Cycle 1
Health 2024-08-06 · Fire 2024-08-06
8 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
8 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
West Springfield, MA
Vantage at West Springfield LLC
2-star overall rating with 2-star inspections with $13,748 in total fines with 8 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
42 Prospect Avenue, West Springfield, MA
(413) 733-3151
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
168
Certified beds
Average residents
116
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Vantage Care
Operator or chain grouping
Approved since
1979-01-01
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
No
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
0.43
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.04
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.36
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
3.83
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.47
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.50
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.43
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.43
CMS adjusted RN staffing hours
Adjusted total hours
3.81
CMS adjusted total nurse staffing hours
Case-mix index
1.38
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,759
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
19.2
Composite VBP score used to determine payment impact.
Payment multiplier
0.9821
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.98% · Performance 21.87% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
1.67
Baseline 6.46% · Performance 7.33% · Measure score 1.67 · Achievement 1.67 · Improvement 0
Total nurse turnover
5.06
Baseline 60.35% · Performance 42.98% · Measure score 5.06 · Achievement 5.06 · Improvement 4.39
Adjusted total nurse staffing
0.94
Baseline 3.62 hours · Performance 3.35 hours · Measure score 0.94 · Achievement 0.94 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.81% |
10.72%
3.1 pts worse
|
No Different than the National Rate · Eligible stays 117 · Observed rate 19.66% · Lower 95% interval 10.38% |
| Discharge to community | 43.65% |
50.57%
6.9 pts worse
|
No Different than the National Rate · Eligible stays 99 · Observed rate 35.35% · Lower 95% interval 33.98% |
| Medicare spending per beneficiary | 0.88 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 60 · Denominator 60 |
| Falls with major injury | 1.67% |
0.77%
0.9 pts worse
|
Numerator 1 · Denominator 60 |
| Discharge self-care score | 32.26% |
53.69%
21.4 pts worse
|
Numerator 10 · Denominator 31 |
| Discharge mobility score | 48.39% |
50.94%
2.5 pts worse
|
Numerator 15 · Denominator 31 |
| Pressure ulcers or injuries, new or worsened | 1.67% |
2.29%
0.6 pts better
|
Numerator 1 · Denominator 60 · Adjusted rate 1.91% |
| Healthcare-associated infections requiring hospitalization | 7.33% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 59 · Observed rate 8.47% · Lower 95% interval 4.42% |
| Staff COVID-19 vaccination coverage | 11.68% |
8.2%
3.5 pts better
|
Numerator 16 · Denominator 137 |
| Staff flu vaccination coverage | 40.15% |
42%
1.9 pts worse
|
Numerator 55 · Denominator 137 |
| Discharge function score | 38.71% |
56.45%
17.7 pts worse
|
Numerator 12 · Denominator 31 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 22 · Denominator 22 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 21.62% |
25.2%
3.6 pts worse
|
Numerator 8 · Denominator 37 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
1.9
0.4 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.1 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.5
0.2 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.4 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.8% |
92.2%
5.6 pts better
|
93.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.1% · Q2 99.1% · Q3 97.1% · Q4 97.0% · 4Q avg 97.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.1% |
94.8%
4.3 pts better
|
95.5%
3.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.6% |
3.5%
0.9 pts better
|
3.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 3.6% · Q3 2.9% · Q4 1.0% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
12.0%
12 pts better
|
11.4%
11.4 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 who lose too much weight | 8.0% |
5.2%
2.8 pts worse
|
5.4%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 13.1% · Q3 6.7% · Q4 8.4% · 4Q avg 8.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.4% |
19.2%
1.8 pts better
|
19.6%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.6% · Q2 18.3% · Q3 14.9% · Q4 16.5% · 4Q avg 17.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.6% |
22.5%
0.9 pts better
|
16.7%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.5% · Q2 19.4% · Q3 21.1% · Q4 21.9% · 4Q avg 21.6% · 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 | 25.4% |
17.7%
7.7 pts worse
|
16.3%
9.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.5% · Q2 20.2% · Q3 33.9% · Q4 21.7% · 4Q avg 25.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 35.2% |
17.6%
17.6 pts worse
|
14.9%
20.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.6% · Q2 27.2% · Q3 46.4% · Q4 41.0% · 4Q avg 35.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
1.0%
0.3 pts better
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 1.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.5% |
2.0%
0.5 pts better
|
1.7%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.0% · Q4 4.1% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 11.1% |
21.7%
10.6 pts better
|
19.8%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.0% · Q2 15.6% · Q3 4.8% · Q4 12.8% · 4Q avg 11.1% |
| Percentage of long-stay residents with pressure ulcers | 5.4% |
4.6%
0.8 pts worse
|
5.1%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 7.9% · Q3 4.1% · Q4 4.1% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 80.1% |
77.1%
3 pts better
|
81.7%
1.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 77.2% · Q2 78.8% · Q3 81.2% · Q4 83.2% · 4Q avg 80.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.9% |
11.8%
0.9 pts better
|
12.0%
1.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.9% · Observed 10.8% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.3%
0.7 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 0.0% · Q4 1.3% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 75.7% |
77.7%
2 pts worse
|
79.7%
4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 75.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 32.6% |
25.8%
6.8 pts worse
|
23.9%
8.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 32.6% · Observed 29.2% · Expected 21.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-05-31 · Fire 2023-05-31
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Cycle 3
Health 2021-09-30 · Fire 2021-09-30
31 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-08-06
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-09-17
D · Potential for more than minimal harm
2024-08-06
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2024-09-17
D · Potential for more than minimal harm
2024-08-06
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2024-09-17
D · Potential for more than minimal harm
2024-08-06
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2024-09-17
D · Potential for more than minimal harm
2024-08-06
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-09-17
D · Potential for more than minimal harm
2024-08-06
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-09-17
