A list of the most recent deficiencies for Vantage at Wilbraham LLC. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-06-27 | 2023-07-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-06-27 | 2023-07-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-27 | 2023-07-20 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-06-27 | 2023-07-20 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-06-27 | 2023-07-20 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-06-27 | 2023-07-20 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-06-27 | 2023-07-20 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-06-27 | 2023-07-20 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-06-27 | 2023-07-20 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-06-27 | 2023-07-20 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-06-27 | 2023-07-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-06-27 | 2023-07-20 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-07-03 | 2023-07-13 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-10-27 | 2022-12-01 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-10-27 | 2022-12-01 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-27 | 2022-12-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-27 | 2022-12-01 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-06-30 | 2022-09-08 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-06-30 | 2022-09-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-30 | 2022-09-08 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-30 | 2022-09-08 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-06-30 | 2022-09-08 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-06-30 | 2022-09-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-06-30 | 2022-09-08 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-06-30 | 2022-08-26 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-06-30 | 2022-08-26 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-06-30 | 2022-08-26 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-06-30 | 2022-08-26 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-06-30 | 2022-08-26 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-06-30 | 2022-08-26 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-06-30 | 2022-08-26 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-06-30 | 2022-08-26 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-06-30 | 2022-08-26 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-06-30 | 2022-08-26 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-06-30 | 2022-08-26 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-06-30 | 2022-08-26 | N |
| Provide activities to meet all resident's needs. | Health | 2022-06-30 | 2022-08-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-30 | 2022-08-26 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-06-30 | 2022-08-26 | N |
| Provide appropriate foot care. | Health | 2022-06-30 | 2022-08-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-30 | 2022-08-26 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-06-30 | 2022-08-26 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-06-30 | 2022-08-26 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-06-30 | 2022-08-26 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-06-30 | 2022-08-26 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-06-30 | 2022-08-26 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-06-30 | 2022-08-26 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-06-30 | 2022-08-26 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-06-30 | 2022-08-26 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-06-30 | 2022-08-26 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-06-30 | 2022-08-26 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-06-30 | 2022-08-26 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2022-06-30 | 2022-08-26 | N |
| Provide or obtain dental services for each resident. | Health | 2022-06-30 | 2022-08-26 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-06-30 | 2022-08-26 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-06-30 | 2022-08-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-30 | 2022-08-26 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-06-30 | 2022-08-26 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-06-30 | 2022-08-26 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-02-16 | 2022-04-18 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-16 | 2022-04-18 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-02-16 | 2022-04-18 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-16 | 2022-04-18 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-11-02 | 2021-11-12 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-05-26 | 2021-07-24 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-05-26 | 2021-07-17 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-05-26 | 2021-07-17 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-05-26 | 2021-07-17 | N |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2021-05-26 | 2021-07-17 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-05-26 | 2021-07-17 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-05-26 | 2021-07-17 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2021-05-26 | 2021-07-17 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2021-05-26 | 2021-07-17 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-05-26 | 2021-07-17 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-05-26 | 2021-07-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-05-26 | 2021-07-17 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-05-26 | 2021-07-17 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-05-26 | 2021-07-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-05-26 | 2021-07-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-05-26 | 2021-07-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-26 | 2021-07-17 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-05-26 | 2021-07-17 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2021-05-26 | 2021-07-17 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-05-26 | 2021-07-17 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-05-26 | 2021-07-17 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-05-26 | 2021-07-17 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-05-26 | 2021-07-17 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2021-05-26 | 2021-07-17 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-05-26 | 2021-07-17 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-05-26 | 2021-07-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-05-26 | 2021-07-17 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2021-05-26 | 2021-07-17 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2021-05-26 | 2021-07-17 | N |
