Vantage at West Springfield LLC

In the surveyor’s words

From the most serious findings on record at Vantage at West Springfield LLC, in the surveyor’s own words.

• Actual harm, patternF692Mar 8, 2023

  Based on records reviewed and interviews, for two of three sampled residents (Resident #1 and Resident #2), who had gastrostomy tubes (G-Tube, tube placed through the abdomen into the stomach, for feedings, liquids and medications), in place to meet their nutritional care needs, the Facility failed to ensure their nutritional status' including body weights, were adequately monitored by nursing in an effort to maintain acceptable parameters related to nutrition to prevent unplanned/undesired weight loss, when Resident #1 experienced an unplanned significant weight loss of 15% in three months, and Resident #2 experienced an unplanned significant weight loss of 20% in a six month period. […]

• Actual harm, patternF693Mar 8, 2023

  Based on records reviewed and interviews, for two of three sampled residents (Resident #1 and Resident #2), who had gastrostomy tubes (G-tube, placed through the abdomen into the stomach, for feedings, liquids and medications) in place to meet their nutritional and fluid intake needs, and whose physician's orders included parameters for daily administration of formula feeds and water flushes, the Facility failed to ensure that Resident #1 and Resident #2 were provided with appropriate treatment and services in an effort to prevent potential complications associated with G-tubes (such as clogged G-tubes, dehydration, aspiration pneumonia, diarrhea, vomiting, metabolic abnormalities). […]

• Actual harm, isolatedF656Oct 12, 2023

  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. […]

• Actual harm, isolatedF689Oct 12, 2023

  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. […]

• Actual harm, isolatedF686Mar 8, 2023

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who upon admission to the Facility in August 2022, had no areas of skin breakdown, the Facility failed to ensure he/she was provided with care and services that met professional standards of practice in an effort to prevent the development of a pressure injury, when several months after his/her admission Resident #1 developed a pressure injury to his/her coccyx which continued to worsen and progressed to an unstageable area. Findings include: The Facility Policy titled, Pressure Ulcer Prevention, dated 12/22/22, indicated that the Facility will provide the appropriate care and services to residents to assist in the prevention of pressure injuries and to promote optimal healing. […]