Westfield Center

F-F726.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 30 225380 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225380 B. Wing 01/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Vantage at Westfield LLC 60 East Silver Street Westfield, MA 01085

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 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. Level of Harm - Minimal harm or potential for actual harm 42761

Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure that staff competencies were assessed for three employees (Certified Nurses Aides [CNAs #7 and #8], and Activities Assistant [AA #1]) out of three employees reviewed and relative to meal monitoring and documentation for one Resident (#14).

Specifically, the facility failed to:

-Assess competency for Activities Assistant (AA) #1 relative to accurately monitoring meal percentage intakes when AA #1 was tasked with monitoring and recording resident meal percentage intakes in the facility's main dining room and AA #1 monitored and recorded an inaccurate meal intake for Resident #14.

-Assess nursing assistant competencies, identified by the facility for assessment, for CNAs #7 and #8 upon hire, and since working at the facility, when CNAs #7 and #8 were working in the facility and providing direct care to residents.

Findings include:

Review of the Facility Assessment Work Document, dated 8/5/24, indicated the following:

-The facility provided care for residents with cognitive impairments.

-The facility provided care for residents requiring assistance with activities of daily living (ADLs).

-The facility provided care relative to nutrition for residents.

-Staff training/education programs were conducted to provide the level and types of support and care needed for the resident population.

-Training programs applied to all facility staff to include direct care staff, managers, supervisors, contracted staff, and volunteers, as appropriate.

-Training programs, as appropriate were provided as part of the facility's orientation process for new and newly assigned staff, annually, and/or as needed.

-Training programs contain learning objectives, performance standards, and evaluation criteria.

Review of the facility policy titled Staffing, Sufficient and Competent Nursing, dated 2001, indicated but was not limited to the following:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 30 225380 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225380 B. Wing 01/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Vantage at Westfield LLC 60 East Silver Street Westfield, MA 01085

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 -The facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care Level of Harm - Minimal harm or plans and the facility assessment. potential for actual harm - . the skill requirements of direct care staff are determined by the needs of the residents based on each Residents Affected - Few resident's plan of care, the resident assessments, and the facility assessment.

-Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that

an individual needs to perform work roles .

-Staff must demonstrate the skills and techniques necessary to care for resident needs .

-Competency requirements . for nursing staff are established and monitored by nursing leadership . to ensure that gaps in education are identified and addressed .

Review of the facility's document titled Facility Orientation Competency: Nursing Assistant, undated, indicated the following:

-The evaluator will place their initials in the appropriate column on the line that corresponds to the skill after competency in the area is achieved by employee.

-All evaluators are to sign the bottom of this form identifying their signature, title, initials, and date.

-Checklist must be complete and handed in prior to coming off orientation.

-Topics requiring competency assessment included meal percentage monitoring.

Review of the Dietary Intake Guide, undated, provided by the facility indicated but was not limited to the following:

-The Dietary Intake Guide was a resource to help measure meals, liquids, . consumed.

-Record amount of the total meal . consumed using the following guidelines:

>Refused - 0% (refused meal completely or consumed only one or two bites of each item).

>Poor - 25% (approximately 25% of entree or 50% of one item consumed).

>Fair - 50% (approximately half of food is consumed, [e.g., 50% of entree, 25% of vegetable and soup left]. If total entree is consumed but no other food is touched, record as Poor/25%, not Fair/50%).

>Good - 75% (majority of meal is consumed but a significant amount of one or more items is left [e.g., 25% of entree or 75% of vegetable left]).

>All - 100% (entire meal is consumed except for a minimal amount of food [e.g., less than 25% of vegetable left]).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 30 225380 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225380 B. Wing 01/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Vantage at Westfield LLC 60 East Silver Street Westfield, MA 01085

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Resident #14 was admitted to the facility in August 2024 with a diagnoses of Dementia and Dysphagia.

Level of Harm - Minimal harm or Review of Resident #14's Minimum Data Set (MDS) Assessment, dated 10/31/24, indicated the Resident potential for actual harm was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) of nine out of 15 total possible points. Residents Affected - Few

Review of Resident #14's Nutrition Care Plan, revised 11/5/24, indicated:

-Diet as ordered (monitor and record).

On 1/3/25 between 12:05 P.M. and 12:45 P.M., the surveyor observed the following in the facility's main dining room:

-Resident #14 was seated in a wheelchair at a table with one other resident.

