Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Westfield Llc during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and osteoarthritis, who required substantial staff assistance for transfers and ADLs, was weighed in a wheelchair‑accessible platform scale whose access was obstructed on three sides by walls and a large shower bed. A CNA, confined behind the wheelchair due to the room setup, could only use one accessible ramp and had limited ability to maneuver around the resident. As the CNA attempted to roll the wheelchair off the scale, the resident suddenly put a foot down and leaned forward; because of the obstructions, the CNA could not move to the front in time to adequately assist, and the resident fell forward to the floor, sustaining a forehead laceration that required sutures. The DON later reported being unaware that the shower bed was stored in that room in a way that restricted safe access to the scale.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
A resident with complex medical needs was transferred to the ED without essential clinical documentation, including the MOLST, Health Care Proxy Form, and Hospital Transfer Form. Only a face sheet and medication list were sent, and no nurse-to-nurse report was provided. Facility staff confirmed that required transfer protocols were not followed, and the ED had to contact the facility later to obtain necessary information.
The facility did not conduct annual performance evaluations for five CNAs, missing the opportunity to address areas of weakness and resident needs. The DON acknowledged the oversight, confirming that evaluations should occur annually on each employee's hire anniversary.
A resident with a history of femur fracture and pulmonary embolism experienced improper use of compression stockings due to the facility's failure to assess and measure for proper fit. The resident's T.E.D. stockings were observed rolled down under the knees, causing indentations, and were applied daily without a physician's order. Staff confirmed the lack of assessment and measurement, increasing the risk of impaired skin integrity and circulation.
A resident at a facility experienced severe weight loss due to the failure to implement timely nutritional interventions. Despite recommendations for a nutrition consult and weekly weight monitoring, these were delayed, and the resident's meal intake was inaccurately recorded. The facility's policy for immediate dietician notification in cases of significant weight change was not followed, contributing to the resident's continued weight loss.
The facility failed to assess staff competencies for two CNAs and an Activities Assistant, resulting in inaccurate meal monitoring for a resident with dementia and dysphagia. The resident consumed most of the chicken and carrots but left other items untouched, yet the meal intake was inaccurately recorded as 80% consumed. The Registered Dietician highlighted the importance of accurate meal intake records, but there was no evidence of competency assessments for the involved staff.
A resident was administered Clarithromycin for 29 days without a documented indication or diagnosis, contrary to the facility's medication management policy. Despite the resident's report of taking the medication for a skin infection, staff, including the DON and Infection Preventionist, were unable to provide a documented reason for its use.
A nurse in an LTC facility improperly crushed and administered two extended-release medications to a resident, resulting in a medication error rate of 7.41%. The resident, with heart-related diagnoses, was given Isorbide Mononitrate ER and Metoprolol Succinate ER in crushed form without proper orders or pharmacy consultation, contrary to facility policy.
A resident with heart conditions received crushed extended-release medications, Isorbide Mononitrate ER and Metoprolol Succinate ER, contrary to manufacturer instructions. The nurse crushed the medications due to the resident's swallowing difficulties, without consulting the pharmacy or having a physician's order. Interviews revealed a lack of clarity on medication crushing protocols, and the facility's policies were not adhered to, resulting in a significant medication error.
A resident with acute osteomyelitis and pressure ulcers required enhanced barrier precautions (EBPs) due to wounds and a PICC line. Despite clear signage and policy, staff failed to consistently wear gowns and gloves during high-contact care activities. Observations showed a CNA and a nurse not adhering to EBP requirements, increasing infection risk. Interviews confirmed staff awareness of the precautions but highlighted non-compliance.
