previously expressed concerns about mood changes and requested a medication evaluation. The facility's investigation substantiated the abuse allegation, leading to the nurse's termination.
The facility failed to conduct interdisciplinary care plan meetings and involve residents or their representatives in the care planning process after MDS assessments for six residents. Despite facility policies requiring such involvement, there was no evidence of meetings or resident participation. Interviews with staff revealed a lack of documentation and coordination in scheduling these meetings, leading to the deficiency.
The facility failed to adhere to infection control standards on two units, leading to potential transmission of infections. On Unit One, a CNA did not wear a required gown while caring for a resident on Enhanced Barrier Precautions. On Unit Four, multiple CNAs improperly used PPE while caring for COVID-19 positive residents, including wearing surgical masks under N95 masks, not wearing gloves, and failing to disinfect eye protection. These actions were against facility policy and CDC guidelines.
A resident with a Stage Two pressure wound on the coccyx was readmitted to the facility after hospitalization. Despite assessments indicating the need for a care plan, the facility failed to develop one addressing the wound's interventions and goals. The Wound Physician confirmed ongoing treatment, and the Infection Preventionist acknowledged the oversight.
A resident with a pressure ulcer on the right leg did not receive timely wound care due to the facility's failure to implement physician's orders and conduct weekly wound assessments. The resident's medical record lacked documentation of a wound-specific assessment, and recommended lab work to assess nutritional status was not obtained. The DON acknowledged the oversight in consulting the primary physician and implementing the wound physician's orders.
A resident with chronic respiratory failure and COPD was observed using oxygen without a physician's order specifying the equipment and flow rate, contrary to facility policy. The resident's oxygen was set at varying flow rates without corresponding orders, and a nurse confirmed the absence of necessary orders for oxygen administration and equipment care.
A facility failed to act on a Consultant Pharmacist's recommendation to update a PRN Ativan order for a resident with Major Depressive Disorder. The recommendation to include an evaluation date was not completed, as confirmed by the DON and Regional Nurse, indicating a lapse in the facility's process for handling medication regimen reviews.
The facility failed to obtain physician orders before conducting COVID-19 tests on two residents, despite its policy requiring such orders. One resident with Alzheimer's was tested multiple times in July and August, while another with unspecified dementia underwent similar testing, all without documented physician orders. This was confirmed by the Corporate Infection Control Nurse.
The facility failed to accurately code the MDS Assessments for two residents. One resident was incorrectly documented as receiving antibiotics, while another was inaccurately coded as not receiving hospice services and not using eyeglasses. These errors were confirmed by the MDS Nurse, indicating a need for assessment modification.
Failure to Complete Significant Change MDS Assessments for Two Residents
Penalty
Summary
The facility failed to determine that two residents had significant changes in status and failed to complete Significant Change in Status MDS assessments when those changes occurred. The facility policy stated that a significant change assessment is required when the interdisciplinary team determines a resident meets significant change guidelines for major improvement or decline, including changes that affect more than one area of health status and require interdisciplinary review or care plan revision. One resident, admitted in June 2025 with vascular dementia, was initially documented as independent for eating and personal hygiene, required only supervision for toilet hygiene and ambulation, moderate assistance for transfers, and was continent of bowel and bladder. By the quarterly MDS, the resident had declined to moderate assistance for eating and became dependent on staff for toilet hygiene, transfers, bed mobility, ambulation, and personal hygiene, with frequent bladder incontinence and occasional bowel incontinence. The medical record did not show that a significant change assessment was completed after this decline in ADLs and continence from June 2025 to September 2025. The Unit Manager stated the resident had declined since admission and needed more assistance, and the MDS Nurse stated the resident should have been evaluated for significant change when the quarterly assessment was completed. A second resident, admitted in December 2024 with cerebral palsy, right below-knee amputation, lumbar spondylosis, need for assistance with personal care, and anxiety disorder, showed worsening mood and functional status. The quarterly MDS showed mild depressive symptoms, setup or clean-up assistance for personal hygiene and oral hygiene, occasional urinary incontinence, and continence of bowels. The annual MDS later showed a marked increase in depressive symptoms, including little interest, feeling down or depressed more often, fatigue, trouble concentrating, slowed movement or speech, and a total mood severity score of 11, along with dependence for oral hygiene, toilet hygiene, and personal hygiene, and being always incontinent of urine and bowels. The MDS Nurse stated a significant change assessment should have been completed because of functional decline in personal hygiene, bed mobility, and toilet transfers, and the Unit Manager also stated the resident had declined in ADL care and required more assistance than before.
