Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Chicopee Rehabilitation And Nursing during CMS and state inspections, most recent first.
The facility failed to notify the Physician or PA of significant weight loss in two residents, leading to a deficiency. One resident experienced severe weight loss due to conditions like diabetes and lung cancer, while another had a 25% weight loss in less than a month. Despite facility policies requiring notification of significant changes, there was no documentation or communication with the Physician or PA, as confirmed by interviews with staff.
A facility failed to complete a Significant Change in Status Assessment (SCSA) for a resident who experienced a decline in ADLs and developed a new pressure ulcer. Initially, the resident required supervision and partial assistance for daily activities and had no pressure ulcers. Later, the resident required substantial assistance, was dependent for dressing, and developed an unstageable pressure ulcer. Despite these changes, no SCSA was completed, as confirmed by the MDS Nurse.
A resident with Type 2 Diabetes did not receive insulin within the prescribed time frame at a facility. Lantus SoloStar and Humalog KwikPen insulin were administered outside the one-hour window before or after the ordered times on multiple occasions. Interviews with nursing staff revealed awareness of the timing requirement, but there was a lack of proper documentation and communication when deviations occurred.
A resident with multiple health conditions experienced significant weight loss, which the facility failed to address adequately. Despite being prescribed a nutritional supplement, the resident frequently refused it, and it was discontinued without alternative interventions. Staff interviews revealed a lack of communication and documentation regarding the resident's nutritional needs and weight loss.
A facility failed to ensure that a Physician reviewed recommendations made by a Consultant Pharmacist during a monthly Medication Regimen Review for a resident with Vascular Dementia. The medical record lacked evidence of the Pharmacy Recommendations and Clinical Pharmacy Reports, and the Director of Nursing could not provide additional information during the survey.
A facility failed to coordinate hospice care for a resident with a cerebral infarction by not designating an IDT member to work with hospice representatives and not maintaining the hospice plan of care. Interviews revealed that staff were unsure who was responsible for hospice documentation, leading to incomplete records.
The facility failed to implement proper infection control practices, including Enhanced Barrier Precautions, Contact Precautions, and Transmission-Based Precautions, for residents with wounds, C-Diff, and potential infections. Staff were observed not using required PPE, such as gowns and eye protection, and did not follow hand hygiene protocols, leading to potential contamination and spread of infections.
A resident with moderate cognitive impairment and dependency for transfers was found in a wheelchair missing a left armrest, exposing a metal bar and screw. This deficiency was not reported to maintenance as required by facility policy, posing a risk of injury. The Maintenance Director confirmed no prior work order was received.
A resident with multiple health conditions experienced a significant weight loss of 16.20% over six months, but the MDS assessment inaccurately indicated no significant weight loss. The MDS Nurse acknowledged the error, noting that the Dietician is responsible for section K of the MDS, and sometimes staff do not fully sign off on sections, leading to inaccuracies.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the Physician or Physician Assistant (PA) of significant changes in the condition of two residents, leading to a deficiency. For Resident #35, the facility did not inform the Physician or PA about the resident's severe weight loss, which was greater than 10% over six months. Despite the resident's diagnoses, including diabetes, lung cancer, and chronic kidney disease, and the refusal of nutritional supplements, there was no documented evidence that the provider was notified of the significant weight loss on specific dates. Interviews with the nursing staff and the Director of Nursing (DON) confirmed that the expected protocol of notifying the provider was not followed. Similarly, for Resident #58, the facility did not ensure that the Physician or PA was informed of a significant weight change and continued weight decline. The resident, who was admitted with conditions such as malnutrition and stage 4 pressure wounds, experienced a 25% weight loss in less than a month. Despite the dietician's recommendations to stabilize the resident's weight, there was no documentation that the Physician or PA was made aware of the initial or ongoing weight loss. Interviews with the nursing staff, dietician, and PA revealed a lack of communication and documentation regarding the resident's weight changes. The facility's policies required notifying the attending physician of significant changes in a resident's condition, including weight loss. However, the facility failed to adhere to these policies for both residents. The lack of documentation and communication with the Physician or PA regarding the residents' significant weight loss was confirmed through interviews with the nursing staff, dietician, and PA, highlighting a deficiency in the facility's protocol for managing changes in residents' conditions.