Obstructed Platform Scale Access Leads to Resident Fall and Head Laceration
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, hazard‑free environment and provide adequate supervision during the use of a wheelchair‑accessible platform scale. The facility’s own Safety and Supervision of Residents policy stated that the environment should be as free from accident hazards as possible and that resident safety, supervision, and assistance to prevent accidents are facility‑wide priorities. Despite this, the dual‑ramp platform scale in the Unit B shower room was positioned lengthwise against a wall, with one ramp obstructed by the back wall, the back of the platform against the left wall, and the front of the platform blocked by a very large shower bed. This left only the left‑side ramp accessible to residents and staff, significantly limiting staff’s ability to position themselves around the scale to safely assist residents. The resident involved was admitted in June 2023 with diagnoses including dementia with agitation and unspecified osteoarthritis. A quarterly MDS dated 11/06/25 documented that the resident was severely cognitively impaired, with a BIMS score of 3/15, and required substantial assistance from staff for transfers and ADLs. On the day of the incident, a CNA, who had been working regularly at the facility through an agency for about a year and was familiar with the scale, weighed the resident in the wheelchair‑accessible platform scale. To position the resident, the CNA stood behind the wheelchair and pulled the resident up the small left‑side ramp. Once the wheelchair was on the platform, the CNA was confined against the wall on the right side of the scale, with the shower bed obstructing the long edge of the scale, limiting her ability to maneuver around the resident. After obtaining the resident’s weight, the CNA attempted to push the wheelchair down the left‑side ramp to exit the scale. During this maneuver, the resident abruptly lowered a foot and leaned or tipped forward. Due to the obstructions and limited space around the scale, the CNA was unable to move quickly around to the front of the wheelchair to provide adequate physical assistance. The resident fell forward out of the wheelchair onto the floor, striking the head and sustaining a forehead laceration. Nursing staff responding to the incident found the resident on the floor in front of the wheelchair near the left side of the scale, with a forehead laceration and bruising later documented on the forehead, under both eyes, and on the left hand. The resident was sent to the ED, where the injury was diagnosed as an acute forehead laceration from a mechanical fall and closed with five sutures. The DON later stated she was unaware that the shower bed was stored in the Unit B shower room or that it limited staff’s ability to navigate around the scale.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential information and proper record-keeping were not consistently followed. No additional details regarding specific residents, their medical history, or the exact nature of the records involved are provided in the report.
Failure to Provide Required Clinical Documentation and Communication During Resident Hospital Transfer
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including Type 2 Diabetes Mellitus, osteomyelitis of the left ankle and foot, and a diabetic ulcer, experienced a change in condition and was transferred to the hospital emergency department (ED). At the time of transfer, the facility failed to send essential clinical and medical documentation with the resident. The only documents provided were a face sheet and a medication list; critical items such as the Health Care Proxy Form, Massachusetts Medical Orders for Life Sustaining Treatment (MOLST), and a completed Hospital Transfer Form were not sent. Additionally, there was no nurse-to-nurse report provided to the ED at the time of transfer. Interviews with facility staff confirmed that the expected protocol was to send the face sheet, MOLST, Health Care Proxy Form, physician's orders, and a completed Hospital Transfer Form with the resident, and to provide a nurse-to-nurse report to the receiving hospital. However, the nurse responsible for the transfer was uncertain about which documents were sent and did not complete or send all required forms. The ED nurse had to contact the facility hours later to obtain additional clinical information, and a review of the electronic health record confirmed that the Hospital Transfer Form was not completed as required.
Failure to Conduct Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to conduct annual performance evaluations for five Certified Nurses Aides (CNAs) as required. Specifically, CNAs #1, #2, #3, #4, and #5 did not receive performance reviews in the past 12 months, which are necessary to address areas of weakness and the special needs of facility residents. The employee records review confirmed the absence of these evaluations. During interviews, CNA #1 confirmed not having received a performance evaluation since employment, and the Director of Nursing acknowledged the oversight, stating that performance reviews should occur annually on the anniversary of each employee's hire date.