-Resident #14 was served a meal which included chicken breast, cooked carrots, rice, one dinner roll, and one bowl of pineapple wedges.

-The Resident fed him/herself during the meal.

-At the end of mealtime, Resident #14 had consumed most of the chicken breast (leaving a few small pieces

on the plate) and most of the cooked carrots (leaving a few carrots on the plate). The Resident did not eat any of the rice and dinner roll, or any of the pineapple wedges.

During an interview on 1/3/25 at 12:30 P.M., Resident #14 said that he/she liked the food and that he/she just did not have a big appetite.

At the same time, the surveyor observed AA #1 approach Resident #14's table, ask the Resident if he/she was done eating, and removed the Resident's meal plate.

Review of the facility's Lunch Meal Intake Sheet, dated 1/3/25 and completed by AA #1, indicated Resident #14 consumed 80% of his/her lunch meal that same day.

During an interview on 1/3/25 at 1:45 P.M., AA #1 said she recorded meal percentage intakes for residents who ate lunch in the facility's main dining room that same day and that she recorded Resident #14's lunch meal intake percentage. AA #1 said that when she records resident meal intakes, she looks at the residents' plates and estimates how much of the total meal the resident consumed. AA #1 said she recorded Resident #14's lunch meal intake as 80% consumed. AA #1 said that after she completes the Meal Intake Sheet, she leaves the sheet at the nurses station and the meal percentages documented on the sheet are then entered into the residents meal records on the computer by the CNAs. At the time, the surveyor and AA #1 reviewed

the Lunch Meal Intake Sheet and discussed the lunch meal observation for Resident #14. AA #1 said that

the meal percentage she recorded on the Meal Intake Sheet may have been inaccurate.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 30 225380 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225380 B. Wing 01/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Vantage at Westfield LLC 60 East Silver Street Westfield, MA 01085

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 During an interview on 1/3/25 at 1:54 P.M., with CNA #7 and CNA #8, CNA #8 said that all resident meal intake percentages are entered into the computer. CNA #7 said that when meal percentages are recorded Level of Harm - Minimal harm or from staff in the main dining room, the staff bring the completed meal percentage sheet to the nurses station potential for actual harm and a CNA enters the meal percentages recorded into the resident meal records on the computer.

Residents Affected - Few Review of Resident #14's electronic meal intake record for 1/3/25 indicated Resident #14 consumed 51% -75% of his/her lunch time meal on 1/3/25.

During an interview on 1/7/25 at 10:20 A.M., the Registered Dietician (RD) said it was important to have accurate information relative to meal percentage intakes to ensure residents consume percentages of food that matches their estimated dietary needs. The RD said that she was not sure how staff had been trained to monitor and record meal percentages, and offered that the surveyor should ask the Staff Development Coordinator (SDC).

During a follow-up interview on 1/7/25 at 11:08 A.M., the RD said the standard for measuring meal intake percentage relative to the items Resident #14 consumed at lunch time on 1/3/25 should have been recorded as 25%-50%. The RD then provided the surveyor with the Dietary Intake Guide used to measure meals consumed.

During an interview on 1/7/25 at 11:58 A.M., the SDC said nursing staff competencies were completed

during orientation, when staff were newly hired, and annually. The SDC said that competency assessments were recorded on the competency checklists and maintained in the employee education files. The SDC said that meal percentage monitoring was included in topics requiring competency assessment for CNAs and that there was no competency assessment checklist for activities staff. The SDC said that AA #1 does record meal percentages for residents who eat in the main dining room and that AA #1 would have needed to be trained to ensure she was recording meal percentages accurately. The SDC said that she would provide the survey team with evidence that the required competencies had been completed.

During a follow-up interview on 1/7/25 at 4:22 P.M., the SDC said CNA #7 began working at the facility on 11/1/23, CNA #8 began working at the facility on 4/29/24, and AA #1 began working at the facility on 7/31/24.

The SDC said there was no evidence that any competency assessments had been completed for CNA #7 and CNA #8. The SDC also said there was no evidence competency had been assessed for AA #1 relative to monitoring and recording resident meal percentages.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 30 225380 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225380 B. Wing 01/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Vantage at Westfield LLC 60 East Silver Street Westfield, MA 01085

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0730 Observe each nurse aide's job performance and give regular training.