Failure to Update Toileting Care Plan After Functional Change
Penalty
Summary
The facility failed to review, revise, and implement a person-centered care plan for Resident #52 related to ADL assistance and toileting. Resident #52 was admitted with diagnoses including need for assistance with personal care, cerebral palsy, major depressive disorder with severe psychotic feature, and acquired absence of the right leg below-knee amputation. The resident’s OT discharge summary stated that toilet transfer was not attempted due to medical condition or safety concerns and recommended toileting at bed level with mechanical lift transfers. The most recent MDS showed moderate cognitive impairment, dependence on staff to get on and off a toilet or commode, occasional bladder incontinence, and always incontinent bowel status without a toileting program. The ADL care plan, initiated in July 2024 and revised in July 2025, documented that the resident was dependent on staff for toileting but also stated the resident was able to use the commode in the room, with the commode placed against the wall for stability. The CNA care card documented bladder and bowel incontinence and dependent toilet use with briefs. During observations and interviews, the resident stated multiple times that he/she wanted to use the commode but staff gave a bedpan instead, and that the bedpan was uncomfortable. The resident also stated staff used a mechanical lift for transfers and were unable to assist him/her out of bed to use the commode. Staff interviews showed inconsistent understanding of the resident’s toileting needs and preferences. A CNA said the resident was typically assisted with toileting by mechanical lift transfer to bed for incontinent care and then back to the wheelchair. The UM said staff should transfer the resident to the bathroom for toilet use and also said the resident was at times transferred to bed for incontinent care. The Rehabilitation Service Director stated the resident had not used a commode since the below-knee amputation surgery, that the care plan had not been updated to reflect the resident’s status, and that therapy and/or the physician were not aware of the resident’s inability to use the commode or the resident’s desire to be transferred to a commode. The MDS nurse stated the resident should have been assessed after the amputation by the IDT but had not been, and the resident’s HCP said the facility had not discussed any attempts to evaluate or assist the resident to use the commode.
Failure to Provide Grooming Assistance for Unwanted Facial Hair
Penalty
Summary
The facility failed to ensure that one resident with moderate cognitive impairment and a need for assistance with personal hygiene received grooming assistance for the removal of unwanted facial hair. The resident was admitted with diagnoses including unspecified dementia and anxiety, had a BIMS score of 9, and required assistance with personal hygiene per the MDS, CNA care card, ADL flow sheet, and care plan. The facility policy stated that residents unable to perform ADLs would receive services to maintain grooming and personal hygiene. Surveyors observed the resident on two occasions dressed and in his/her room with facial hair on the upper lip and chin, which became denser and longer over time. During interview, the resident stated he/she did not like facial hair and was waiting for family to assist with removal. CNA staff said they had not noticed the facial hair, and one CNA stated she had only provided bathing and dressing that morning. The UM stated CNAs were expected to provide grooming, including removing unwanted facial hair, and the DON stated the resident should have been assisted with facial hair removal but was not.
Controlled Substance Book Entries Were Not Updated for Medication Removal, Transfer, or Destruction
Penalty
Summary
The facility failed to ensure that controlled substance records were accurately maintained in the Controlled Substance Book on Unit Two. During a surveyor observation and record review, four controlled medication entries were reviewed and found to be inconsistent with the actual location or status of the medications. Page #49 showed four tablets of Oxycodone remaining, page #54 showed seven tablets of Tramadol remaining, page #70 showed 27 tablets of Oxycodone remaining, and page #73 showed 27 tablets of Oxycodone remaining, but Nurse #6 could not locate any of these medications in the medication cart lock box. During interviews, Nurse #5 stated that two of the identified controlled substances had been destroyed and that the Controlled Substance Book should have reflected the destruction on the designated pages, including an X across the page and two nurse signatures, but that documentation was missing. Nurse #5 also stated that two of the medications were likely transferred to another Controlled Substance Book because the residents had moved to another unit. The DON later reported that the four tablets of Oxycodone and seven tablets of Tramadol had been destroyed, one 27-tablet Oxycodone entry had been transferred to another medication cart lock box, and the other 27-tablet Oxycodone entry had been removed for destruction, but the designated pages in the Controlled Substance Book were not updated to reflect the removal, transfer, or destruction.