Improper Use of Compression Stockings
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice regarding the use of compression stockings for a resident. The resident, who was admitted with a history of a left femur fracture and pulmonary embolism, experienced swelling in the lower extremities. Despite this, the facility did not assess the resident for the proper use of compression stockings, leading to the application of improperly fitted stockings. Observations revealed that the resident's T.E.D. stockings were rolled down under the knees, causing indentations around the lower legs. The resident reported that the stockings felt tight and always rolled down, indicating improper fit and application. The resident required substantial assistance for lower body dressing, and staff applied the stockings daily without a physician's order or proper measurement to ensure the correct size. Interviews with staff confirmed that there was no physician's order for the compression stockings, and the facility did not typically use T.E.D. stockings. The staff acknowledged that the resident should have been assessed for the use of compression stockings, and proper measurements should have been taken to ensure the correct fit. The failure to follow these procedures increased the risk of impaired skin integrity and circulation for the resident.
Failure to Implement Timely Nutritional Interventions Leads to Severe Weight Loss
Penalty
Summary
The facility failed to provide adequate nutritional care for a resident identified as being at nutritional risk, resulting in severe weight loss. The resident, who was admitted with conditions including dementia, type 2 diabetes, and dysphagia, experienced a significant weight loss of over 20 pounds within two weeks. Despite the physician assistant's recommendations for a nutrition consult and weekly weight monitoring, these interventions were not implemented in a timely manner. The resident's weight was not consistently monitored, and the dietary consult was delayed by approximately 2.5 months. The facility's policy required immediate notification of the dietician in cases of significant weight change, but this was not adhered to. The resident's meal intake was inaccurately recorded, with discrepancies noted between observed consumption and documented percentages. The resident's nutritional care plan included routine surveillance of weight and monitoring of meal intake, but these measures were not effectively executed, contributing to the resident's continued weight loss. Interviews with facility staff revealed a lack of follow-up on the physician assistant's recommendations and inadequate communication with the registered dietician. The unit manager acknowledged the failure to implement weekly weights and the delay in the dietary consult. The registered dietician confirmed that the dietary consult was not completed in response to the weight loss but rather as part of a routine assessment. The physician noted that weight variances were discussed in QAPI meetings, but there was no record of the resident's weight loss being addressed.
Inadequate Staff Competency Assessment Leads to Inaccurate Meal Monitoring
Penalty
Summary
The facility failed to ensure that staff competencies were assessed for three employees, including two Certified Nurses Aides (CNAs) and one Activities Assistant (AA), which led to inaccurate meal monitoring and documentation for a resident. The Activities Assistant was responsible for monitoring and recording meal percentage intakes in the facility's main dining room but recorded an inaccurate meal intake for a resident. The resident, who was moderately cognitively impaired and diagnosed with dementia and dysphagia, consumed most of the chicken breast and cooked carrots but did not eat the rice, dinner roll, or pineapple wedges. Despite this, the AA recorded the resident's meal intake as 80% consumed, which was inconsistent with the actual observation. The facility's policy required that staff demonstrate the skills and techniques necessary to care for resident needs, and competency requirements for nursing staff were to be established and monitored by nursing leadership. However, there was no evidence that competency assessments had been completed for the CNAs upon hire or during their tenure at the facility. Additionally, there was no competency assessment checklist for activities staff, and the AA had not been trained to ensure accurate recording of meal percentages. The Registered Dietician (RD) emphasized the importance of accurate meal percentage intakes to ensure residents' dietary needs are met. The RD noted that the standard for measuring meal intake percentage for the resident should have been recorded as 25%-50%, based on the items consumed. The Staff Development Coordinator (SDC) confirmed that competency assessments were supposed to be completed during orientation and annually, but there was no evidence of such assessments for the involved staff members.
Unnecessary Medication Administration Without Indication
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications. Specifically, a resident was administered Clarithromycin for 29 days without adequate indication or documented diagnosis for its use. The facility's policy on Medication Monitoring and Management requires that each medication order be supported by a written diagnosis or documented objective findings, which was not adhered to in this case. The resident, who was cognitively intact, reported taking Clarithromycin for a bacterial skin infection. However, upon review, neither the nurse nor the Director of Nursing could provide a documented reason for the medication's use. The Director of Nursing initially thought the medication was for a urinary tract infection, but this was not supported by the resident's clinical records. The Infection Preventionist was also unaware of the specific reason for the medication. This lack of documentation and clarity led to the deficiency identified by the surveyors.