Level of Harm - Minimal harm or 50138 potential for actual harm Based on record review, and interview, the facility failed to complete a performance review at least once Residents Affected - Some every 12 months for five Certified Nurses Aides ([CNA's] #1, #2, #3, #4 and #5) out of five employee records reviewed. Specifically, the facility failed to complete annual performance evaluations for CNA's #1, #2, #3, #4 and #5 as required, to address areas of weakness identified in the evaluation and the special needs of the facility residents.

Findings include:

Review of the facility employee records indicated that:

-CNA #1 was hired on 1/21/22

-CNA #2 was hired on 5/15/18

-CNA #3 was hired on 10/16/23

-CNA #4 was hired on 12/19/17

-CNA #5 was hired on 11/27/18

Further review of the employee records did not indicate that performance evaluations had been completed for the employees for the past 12 months.

During an interview on 1/7/25 at 11:22 A.M., CNA #1 said that she had worked at the facility for over a year and had never received an employee performance evaluation since being employed at the facility.

During an interview on 1/7/25 at 2:28 P.M., the Director of Nursing (DON) said that she was responsible to complete performance reviews for all CNA staff. The DON said that CNA's #1, #2, #3, #4 and #5 had not been given a performance review in the past 12 months but should have. The DON further said employee performance reviews should be done every year on the employees' anniversary date of hire to evaluate the CNA performance and opportunities for improvement if needed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 30 225380 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225380 B. Wing 01/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Vantage at Westfield LLC 60 East Silver Street Westfield, MA 01085

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47901 potential for actual harm Based on interview and record review, the facility failed to ensure that one Resident (#366) out of a total Residents Affected - Few sample of 17 residents, was free from unnecessary medication administration.

Specifically, for Resident #366, the facility failed to ensure that the Resident had adequate indication for the use of an antibiotic medication (Clarithromycin - used to treat chest and skin infections) that was ordered by

the Physician to be administered for twenty-nine days.

Findings include:

Review of the facility policy titled Medication Monitoring and Management, dated 1/1/21, indicated:

>When a resident receives a new medication, the medication order is evaluated for the following:

-The dose, route of administration, duration, and monitoring are in agreement with current clinical practice, clinical guidelines, and/or manufacturer's specifications for use.

-A written diagnosis, an indication, and/or documented objective findings support each medication.

-The prescriber documents the clinical rationale in the resident's active record for using a medication outside

these stated guidelines.

Resident #366 was admitted to the facility in December 2024 with diagnoses of Crohn's Disease, Muscle Weakness and Wedge Compression Fractures of the Vertebra.

Review of the Minimum Data Set (MDS) assessment dated [DATE REDACTED], indicated Resident #366 was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of 15.

During an interview on 1/3/25 at 9:42 A.M., Resident #366 said he/she was taking Clarithromycin medication for a bacterial infection called Mycobacterium Chelonae (severe skin infection that causes prolonged skin lesions that is resistant to standard antibiotic therapy) to the skin.

Review of Resident #366's January 2025 Physician's orders indicated:

-Clarithromycin Oral Tablet 500 milligram (mg), give one table by mouth every 12 hours for infection for 29 days, start date of 12/22/24.

During an interview on 1/3/24 at 1:48 P.M., Nurse #4 said Resident #366 was taking the Clarithromycin medication for an infection but was unsure what type of infection. The surveyor and Nurse #4 reviewed the Resident's clinical records and Nurse #4 said there was no documented diagnoses for the use of the Clarithromycin medication.

During an interview on 1/3/25 at 1:56 P.M., the Director of Nursing (DON) said she thought the Resident was being treated for a Urinary Tract Infection (UTI - infection in the bladder) but would review the Resident's clinical record and update the surveyor.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 30 225380 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225380 B. Wing 01/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Vantage at Westfield LLC 60 East Silver Street Westfield, MA 01085

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 During an interview on 1/3/25 at 2:09 P.M., the Infection Preventionist (IP) said she knew Resident #366 was receiving the Clarithromycin medication but was unsure why the Resident was taking the Clarithromycin Level of Harm - Minimal harm or medication. potential for actual harm

During a follow-up interview on 1/3/25 at 2:45 P.M., the DON said all medications administered should have Residents Affected - Few an indication for use. The DON said Resident #366 had no documented indication for the use of the prescribed Clarithromycin medication.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 30 225380 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225380 B. Wing 01/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Vantage at Westfield LLC 60 East Silver Street Westfield, MA 01085

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater.