Unlabeled Pre-Poured Medications Left in Medication Cart
Penalty
Summary
Medication labeling and storage were not maintained in accordance with accepted professional principles on Unit 4, where surveyors observed one plastic medication cup containing four tablets with no name or label in the top drawer of the medication cart. The cart was locked, but the medications were left pre-poured and stored inside it without identification. This was observed on one of four medication carts reviewed. During interview, Nurse #4 stated the medications had been refused earlier by a resident and were kept in the cart so they could be re-administered later. Nurse #4 said the resident wanted the medications left on the bedside table, but the nurse kept them in the cart because it was locked and safe. UM #2 and the DON stated that the medications should have been destroyed when refused and that nurses are not to pre-pour medications and leave them inside the medication cart to prevent medication errors.
Infection Control Failures During Medication Administration
Penalty
Summary
The facility failed to adhere to infection control standards during medication administration on Unit 4 when two nurses handled medications that had been dropped onto medication cart surfaces. During one observation, Nurse #4 was seen administering a medication tablet after it fell onto the surface of an unsanitized medication cart; she picked up the tablet with gloved hands and placed it into a medication cup for a resident. The cart surface had a computer mouse, a pen, and Nurse #4’s forearms resting on it, and Nurse #4 stated she had cleaned the cart earlier but was unsure whether the surface was dirty or clean. The UM and DON both stated the medication should not have been administered after being dropped on the contaminated cart. During a second observation, Nurse #1 was seen administering medications from a cart that contained a glucometer, test strips, a portable blood pressure machine, water, and juices on its surface. Nurse #1 used the portable blood pressure machine, returned it to the cart without disinfecting it or performing hand hygiene, then dropped a medication on the cart and picked it up with bare, unsanitized hands before placing it in a medication cup and giving it to a resident. Nurse #1 stated the cart was not clean and that he had not disinfected it, and the DON later stated he should not have administered the dropped medication after picking it up with ungloved and unsanitized hands.
Resident Abuse by Staff Member
Penalty
Summary
The facility failed to protect a cognitively intact resident from physical abuse by a staff member. The incident occurred when a nurse engaged in a verbal altercation with the resident, who had a history of verbal aggression and mood deregulation. During the altercation, the nurse grabbed the resident's chin and reprimanded them for their behavior. The resident responded by pushing the nurse's hand away and throwing water at her. The nurse admitted to physically touching the resident during the incident, which was reported and substantiated as abuse. The resident, who had been admitted to the facility with diagnoses including Parkinsonism, bipolar disorder, anxiety disorder, and major depressive disorder, had expressed concerns about their mood changes and requested a medication evaluation prior to the incident. The resident's care plan included interventions to manage agitation and verbal aggression, such as providing one-to-one support and engaging the resident in calm conversation. However, these interventions were not effectively implemented during the altercation, leading to the physical abuse incident. The facility's internal investigation confirmed the abuse allegation, and the nurse involved was terminated. The facility's policy on abuse prohibition clearly stated that residents should not be subjected to abuse by anyone, including staff. Despite this policy, the nurse's actions violated the resident's right to be free from physical abuse, highlighting a failure in adhering to established protocols for managing resident behavior and ensuring their safety.