Medication Error Due to Improper Crushing of Extended-Release Medications
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by a 7.41% error rate during a medication pass observation. Nurse #1, one of the three nurses observed, made two errors out of 27 opportunities, impacting one resident out of the five observed. Specifically, Nurse #1 crushed and administered two extended-release medications, Isorbide Mononitrate ER and Metoprolol Succinate ER, to a resident without proper orders or consultation with the pharmacy, contrary to the facility's medication administration policies. The resident involved was admitted with diagnoses including Hypertensive Heart Disease with Heart Failure and Atherosclerotic Heart Disease. The physician's orders did not indicate that the extended-release medications should be crushed. During the medication pass, Nurse #1 crushed these medications due to the resident's difficulty swallowing, without consulting the pharmacist or obtaining an alternative medication form. The Director of Nursing and the Consultant Pharmacist confirmed that these medications should not have been crushed, and there was no evidence that the pharmacy had been notified of the need for crushed medications for this resident.
Failure to Follow Medication Administration Protocols
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically in the administration of Isorbide Mononitrate ER and Metoprolol Succinate ER. These medications are extended-release and should not be crushed, as per the manufacturer's specifications. However, during a medication pass observation, a nurse was observed crushing these medications and mixing them with applesauce for administration to the resident. The resident involved had been admitted with diagnoses including Hypertensive Heart Disease with Heart Failure and Atherosclerotic Heart Disease of Native Coronary Artery. The physician's orders for the resident did not include instructions to crush the medications, and there was no documented evidence that the pharmacy had been consulted regarding the crushing of these extended-release medications. The nurse involved admitted to crushing the medications due to the resident's difficulty swallowing, but acknowledged that this was against protocol. Interviews with other nursing staff and the Unit Manager revealed a lack of clarity and accessibility regarding a list of medications that should not be crushed. The Director of Nursing and the Consultant Pharmacist confirmed that the medications should not have been crushed, and the pharmacy had not been notified of any need to crush the resident's medications. The facility's policies on medication administration and crushing were not followed, leading to this significant medication error.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to infection control standards for Resident #25, who was admitted with acute osteomyelitis and pressure ulcers on both heels. The resident required enhanced barrier precautions (EBPs) due to the presence of wounds and a peripherally inserted central catheter (PICC) line for intravenous medication administration. Despite the facility's policy requiring the use of gowns and gloves during high-contact care activities, staff members did not consistently follow these precautions. During observations, it was noted that CNA #6 entered Resident #25's room without donning a gown, although gloves were worn. Similarly, Nurse #4 entered the room without wearing either gloves or a gown while administering medications. Both staff members failed to adhere to the EBP requirements, which were clearly indicated by signage outside the resident's room. The signage instructed staff to wear gowns and gloves during activities such as dressing, bathing, and device care, which were relevant to the care being provided to Resident #25. Interviews with the staff, including Nurse #4, CNA #6, the Unit Manager, and the Infection Preventionist, confirmed that the staff were aware of the EBP requirements but did not comply with them. The Infection Preventionist and Unit Manager acknowledged that the staff should have been wearing gowns and gloves when providing care to Resident #25. The failure to follow these precautions increased the risk of contamination and the spread of infections within the facility.
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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 Westfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westfield Rehabilitation And Health Center | 1.8 mi | — | 0 | 0 |
| Vantage At West Springfield Llc | 6.2 mi | — | 10 | 0 |
| Mary's Meadow At Providence Place | 6.2 mi | — | 0 | 0 |
| Agawam South Rehab And Nursing | 6.6 mi | — | 8 | 0 |
| Agawam West Rehab And Nursing | 6.6 mi | — | 10 | 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.