Level of Harm - Minimal harm or 45435 potential for actual harm Based on observation, record review, and interview, the facility failed to ensure that it was free of a Residents Affected - Few medication error rate of five percent (5%), or greater when one Nurse (#1) out of three Nurses observed

during the medication pass procedure, made two errors in 27 total opportunities, for a medication error rate of 7.41%, impacting one Resident (#45) out of five residents observed, out of a total sample of 19 residents.

Specifically, for Resident #45, the facility failed to ensure that:

-Nurse #1 did not crush medications that were not ordered to be crushed.

-Nurse #1 properly administered two Extended Release (ER) medications.

Findings include:

Review of the facility policy titled Medication Administration-General Guidelines, dated 1/1/21, indicated:

-Tablet Crushing/Capsule Opening: Crushing tablets may require a Physician's order, per facility policy.

-Long acting or enteric coated dosage forms should not be crushed, an alternative should be sought.

-Consult with the Pharmacist for an alternative medication.

-The Pharmacist should be contacted to review all medications being considered for crushing, whether a Physician's order is present or not. The Pharmacist can assist in finding appropriate alternatives to medications that should not be crushed. When identified, the Prescriber shall be contacted for an order change.

-Instructions for crushing medications should be included on the resident's orders and the medication administration record (MAR) so that all personnel administering medications are aware of this need.

-Please consult with product literature or Do Not Crush lists which the facility may have or with the Pharmacist if there is a question about medications to be crushed when crushing multiple medications for the same resident.

Review of the facility policy titled Crushing Medications, dated April 2018, indicated:

-The nursing staff and/or Consultant Pharmacist shall notify any attending Physician who gives an order to crush a drug that the manufacturer states should not be crushed (for example, long-acting or enteric coated medications).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 30 225380 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225380 B. Wing 01/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Vantage at Westfield LLC 60 East Silver Street Westfield, MA 01085

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 a. The attending Physician or Consultant Pharmacist must identify an alternative medication and/or dosage form; or Level of Harm - Minimal harm or potential for actual harm b. The attending Physician must document (or provide the nurses with a clinically pertinent reason to document) why crushing the medication will not adversely affect the resident; or Residents Affected - Few c. The facility or Practitioner must provide literature from the manufacturer or peer-reviewed journal to justify why modification of the dosage form will not compromise resident care .

Resident #45 was admitted to the facility December 2024 with diagnoses including Hypertensive Heart Disease with Heart Failure and Atherosclerotic Heart Disease of Native Coronary Artery.

Review of the Physician's orders, dated January 2025, indicated the following:

-Isorbide Mononitrate ER (medication used to prevent chest pain) Oral Tablet Extended Release, give 30 mg by mouth one time a day for Heart Failure, initiated 12/10/24.

-Metoprolol Succinate ER (medication used to treat chest pain and high blood pressure) Oral Tablet Extended Release, give 25 mg by mouth one time a day for HTN (hypertension), date initiated 12/10/24.

Further review of the Physician's orders did not indicate the Isorbide Mononitrate ER 30 mg and/or Metoprolol Succinate ER 25 mg medications should be crushed.

Review of Resident #45's clinical record showed no documented evidence that the Pharmacy had been consulted relative to the crushing of the two extended-release medications.

On 1/3/25 at 8:15 A.M., during a medication pass observation on the B wing unit, the surveyor observed Nurse #1 crush, mix in applesauce, and administer the following medications to Resident #45:

-Isorbide Mononitrate ER Oral Tablet 30 mg, one tablet, crushed, mixed with applesauce and given by mouth.

-Metoprolol Succinate ER Oral Tablet 25 mg, one tablet, crushed, mixed with applesauce and given by mouth.

During an interview on 1/3/25 at 8:50 A.M., Nurse #1 said that she had crushed the medications very fine because the Resident had difficulty swallowing them. The surveyor and Nurse #1 reviewed Resident #45's individual medication cards for Isorbide Mononitrate ER 30 mg and Metoprolol Succinate ER 25 mg and Nurse #1 said she should not have crushed the extended-release medications. Nurse #1 said that she would notify the Physician that she had crushed and administered the medications.