Failure to Complete SCSA for Resident with Decline in ADLs and New Pressure Ulcer
Penalty
Summary
The facility failed to complete a Significant Change in Status Minimum Data Set (SCSA) assessment for a resident who experienced a decline in activities of daily living (ADLs) and developed a new pressure ulcer. The resident, admitted in November 2024 with diagnoses including dementia and an intertrochanteric fracture of the right femur, initially required supervision for oral hygiene, partial assistance for upper body dressing, substantial assistance for lower body dressing, and had no pressure ulcers. By February 2025, the resident required substantial assistance for oral hygiene, was dependent for upper and lower body dressing, and had developed an unstageable pressure ulcer. Despite these changes, no SCSA was completed between the November 2024 and February 2025 assessments. The MDS Nurse acknowledged that the January 2025 documentation reflected the resident's decline and the development of the pressure ulcer, and confirmed that an SCSA should have been completed but was not.
Failure to Administer Insulin Within Prescribed Time Frame
Penalty
Summary
The facility failed to adhere to professional standards of practice in administering medication to a resident with Type 2 Diabetes. The resident was prescribed Lantus SoloStar and Humalog KwikPen insulin to be administered at specific times. However, the facility did not ensure that these medications were administered within the one-hour window before or after the prescribed times. Specifically, there were multiple instances where both types of insulin were administered outside the acceptable time frame, as documented in the Location of Administration Reports for January and February 2025. Interviews with nursing staff, including a nurse, the Director of Nursing (DON), and the Assistant Director of Nursing (ADON), revealed that the staff was aware of the requirement to administer insulin within the specified time frame. However, there was a lack of proper documentation and communication when insulin was administered outside the acceptable time frame. The ADON acknowledged uncertainty about whether the medication was administered outside the time frame or if there was a failure in documentation, indicating a need for staff education on proper medication administration and documentation practices.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident, identified as Resident #35, who experienced significant weight loss. Resident #35 was admitted with multiple diagnoses, including diabetes, lung cancer, COPD, C-Diff, chronic kidney disease, anxiety, and depression. Despite being cognitively intact and requiring only setup or cleanup assistance with eating, the resident experienced a weight loss of over 17% from July 2024 to February 2025, which was not adequately addressed by the facility. The facility's policy on weighing and measuring residents indicates that a weight loss of greater than 10% in six months is severe. Resident #35's weight loss exceeded this threshold, yet the facility did not implement effective nutritional interventions. Although the resident was prescribed ProHeal Liquid Protein, they refused it 31 times out of 55 opportunities, and the supplement was discontinued without alternative interventions being offered. The resident expressed dissatisfaction with the facility's food and mentioned relying on soup and snacks brought by family. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's nutritional needs and weight loss. The dietician was unaware of the frequent refusals of the ProHeal supplement and did not document conversations with the provider about the resident's weight loss. The physician assistant also indicated that they were not informed of the significant weight loss or the discontinuation of the nutritional supplement. The facility's dietary staff mentioned limitations in ordering supplemental foods, which may have contributed to the lack of alternative nutritional interventions for the resident.
Failure to Review Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that recommendations made by the Consultant Pharmacist during a monthly Medication Regimen Review (MRR) were reviewed by the Physician as required. This deficiency was identified for one resident, who was admitted with a diagnosis of Vascular Dementia. The Pharmacist's Progress Notes indicated that recommendations were made on two occasions, but the medical record did not provide evidence of these Pharmacy Recommendations or the Clinical Pharmacy Reports. Furthermore, there was no indication that the Physician had reviewed these recommendations. During the survey, the Director of Nursing was unable to provide additional information or evidence of the Physician's review of the Pharmacy Recommendations.
