Wakefield, MA

Vantage at Wakefield LLC

1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $61,461 in total fines with 28 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle

One Bathol Street, Wakefield, MA

(207) 776-0678

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

149

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Vantage Care

Operator or chain grouping

Approved since

1990-07-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

8 facilities

Chain averages 2 overall / 3 health / 2 staffing / 3 quality stars

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.66

Registered nurse staffing · state 0.65 · national 0.68

LPN hours / resident day

0.84

Licensed practical nurse staffing · state 0.96 · national 0.87

Aide hours / resident day

2.24

Nurse aide staffing · state 2.26 · national 2.35

Total nurse hours

3.73

All reported nurse hours · state 3.86 · national 3.89

Licensed hours

1.49

RN + LPN hours · state 1.60 · national 1.54

Weekend hours

3.73

Weekend nurse staffing · state 3.45 · national 3.43

Weekend RN hours

0.75

Weekend registered nurse coverage · state 0.46 · national 0.47

Physical therapist

0.01

Reported PT staffing · state 0.08 · national 0.07

Adjusted RN hours

0.73

CMS adjusted RN staffing hours

Adjusted total hours

4.14

CMS adjusted total nurse staffing hours

Case-mix index

1.23

Higher values indicate more complex resident acuity

RN turnover

61%

Annual RN turnover · state 45% · national 45%

Total nurse turnover

30%

Annual nurse turnover · state 40% · national 46%

SNF VBP

Value-based purchasing

Program rank

3,448

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

44.28

Composite VBP score used to determine payment impact.

Payment multiplier

0.9974

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Baseline 19.75% · Performance 22.65% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

5.28

Baseline 7.21% · Performance 6.26% · Measure score 5.28 · Achievement 5.28 · Improvement 3.79

Total nurse turnover

8.43

Baseline 37.93% · Performance 29.21% · Measure score 8.43 · Achievement 8.43 · Improvement 6.17

Adjusted total nurse staffing

Baseline 3.46 hours · Performance 4.22 hours · Measure score 4 · Achievement 4 · Improvement 2.76

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.23%	10.72% 0.5 pts worse	No Different than the National Rate · Eligible stays 80 · Observed rate 11.25% · Lower 95% interval 7.46%
Discharge to community	30.27%	50.57% 20.3 pts worse	Worse than the National Rate · Eligible stays 48 · Observed rate 14.58% · Lower 95% interval 20.09%
Medicare spending per beneficiary	0.77	1.02 0.2 pts better
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 49 · Denominator 49
Falls with major injury	2.04%	0.77% 1.3 pts worse	Numerator 1 · Denominator 49
Discharge self-care score	32.26%	53.69% 21.4 pts worse	Numerator 10 · Denominator 31
Discharge mobility score	45.16%	50.94% 5.8 pts worse	Numerator 14 · Denominator 31
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 49 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	6.26%	7.12% 0.9 pts better	No Different than the National Rate · Eligible stays 45 · Observed rate 2.22% · Lower 95% interval 3.61%
Staff COVID-19 vaccination coverage	6.54%	8.2% 1.7 pts worse	Numerator 7 · Denominator 107
Staff flu vaccination coverage	16.67%	42% 25.3 pts worse	Numerator 18 · Denominator 108
Discharge function score	41.94%	56.45% 14.5 pts worse	Numerator 13 · Denominator 31
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	19.05%	25.2% 6.1 pts worse	Numerator 4 · Denominator 21