Failure to Conduct Care Plan Meetings and Involve Residents
Penalty
Summary
The facility failed to conduct interdisciplinary care plan meetings after the Minimum Data Set (MDS) assessments were completed and did not involve the residents or their representatives in the care planning process for six residents. This deficiency was identified through record and policy reviews, as well as interviews with staff members. The facility's policy requires that care plans be developed and maintained by the Care Planning/Interdisciplinary Team (IDT) in coordination with the resident and their family or representative. However, there was no evidence of care plan meetings being held or resident involvement in the care planning process for the specified residents. Resident #11, admitted in May 2024, had an MDS assessment completed on 5/20/24, indicating cognitive intactness with a BIMS score of 15 out of 15. Despite this, there was no evidence of a care plan meeting or involvement of the resident or their representative in the care planning process. Similarly, Resident #1, admitted in April 2018, had MDS assessments completed on 3/25/24 and 6/25/24, with no evidence of care plan meetings or involvement of the resident or their representative. Resident #2, admitted in November 2019, also had multiple MDS assessments with no documented care plan meetings or involvement. The deficiency extended to other residents, including Resident #23, who was admitted in December 2023 and had several MDS assessments without documented care plan meetings or involvement. Resident #54, admitted in May 2024, reported not having any care plan meetings since admission, and there was no documentation of such meetings following the MDS assessment. Lastly, Resident #8, admitted in April 2021, had MDS assessments completed without evidence of care plan meetings or involvement. Interviews with the MDS Nurse and Social Worker revealed a lack of documentation and coordination in scheduling and holding care plan meetings, contributing to the deficiency.
Infection Control Deficiencies in PPE Usage
Penalty
Summary
The facility failed to adhere to infection control standards on two units, Unit One and Unit Four, leading to potential transmission of communicable diseases and infections. On Unit One, a Certified Nurses Aide (CNA) was observed providing care to a resident on Enhanced Barrier Precautions (EBP) without wearing the required gown, despite signage indicating that a gown should be worn for high-contact care activities such as shaving. The CNA acknowledged the oversight during an interview with the surveyor. On Unit Four, multiple deficiencies were observed related to the improper use of Personal Protective Equipment (PPE) while caring for COVID-19 positive residents. A CNA was seen wearing a surgical mask underneath an N95 mask, which compromised the fit of the N95 mask. The CNA had not been fit tested for the N95 mask until after the surveyor's observation. Another CNA was observed assisting a COVID-19 positive resident without wearing gloves and using a surgical mask instead of an N95 mask. The CNA also failed to disinfect reusable eye protection after exiting the resident's room. Additionally, another CNA on Unit Four was observed wearing a surgical mask under an N95 mask and not wearing the required eye protection while briefly entering a COVID-19 positive resident's room. The CNA believed that the additional surgical mask provided extra protection and that the brief duration in the room did not necessitate full PPE compliance. These actions were contrary to the facility's policy and CDC guidelines, which require specific PPE for COVID-19 positive residents to prevent the spread of infection.
Failure to Develop Care Plan for Pressure Wound
Penalty
Summary
The facility failed to develop a care plan addressing the medical needs of a resident with a pressure wound. The resident, admitted in February 2022, had a Stage Two pressure wound on the coccyx. Upon readmission to the facility after hospitalization, the Nursing Admission/Readmission Nursing Assessment noted the presence of the pressure wound. However, despite the comprehensive MDS Assessment on 6/20/24 indicating an unhealed pressure wound, no care plan was created to address this issue. The Care Area Assessments (CAA) triggered by the MDS Assessment suggested that a care plan should have been developed for the pressure wound. Despite this, the resident's care plan lacked any interventions or goals related to the pressure wound. The Wound Physician's note from 8/5/24 confirmed ongoing treatment for the Stage 2 pressure wound. During an interview, the Infection Preventionist acknowledged that a care plan should have been developed upon the resident's return from hospitalization, but it was not done.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to adhere to professional standards of practice in preventing the development and promoting the healing of pressure ulcers for a resident. Upon admission, the resident had a pressure area on the outer right leg caused by a leg immobilizer. The facility did not ensure that physician's orders for wound care were in place, leading to a delay in treatment. The resident's medical record lacked documentation of a wound-specific assessment when the wound was identified, and no orders for wound care were in place until several days after the wound physician's recommendations. Additionally, the facility did not complete weekly wound assessments as required by their policy. The Director of Nursing acknowledged that the resident's primary physician should have been consulted for wound treatment orders upon admission, and the wound physician's orders should have been implemented immediately. Furthermore, the facility failed to obtain the recommended lab work to assess the resident's nutritional status, as suggested by the wound physician. At the time of the survey exit, there was no documentation that the recommended lab work had been completed.