During an interview on 1/3/25 at 11:49 A.M., the Director of Nursing (DON) said Isorbide Mononitrate ER and Metoprolol Succinate ER should not have been crushed. The DON further said Nurse #1 had been instructed to complete a Medication Error Report.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 30 225380 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225380 B. Wing 01/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Vantage at Westfield LLC 60 East Silver Street Westfield, MA 01085

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 During an interview on 1/3/25 at 1:34 P.M, the Consultant Pharmacist said Isorbide Mononitrate ER and Metoprolol Succinate ER should not be crushed. The Consultant Pharmacist said the pharmacy would have Level of Harm - Minimal harm or no way to know that a Resident needed crushed medications unless the pharmacy had been notified by the potential for actual harm facility, and he had no evidence of this notification for Resident #45. The Consultant Pharmacist said it is the responsibility of the facility to follow the instructions for medication administration. The Consultant Residents Affected - Few Pharmacist further said that nursing staff could call the pharmacy 24 hours a day for instructions if there were any questions regarding the crushing of medications.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 30 225380 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225380 B. Wing 01/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Vantage at Westfield LLC 60 East Silver Street Westfield, MA 01085

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Ensure that residents are free from significant medication errors.

Level of Harm - Minimal harm or 45435 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure that one Resident (#45) out Residents Affected - Few of a total sample of 19 residents were free from significant medication errors.

Specifically, the facility failed to ensure the proper administration of Isorbide Mononitrate ER (an extended release [ER] medication used to prevent chest pain) and Metoprolol Succinate ER (an extended-release medication used to treat chest pain and high blood pressure) when the manufacturer's specifications regarding the preparation and administration of both medications were not followed, putting the resident at risk for worsening cardiac symptoms.

Findings include:

Review of the facility policy titled Medication Administration-General Guidelines, dated 1/1/21, indicated:

-Tablet Crushing/Capsule Opening: Crushing tablets may require a Physician's order, per facility policy.

-Long acting or enteric coated dosage forms should not be crushed, an alternative should be sought.

-Consult with the Pharmacist for an alternative medication.

-The Pharmacist should be contacted to review all medications being considered for crushing, whether a Physician's order is present or not. The Pharmacist can assist in finding appropriate alternatives to medications that should not be crushed. When identified, the Prescriber shall be contacted for an order change.

-Instructions for crushing medications should be included on the resident's orders and the medication administration record (MAR) so that all personnel administering medications are aware of this need.

-Please consult with product literature or Do Not Crush lists which the facility may have or with the Pharmacist if there is a question about medications to be crushed when crushing multiple medications for the same resident.

Review of the facility policy titled Crushing Medications, dated April 2018, indicated:

-The nursing staff and/or Consultant Pharmacist shall notify any attending Physician who gives an order to crush a drug that the manufacturer states should not be crushed (for example, long-acting or enteric coated medications).

a. The attending Physician or Consultant Pharmacist must identify an alternative medication and/or dosage form; or

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 30 225380 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225380 B. Wing 01/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Vantage at Westfield LLC 60 East Silver Street Westfield, MA 01085

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 b. The attending Physician must document (or provide the Nurses with a clinically pertinent reason to document) why crushing the medication will not adversely affect the resident; or Level of Harm - Minimal harm or potential for actual harm c. The facility or Practitioner must provide literature from the manufacturer or peer-reviewed journal to justify why modification of the dosage form will not compromise resident care . Residents Affected - Few

Review of Davis's Drug Guide for Nurses, 19th edition, Copyright 2025, Vallerand, A. H. and Sanoski, C.A. indicated the following:

-Isosorbide Mononitrate - Swallow extended-release tablets whole; do not break, crush, or chew.

-Metoprolol - **Do not crush** High Alert Medication: This medication bears a heightened risk of causing significant patient harm when it is used in error. Extended-release tablets may be broken in half; do not crush or chew.

Resident #45 was admitted to the facility December 2024 with diagnoses including Hypertensive Heart Disease with Heart Failure and Atherosclerotic Heart Disease of Native Coronary Artery.

Review of Resident #45's Physician's orders, dated January 2025, indicated:

-Isorbide Mononitrate ER Oral Tablet Extended Release, give 30 mg by mouth one time a day for Heart Failure, initiated 12/10/24.