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.7	1.9 0.8 pts worse	1.9 0.8 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 1.7 · Expected 1.2 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	0.8	1.5 0.7 pts better	1.8 1 pts better	Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.7 · Expected 1.5 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	94.8%	92.2% 2.6 pts better	93.4% 1.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 98.0% · Q2 94.4% · Q3 95.1% · Q4 90.7% · 4Q avg 94.8%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	96.9%	94.8% 2.1 pts better	95.5% 1.4 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 96.9%
Percentage of long-stay residents experiencing one or more falls with major injury	2.0%	3.5% 1.5 pts better	3.3% 1.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 1.1% · Q3 2.4% · Q4 1.3% · 4Q avg 2.0% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	2.5%	12.0% 9.5 pts better	11.4% 8.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.4% · Q3 4.4% · Q4 3.5% · 4Q avg 2.5%
Percentage of long-stay residents who lose too much weight	6.3%	5.2% 1.1 pts worse	5.4% 0.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 7.7% · Q3 7.8% · Q4 3.3% · 4Q avg 6.3%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	29.2%	19.2% 10 pts worse	19.6% 9.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 27.3% · Q2 28.6% · Q3 31.6% · Q4 29.9% · 4Q avg 29.2%
Percentage of long-stay residents who received an antipsychotic medication	36.2%	22.5% 13.7 pts worse	16.7% 19.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 30.9% · Q2 38.0% · Q3 38.5% · Q4 38.1% · 4Q avg 36.2% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.1% 0.1 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	7.8%	17.7% 9.9 pts better	16.3% 8.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 14.6% · Q3 2.7% · Q4 5.4% · 4Q avg 7.8% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	11.6%	17.6% 6 pts better	14.9% 3.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 12.3% · Q3 16.4% · Q4 7.7% · 4Q avg 11.6% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.5%	1.0% 0.5 pts better	1.0% 0.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 1.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	1.2%	2.0% 0.8 pts better	1.7% 0.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.2% · Q3 1.3% · Q4 1.4% · 4Q avg 1.2% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	17.7%	21.7% 4 pts better	19.8% 2.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 17.5% · Q3 14.4% · Q4 15.9% · 4Q avg 17.7%
Percentage of long-stay residents with pressure ulcers	4.7%	4.6% 0.1 pts worse	5.1% 0.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 8.6% · Q3 5.3% · Q4 1.3% · 4Q avg 4.7% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	67.1%	77.1% 10 pts worse	81.7% 14.6 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 67.4% · Q2 70.6% · Q3 63.0% · Q4 66.7% · 4Q avg 67.1%
Percentage of short-stay residents who had an outpatient emergency department visit	12.6%	11.8% 0.8 pts worse	12.0% 0.6 pts worse	Short Stay · 20240701-20250630 · Adjusted 12.6% · Observed 13.8% · Expected 12.2% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	3.0%	1.3% 1.7 pts worse	1.6% 1.4 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.0% · 4Q avg 3.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	70.6%	77.7% 7.1 pts worse	79.7% 9.1 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 70.6%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	16.2%	25.8% 9.6 pts better	23.9% 7.7 pts better	Short Stay · 20240701-20250630 · Adjusted 16.2% · Observed 17.2% · Expected 25.4% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-02-04 · Fire 2025-02-04

28 health deficiencies

Top issue: Quality of Life and Care (8 deficiencies)

10 fire-safety deficiencies

Top issue: Smoke (6 deficiencies)

Cycle 2 Health 2024-02-29 · Fire 2024-02-29

5 health deficiencies

Top issue: Resident Rights (3 deficiencies)

11 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 3 Health 2023-01-20 · Fire 2023-01-20

15 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

11 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-02-04

E6 · Emergency Preparedness Deficiencies

Fire Safety

Conduct risk assessment and an All-Hazards approach.

Corrected 2025-03-12

F · Potential for more than minimal harm 2025-02-04

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2025-03-12

F · Potential for more than minimal harm 2025-02-04

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2025-03-12

F · Potential for more than minimal harm 2025-02-04

K352 · Smoke Deficiencies

Fire Safety

Properly install and monitor supervisory attachments on automatic sprinkler systems.

Corrected 2025-03-12

F · Potential for more than minimal harm 2025-02-04

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-03-12

F · Potential for more than minimal harm 2025-02-04

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2025-03-12

F · Potential for more than minimal harm 2025-02-04

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2025-03-12

F · Potential for more than minimal harm 2025-02-04

K711 · Miscellaneous Deficiencies

Fire Safety

Provide a written emergency evacuation plan.