D · Potential for more than minimal harm
2024-08-06
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-09-17
D · Potential for more than minimal harm
2024-08-06
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-09-17
D · Potential for more than minimal harm
2023-05-31
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-07-07
D · Potential for more than minimal harm
2023-05-31
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-07-07
D · Potential for more than minimal harm
2023-05-31
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-07-07
D · Potential for more than minimal harm
2023-05-31
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-07-07
F · Potential for more than minimal harm
2021-09-30
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2021-11-05
D · Potential for more than minimal harm
2021-09-30
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2021-11-05
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-10-15
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 2024-11-19
E · Potential for more than minimal harm
2024-08-06
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-09-14
E · Potential for more than minimal harm
2024-08-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-14
D · Potential for more than minimal harm
2024-08-06
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-09-14
D · Potential for more than minimal harm
2024-08-06
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-09-14
D · Potential for more than minimal harm
2024-08-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-09-14
D · Potential for more than minimal harm
2024-08-06
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 2024-09-14
D · Potential for more than minimal harm
2024-08-06
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2024-09-14
B · Minimal harm
2024-08-06
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-09-14
D · Potential for more than minimal harm
2023-12-06
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 2024-01-19
D · Potential for more than minimal harm
2023-12-06
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-01-19
D · Potential for more than minimal harm
2023-12-06
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-01-19
D · Potential for more than minimal harm
2023-12-06
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-01-19
D · Potential for more than minimal harm
2023-12-06
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-01-19
D · Potential for more than minimal harm
2023-12-06
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-01-19
G · Actual harm
2023-10-12
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-10-10
G · Actual harm
2023-10-12
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-10-10
E · Potential for more than minimal harm
2023-05-31
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 2023-07-07
E · Potential for more than minimal harm
2023-05-31
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-07-07
D · Potential for more than minimal harm
2023-05-31
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2023-07-07
D · Potential for more than minimal harm
2023-05-31
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2023-07-07
D · Potential for more than minimal harm
2023-05-31
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-07-07
D · Potential for more than minimal harm
2023-05-31
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2023-07-07
D · Potential for more than minimal harm
2023-05-31
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-07-07
D · Potential for more than minimal harm
2023-05-31
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-07-07
D · Potential for more than minimal harm
2023-05-31
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-07-07
D · Potential for more than minimal harm
2023-05-17
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-05-18
H · Actual harm
2023-03-08
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-04-26
H · Actual harm
2023-03-08
F693 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2023-04-26
G · Actual harm
2023-03-08
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-04-26
D · Potential for more than minimal harm
2023-03-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-26
D · Potential for more than minimal harm
2023-03-08
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 2023-04-26
D · Potential for more than minimal harm
2023-03-08
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-04-26
F · Potential for more than minimal harm
2021-09-30
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-11-04
E · Potential for more than minimal harm
2021-09-30
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2021-11-04
E · Potential for more than minimal harm
2021-09-30
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2021-11-04
E · Potential for more than minimal harm
2021-09-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-11-04
D · Potential for more than minimal harm
2021-09-30
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2021-11-04
D · Potential for more than minimal harm
2021-09-30
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 2021-11-04
D · Potential for more than minimal harm
2021-09-30
F606 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
Corrected 2021-11-04
D · Potential for more than minimal harm
2021-09-30
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2021-11-04
D · Potential for more than minimal harm
2021-09-30
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2021-11-04
D · Potential for more than minimal harm
2021-09-30
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 2021-11-04
D · Potential for more than minimal harm
2021-09-30
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2021-11-04
D · Potential for more than minimal harm
2021-09-30
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2021-11-04
D · Potential for more than minimal harm
2021-09-30
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2021-11-04
D · Potential for more than minimal harm
2021-09-30
F772 · Administration Deficiencies
Health
Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided.
Corrected 2021-11-04
D · Potential for more than minimal harm
2021-09-30
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2021-11-04
B · Minimal harm
2021-09-30
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2021-11-04
Penalties and ownership
What sits behind the stars
$13,748
2023-10-12
Fine
Fine · fine $13,748
Fine
Ownership
Bear Mountain Healthcare LLC
5% Or Greater Direct Ownership Interest · Organization
Doyle, Thomas
5% Or Greater Indirect Ownership Interest · Individual
Wynne, John
5% Or Greater Indirect Ownership Interest · Individual
Ziskin, Scott
5% Or Greater Indirect Ownership Interest · Individual
Demaida, Rachael
W-2 Managing Employee · Individual
Doyle, Thomas
Corporate Officer · Individual
Wynne, John
Corporate Officer · Individual
Ziskin, Scott
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Mary's Meadow At Providence Place
Holyoke, MA
5-star overall rating with 4-star inspections with 4 recent health deficiencies
#2
Mont Marie Rehabilitation & Healthcare Center
Holyoke, MA
4-star overall rating with 3-star inspections with $8,278 in total fines with 10 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Mission Care At Holyoke
Holyoke, MA
2-star overall rating with 2-star inspections with abuse icon flag with $16,985 in total fines with 17 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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