Deficiency in Oxygen Administration for Resident with COPD
Penalty
Summary
The facility failed to provide care and services for the administration of supplemental oxygen consistent with professional standards of practice for a resident with pulmonary diagnoses. The resident, who was admitted with chronic respiratory failure and chronic obstructive pulmonary disease (COPD), was observed using oxygen via nasal cannula without a physician's order specifying the oxygen equipment and flow rate. The facility's policy requires that oxygen be administered by licensed nurses with a physician's order, which was not in place for this resident. During observations, the resident was seen using oxygen at different flow rates, 2 liters per minute and 3.5 liters per minute, without corresponding physician's orders. The care plan indicated the use of oxygen as needed, but there were no specific orders for the administration or management of the oxygen equipment. A nurse confirmed the absence of orders and acknowledged that orders should have included details such as the administration of oxygen, liter flow, and maintenance of the equipment.
Failure to Act on Pharmacist's Medication Review Recommendation
Penalty
Summary
The facility failed to ensure that recommendations made by the Consultant Pharmacist during a monthly Medication Regimen Review (MRR) were acted upon for a resident diagnosed with Major Depressive Disorder. The resident was prescribed Ativan, a PRN psychotropic medication, for anxiety/agitation. The Consultant Pharmacist recommended updating the PRN Ativan order to include an evaluation date, but this recommendation was not acted upon by the facility staff. The Director of Nursing (DON) acknowledged that the process for handling MRR recommendations involves receiving them via email, printing them, and giving them to the Provider for action. However, the recommendation for the resident in question was not completed and returned to the DON, indicating a lapse in the facility's process. The Regional Nurse confirmed that the nurses should have requested a re-evaluation or stop date for the Ativan PRN order, but this was not done, leading to the deficiency.
Failure to Obtain Physician Orders for COVID-19 Testing
Penalty
Summary
The facility failed to ensure that physician orders were in place prior to conducting COVID-19 testing for two residents, identified as Resident #52 and Resident #59. According to the facility's policy titled 'Policy and Procedure: Testing for COVID-19,' updated on March 31, 2023, resident testing should be performed per a medical doctor's order. However, a review of the facility's COVID-19 testing line listing revealed that Resident #52 was tested every other day from July 24, 2024, through July 30, 2024, and then daily from August 1, 2024, through August 5, 2024, without any physician's orders documented for these tests. Similarly, Resident #59, who was admitted in March 2024 with a diagnosis of unspecified dementia, was tested for COVID-19 every other day from July 24, 2024, through July 30, 2024, and then daily from August 1, 2024, through August 6, 2024, also without any physician's orders. During an interview on August 6, 2024, the Corporate Infection Control Nurse confirmed that both residents had been tested for COVID-19 during July and August 2024 without the necessary physician's orders in place, indicating a failure to adhere to the facility's established testing policy.
Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) Assessments for two residents, leading to deficiencies in the documentation of their care. Resident #35, who was admitted with a diagnosis of cellulitis, was inaccurately coded as currently receiving antibiotics in the MDS assessment, despite having completed the prescribed antibiotic courses in March 2024. The MDS Nurse confirmed that the resident was not receiving antibiotics at the time of the assessment, indicating an error in the coding process. Similarly, Resident #54, admitted with multiple mental health diagnoses, was inaccurately coded in the MDS assessment as not receiving hospice services and not using eyeglasses, contrary to the information in the resident's records. The resident had signed onto hospice services in May 2024 and was documented as using eyeglasses in the admission assessment. The MDS Nurse acknowledged the inaccuracies in the coding of the MDS assessment, which required modification to reflect the resident's actual status.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near West Springfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mary's Meadow At Providence Place | 0.4 mi | ★★★★★ | 4 | 0 |
| Mont Marie Rehabilitation & Healthcare Center | 1 mi | ★★★★★ | 3 | 0 |
| Mission Care At Holyoke | 1.4 mi | ★★★★★ | 5 | 0 |
| Massachusetts Veterans Home At Holyoke | 3 mi | — | 0 | 0 |
| Renaissance Manor On Cabot | 3.5 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.