Corrected 2025-03-12

F · Potential for more than minimal harm 2025-02-04

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2025-03-12

F · Potential for more than minimal harm 2025-02-04

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2025-03-12

F · Potential for more than minimal harm 2024-02-29

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2024-04-13

F · Potential for more than minimal harm 2024-02-29

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-04-13

F · Potential for more than minimal harm 2024-02-29

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-04-13

F · Potential for more than minimal harm 2024-02-29

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-04-13

F · Potential for more than minimal harm 2024-02-29

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2024-04-13

F · Potential for more than minimal harm 2024-02-29

K711 · Miscellaneous Deficiencies

Fire Safety

Provide a written emergency evacuation plan.

Corrected 2024-04-13

F · Potential for more than minimal harm 2024-02-29

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2024-04-13

F · Potential for more than minimal harm 2024-02-29

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2024-04-13

F · Potential for more than minimal harm 2024-02-29

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-04-13

E · Potential for more than minimal harm 2024-02-29

K221 · Egress Deficiencies

Fire Safety

Provide rooms that can be unlocked from inside without a key.

Corrected 2024-04-13

D · Potential for more than minimal harm 2024-02-29

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-04-13

F · Potential for more than minimal harm 2023-01-20

E41 · Emergency Preparedness Deficiencies

Fire Safety

Implement emergency and standby power systems.

Corrected 2023-01-20

F · Potential for more than minimal harm 2023-01-20

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2023-03-19

F · Potential for more than minimal harm 2023-01-20

K311 · Smoke Deficiencies

Fire Safety

Have an enclosure around a vertical opening shaft.

Corrected 2023-03-27

F · Potential for more than minimal harm 2023-01-20

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2023-02-15

F · Potential for more than minimal harm 2023-01-20

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2023-02-17

F · Potential for more than minimal harm 2023-01-20

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2023-02-10

F · Potential for more than minimal harm 2023-01-20

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2023-02-10

F · Potential for more than minimal harm 2023-01-20

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2023-03-27

F · Potential for more than minimal harm 2023-01-20

K916 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have a battery powered remote alarm panel in a location accessible by operating personnel.

Corrected 2023-03-19

F · Potential for more than minimal harm 2023-01-20

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-02-10

F · Potential for more than minimal harm 2023-01-20

K929 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure precautions for handling oxygen cylinders and equipment are correctly followed.

Corrected 2023-02-14

Inspection history

Recent health citations

J · Immediate jeopardy 2025-02-04

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2025-03-13

J · Immediate jeopardy 2025-02-04

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2025-03-13

J · Immediate jeopardy 2025-02-04

F726 · Nursing and Physician Services Deficiencies

Health

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.

Corrected 2025-03-13

J · Immediate jeopardy 2025-02-04

F740 · Quality of Life and Care Deficiencies

Health

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Corrected 2025-03-13

F · Potential for more than minimal harm 2025-02-04

F867 · Administration Deficiencies

Health

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Corrected 2025-03-13

F · Potential for more than minimal harm 2025-02-04

F881 · Infection Control Deficiencies

Health

Implement a program that monitors antibiotic use.

Corrected 2025-03-13

E · Potential for more than minimal harm 2025-02-04

F756 · Pharmacy Service Deficiencies

Health

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected 2025-03-13

E · Potential for more than minimal harm 2025-02-04

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2025-03-13

E · Potential for more than minimal harm 2025-02-04

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-04-02

E · Potential for more than minimal harm 2025-02-04

F919 · Environmental Deficiencies

Health

Make sure that a working call system is available in each resident's bathroom and bathing area.

Corrected 2025-03-13

E · Potential for more than minimal harm 2025-02-04

F949 · Administration Deficiencies

Health

Provide behavior health training consistent with the requirements and as determined by a facility assessment.

Corrected 2025-03-13