Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 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.
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.
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 | — | 0 | 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 August 2026) and official state health department websites.