Failure to Coordinate Hospice Care and Maintain Documentation
Penalty
Summary
The facility failed to provide continuity of care related to hospice services for Resident #42, who was admitted with a diagnosis of cerebral infarction. The facility did not designate a member of the interdisciplinary team (IDT) to coordinate care with hospice representatives, nor did it obtain or maintain the most recent hospice plan of care for the resident. This lack of coordination and documentation was evident during interviews with the social worker, the Director of Nursing (DON), and Nurse #2, who all expressed uncertainty about who was responsible for maintaining hospice documentation in the resident's hospice binder. The hospice nursing facility services agreement required the facility to develop procedures for communication and documentation to ensure patient needs are met 24/7, and to have patient care policies consistent with hospice protocols. However, the facility did not have a designated staff member to ensure hospice documentation was maintained, leading to the absence of the hospice plan of care in Resident #42's binder. The DON and Nurse #2 both indicated that they expected hospice staff to maintain the documentation, but this expectation was not met, resulting in incomplete records for the resident.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection control practices across two units, leading to multiple deficiencies. For a resident on the North Unit, staff did not utilize Enhanced Barrier Precautions (EBP) despite the resident having a Jejunostomy tube and a leaking Jackson Pratt drain. A rehabilitation staff member was observed assisting the resident without wearing the required gown, only wearing gloves, and was unaware of the EBP requirement for this resident. Another resident on the North Unit, diagnosed with C-Diff, was not provided with proper Contact Precautions. A CNA entered the resident's room without performing hand hygiene or donning the required gown and gloves, despite signage indicating these precautions were necessary. The CNA acknowledged the oversight during an interview. On the [NAME] Unit, a nurse failed to clean and disinfect scissors after using them to remove a soiled dressing from a resident with dementia and a femur fracture. The scissors were then used to cut new dressing materials, potentially contaminating them. Additionally, a resident on the North Unit with symptoms of a transmissible infection was not placed on Transmission-Based Precautions while awaiting test results. The resident was later observed without proper isolation measures, and staff did not have access to necessary PPE, such as eye protection, which was not available in the PPE bin or at the nurses' station.
Failure to Maintain Safe Wheelchair Condition
Penalty
Summary
The facility failed to maintain patient care equipment in a safe operating condition for a resident who was admitted with diagnoses including Cerebral Infarct and Rheumatoid Arthritis. The resident, who had moderate cognitive impairment and was dependent on transfers, was observed sitting in a wheelchair with a missing left armrest. This left a metal bar and an exposed screw, posing a risk of injury to the resident. During observations and interviews, it was revealed that the missing armrest had not been reported to maintenance, despite the facility's policy requiring staff to report broken equipment immediately. The Maintenance Director confirmed that no work order had been received prior to the surveyor's observation, indicating a lapse in communication and adherence to protocol. The exposed screw and missing armrest were acknowledged as a concern due to the potential for injury.
Inaccurate MDS Coding for Resident's Weight Loss
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) Assessment was coded accurately for a resident, specifically regarding weight loss. The resident, who was admitted in July 2024, had multiple diagnoses including diabetes, lung cancer, COPD, C-Diff, CKD, anxiety, and depression. A review of the resident's weight summary from July 24, 2024, to December 1, 2024, showed a significant weight loss of 16.20% over six months. However, the MDS assessment dated December 16, 2024, inaccurately indicated that the resident did not experience a weight loss of 5% or more in the last month or 10% or more in the last six months. During interviews, the MDS Nurse acknowledged that the weight loss should have been coded as significant, as the resident experienced a weight loss of over 10% in six months. The MDS Nurse explained that the Dietician is responsible for completing section K of the MDS, where weight information is documented. The nurse also noted that sometimes staff complete required sections without fully signing off, leading her to finalize them. The failure to accurately code the MDS assessment was attributed to not using the most recent weight obtained within 30 days of the assessment date.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Chicopee
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Loomis Lakeside At Reeds Landing | 3.7 mi | ★★★★★ | 0 | 0 |
| South Hadley Rehabilitation And Nursing Center | 4.3 mi | ★★★★★ | 0 | 0 |
| Mont Marie Rehabilitation & Healthcare Center | 4.7 mi | ★★★★★ | 3 | 0 |
| Renaissance Manor On Cabot | 4.7 mi | ★★★★★ | 3 | 0 |
| Vantage At West Springfield Llc | 4.7 mi | ★★★★★ | 10 | 0 |
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