-Metoprolol Succinate ER Oral Tablet Extended Release give 25 mg by mouth one time a day for HTN (hypertension), initiated 12/10/24.

Further review of Resident #45's Physician's orders did not indicate to crush the Isorbide Mononitrate ER and/or Metoprolol Succinate ER medications.

Review of Resident #45's clinical record showed no documented evidence that the Pharmacy had been consulted relative to the crushing of the extended-release medications.

On 1/3/25 at 8:15 A.M., during a medication pass observation on the B wing unit, the surveyor observed Nurse #1 crush, mix in applesauce, and administer the following medications to Resident #45:

-Isorbide Mononitrate ER Oral Tablet 30 mg, one tablet, given by mouth.

-Metoprolol Succinate ER Oral Tablet 25 mg, one tablet, given by mouth.

During an interview on 1/3/25 at 8:50 A.M., Nurse #1 said that she had crushed the ER medications because

the Resident had difficulty swallowing the medications. The surveyor and Nurse #1 reviewed the individual medication cards for Isorbide Mononitrate ER 30 mg and Metoprolol Succinate ER 25 mg. Nurse #1 said she should not have crushed the extended-release medications and she would notify the Physician that she had crushed and administered the medications.

During an interview on 1/3/25 at 10:31 A.M, Nurse #2 said that there should be a list of medications that cannot be crushed, but she was not sure where the list was and that she would check with the Unit Manager (UM).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 30 225380 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225380 B. Wing 01/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Vantage at Westfield LLC 60 East Silver Street Westfield, MA 01085

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 During an interview on 1/3/25 at 10:49 A.M., Nurse #3 said that she is not sure if there was a list of do not crush medications, but if a medication cannot be crushed, it would be indicated on the medication card. Level of Harm - Minimal harm or potential for actual harm During an interview on 1/3/25 at 10:53 A.M., UM #1 said that extended-release, delayed release and enteric coated medication should not be crushed. UM #1 said that the facility used to have a list of medications that Residents Affected - Few cannot be crushed located on each medication cart, but she was unable to locate any of these lists. The surveyor and UM #1 reviewed Resident #45's medication cards for Isorbide Mononitrate ER and Metoprolol Succinate ER and found no instructions relative to crushing the medications was indicated on the medication card.

During an interview on 1/3/25 at 11:49 A.M., the Director of Nursing (DON) said Resident #45's Isorbide Mononitrate ER and Metoprolol Succinate ER medications should not have been crushed by Nurse #1.

During an interview on 1/3/25 at 1:34 P.M, the Consultant Pharmacist said Isorbide Mononitrate ER and Metoprolol Succinate ER should not have been crushed. The Consultant Pharmacist said the pharmacy had no evidence of a facility notification that Resident #45 needed his/her medications crushed. The Consultant Pharmacist further said it is the responsibility of the facility to follow the instructions for medication administration and that the pharmacy does not print administration instructions on the label unless it is part of

the Physician's order. The Consultant Pharmacist said that nursing staff could call the pharmacy 24 hours a day for instructions if there were any questions regarding the crushing of medications.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 30 225380 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225380 B. Wing 01/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Vantage at Westfield LLC 60 East Silver Street Westfield, MA 01085

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48206 potential for actual harm Based on observation, interview, and record review, the facility failed to adhere to infection control standards Residents Affected - Few of practice for one Resident (#25) out of a total sample of 18 residents, increasing the risk of contamination and the spread of infections to the Resident and other residents within the facility.

Specifically, for Resident #25, the facility staff failed to appropriately follow Enhanced Barrier Precautions (EBP's: the use of protective gowns and gloves during high contact care activities that may provide opportunity for transmission of medication resistant organisms through staff hands and/or clothing), while providing:

-high contact care to the Resident when performing ADLs (Activities of Daily Living such as bathing, dressing, grooming, personal hygiene).

-administration of an Intravenous (IV- method of delivering medication through the vein) medication to the Resident.

Finding include:

Review of the facility policy titled Enhanced Barrier Precautions, revised March 2024, indicated:

-Enhanced barrier precautions (EBPs)are used as an infection prevention and control intervention to reduce

the transmission of multi-drug resistance organisms (MDROs) to residents.

-EBPs employ targeted gown and glove use in addition to standard precautions during high contact care activities.

-Examples of high contact care activities requiring the use of gown and gloves for EBPs include:

>dressing

>bathing/showering

>transferring

>changing linens

>changing briefs or assisting with toileting

>device care or use (central line, urinary catheter, feeding tube (a flexible tube that provides nutrition and hydration when a person is unable to eat or drink safely by mouth), tracheostomy (a surgical procedure that creates an opening in the neck into the windpipe to help a person breathe) /ventilator (a mechanical device that helps people breathe by moving air in and out of their lungs), etc)

>wound care (any skin opening require a dressing).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 30 225380 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225380 B. Wing 01/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Vantage at Westfield LLC 60 East Silver Street Westfield, MA 01085

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 -EBPs are indicated for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. Level of Harm - Minimal harm or potential for actual harm >Wounds generally include chronic wounds (i.e pressure ulcers, diabetic foot ulcers .)

Residents Affected - Few >Indwelling medication devices include central lines, urinary catheters, feeding tubes and tracheostomies.

Resident #25 was admitted to the facility in November 2024 with diagnoses including Acute Osteomyelitis and Pressure Ulcers to the left and right heels.

Review of the MDS (Minimum Data Set) assessment dated [DATE REDACTED], indicated the Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out a total possible score of 15.

Review of Resident #25's Physician's orders for January 2025 indicated:

-PICC (Peripherally Inserted Central Catheter) NonValved: BRAND Bard Power PICC Provena Gauge 4 FR total Length 37 cm (centimeters). Double lumen-use purple lumen for med administration, active 11/29/24

-Normal Saline Flush, use 10 milliliters (ml) intravenously two times a day for SASH/SAS (Saline, Antibiotic, Saline and Heparin/ Saline, Antibiotic, Saline - procedure based on device type) technique prior to med administration, initiated 11/29/24

-Vancomycin HCL Intravenous Solution Reconstituted 1 GM, use 1 gram intravenously two times a day for bilateral Calcaneus Osteomyelitis, to administer via: (Device type) [sic] Single lumen to be used Diluent/volume per manufactures recommendation utilize SASH/SAS technique, initiated 11/29/24

-Normal Saline Flush, use 10 ml intravenously two times a day for SASH/SAS technique after med administration, initiated 11/29/24

-Heparin Lock Flush solution 10 Unit/ML, use 5 ml intravenously two times a day for SASH technique after administration of Saline, initiated 11/29/24.

Review of Resident #25's Plan of Care, initiated 11/29/24 and revised 12/5/24, indicated:

-Resident #25 needed assistance with his/her ADLs (activities of daily living, includes bathing, dressing, hygiene, personal care) due to decreased strength and endurance, bilateral heel ulcers with osteomyelitis, pain, non-weight bearing, weakness.

-Intervention for Enhanced Barrier Precautions, initiated 12/3/24

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 30 225380 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225380 B. Wing 01/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Vantage at Westfield LLC 60 East Silver Street Westfield, MA 01085

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During an observation on 1/2/25 at 10:02 A.M., Resident #25 was observed lying in bed next to the window with the head of the bed elevated. Resident #25 was observed to have left and right heels wrapped in gauze Level of Harm - Minimal harm or and elevated off the bed. The surveyor observed an Intravenous (IV) machine pump running and attached to potential for actual harm his/her left arm via a PICC IV line. The Resident said that he/she was receiving the IV antibiotic to treat Osteomyelitis in his/her heals. Resident #25 further said that he/she received wound treatments to both Residents Affected - Few his/her heels and to another area on his/her buttock (sacrum).

On 1/2/25 from 10:02 A.M. to 10:33 A.M., the surveyor observed the following:

-Signage outside of Resident #25's room, below the room name plate, indicating Enhanced Barrier Precautions (EBP).

The EBP sign indicated:

>Perform hand hygiene before and after patient contact, contact with environment, and after removal of PPE (Personal Protective Equipment).

>Wear gown and gloves prior to these activities:

*During High Contact Care Activities:

*Dressing

*Bathing/Showering

*Transferring

*Providing hygiene

*Changing linens

*Changing briefs or assisting with toileting

*Device Care or use of a device (i.e central lines, urinary catheters, feeding tubes, tracheostomies, ventilators).

-Clear storage bin with PPE including gloves and clean reuseable yellow gowns outside of the room.

-Black Bin labeled for dirty reuseable gowns.

-10:05 A.M.- CNA #6 donned gloves, did not don a gown, entered Resident #25's room and closed the door for privacy.

-10:09 A.M.- Nurse #4 did not don gloves or gown, entered Resident #25's room with medications in a cup to be dispensed, and closed the door.

-10:11 A.M.- Nurse #4 exited the room, and CNA #6 remained in the room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 30 225380 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225380 B. Wing 01/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Vantage at Westfield LLC 60 East Silver Street Westfield, MA 01085

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 -10:33 A.M.- CNA #6 exited the room holding a clear bag of dirty linens, was not wearing a gown or gloves, and walked down the hall to the dispose of the bag of dirty linens. CNA #6 was not observed disposing of Level of Harm - Minimal harm or any used PPE in the bin outside the room upon exiting the room. potential for actual harm

During an interview on 1/2/25 at 10:11 A.M., Nurse #4 said that the EBP sign outside of Resident #25's room Residents Affected - Few indicated that staff should wear gloves and gowns when providing direct care for Resident #25. Nurse #4 said EBP is needed when Residents have wounds, catheters, or other open areas which are a risk for infection. Nurse #4 said that Resident #25 had the EBP in place because of his/her wounds and IV line. Nurse #4 said that the facility has an Infection Preventionist (IP) who monitors and oversees any infection control needs. Nurse #4 said the facility was well stocked with PPE. Nurse #4 further said that when removing PPE, there are plastic bags available inside the Resident rooms so that staff can remove the gowns, place dirty gowns in the bag, and place bags in the bin outside of the room labeled for soiled gowns.

During an interview on 1/2/25 at 10:36 A.M, the surveyor and CNA #6 reviewed the EBP signage outside of Resident #25's room. The CNA said when the sign is hung above or below the room number, it indicates which bed in the room. CNA #6 said that the sign hanging under the room number would indicate Resident #25's bed. CNA #6 said that the sign indicated staff should wear a gown and gloves when giving direct care to the Resident. CNA #6 said when she leaves the room and removes PPE, she would remove the gown, place the dirty gown in the bag, remove her gloves, do hand hygiene, and then place the dirty bagged gown into the bin outside of the room. CNA #6 said that she should have been wearing a gown when providing direct care to Resident #25 and had not been.

On 1/3/25 at 8:34 A.M., the surveyor observed the following:

-Nurse #4 performed hand hygiene, donned gloves, and prepared the infusion IV machine to administer Vancomycin medication to Resident #25 at 100 ml/hr.

-Nurse #4 doffed gloves, performed hand hygiene, and donned new gloves. Nurse #4 was not observed to don a gown.

-Nurse #4 cleansed the central line lumens (access device attached to the IV line) of Resident #25's PICC line with alcohol wipes, opened the sealed syringe package, prepared 10 ml saline solution in a syringe, administered saline via the purple IV lumen, checked blood return, and demonstrated the IV line was patent (open and unobstructed).

-Nurse #4 connected Vancomycin to the infusion pump, and demonstrated that the IV was running as ordered. During an interview at the time, Nurse #4 said that the medication would run about 90 minutes total and after the infusion was finished, she would administer the second doses of saline and then Heparin as ordered per the SASH technique.

During an interview on 1/3/25 at 1:25 P.M., the Unit Manager (UM) said that EBP is to prevent infections and that residents with catheters, wounds, or those on IV medications have EBP in place. The UM said that staff are expected to wear a gown and gloves when providing direct care to a resident with EBP precautions. The UM said that CNA #6 and Nurse #4 should have been wearing gowns when providing care for Resident #25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 30 225380 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225380 B. Wing 01/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Vantage at Westfield LLC 60 East Silver Street Westfield, MA 01085

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During an interview on 1/3/25 at 1:40 P.M., the Infection Preventionist (IP) said that CNA #6 should have been wearing a gown during direct care. The IP further said that Nurse #4 should have been wearing a gown Level of Harm - Minimal harm or when administering IV medications. potential for actual harm

During a follow-up interview on 1/3/25 at 2:12 P.M., Nurse #4 said that she should have been wearing a Residents Affected - Few gown when she administered the IV medication earlier, and had not been.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 30 225380