Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Hampden Post Acute during CMS and state inspections, most recent first.
Failure to Follow PPE and Hand Hygiene Requirements for Residents on TBP: Staff on two units did not follow posted PPE instructions for residents on Droplet and Contact Precautions. A SW and a lab tech kept their N95 masks on after leaving rooms on one unit, while multiple CNAs and laundry staff on another unit entered rooms with incomplete PPE, failed to use eye protection or gowns when indicated, did not remove masks when exiting, and did not perform hand hygiene as required. The IP stated that some rooms should have had both Droplet and Contact signage posted.
A nurse held multiple ordered meds and assessments for a resident with pneumonia, respiratory failure, diabetes, and glaucoma because consent to treat was documented as not signed, even though the admission agreement included consent for admission and treatment. The MAR showed several meds, insulin, oxygen-related care, pain checks, vital signs, and a TB test were not given or completed on multiple shifts, and leadership and the physician stated the resident should have received the ordered interventions.
Medication Administration Errors Exceeded Allowed Rate: A nurse administered three medication errors during a med pass for a resident with a hip prosthesis infection, including the wrong Calcium/Vit D dose, the wrong B12 dose, and the wrong Cefazolin IV solution. The MAR was signed as if the ordered meds had been given, and both the nurse and DON acknowledged the meds were not administered as ordered.
Failure to Provide Routine Dental Services After Consent Was Obtained: A resident with dementia and anxiety, who was dependent on staff for oral hygiene, had dental consent signed by the HCP but there was no evidence of routine dental care for an extended period. The resident later reported tooth pain and difficulty swallowing, staff documented broken teeth and pain, and the resident’s representative said the resident had repeatedly requested dental care but had not been seen by the dentist.
Failure to Post Daily Nursing Staffing Data: The facility did not post required nursing staffing information in a prominent, public location at the beginning of each shift. Surveyors did not find the RN, LPN, and CNA staffing data posted, and interviews with the Receptionist, Scheduler, and DON showed uncertainty about where the information was kept and who was responsible for posting it. The DON confirmed the required hours for nursing staff in the building were not posted as required.
A facility failed to execute valid Advance Directives for a resident with cerebral infarction and hemiplegia. The MOLST form was signed by the Health Care Proxy before being officially invoked by a physician, rendering it invalid. This discrepancy was confirmed during a review of clinical records and an interview with a social worker.
A resident with severe cognitive impairment and behavioral disturbances was not provided with a meaningful activity program as per their care plan. Despite preferences for religious services, outdoor activities, and music, the resident's activity logs showed minimal participation. Observations revealed the resident spent time alone without access to preferred activities, and interviews with staff indicated a lack of awareness and follow-through on the resident's activity preferences.
A resident with COPD, who was cognitively intact, was observed smoking without a required smoking apron, despite care plan recommendations. Staff interviews revealed a lack of awareness and implementation of safety measures, indicating a failure to adhere to the facility's smoking policy.
A resident's g-tube became dislodged during a shower, and the facility failed to have a physician's order or care plan for its replacement. The nurse cleaned and reinserted the tube without consulting a physician, and the DON was not informed. The facility lacked supplies and protocol for such events, leading to a deficiency in care.
The facility failed to ensure that nurses had the necessary competencies to care for residents, resulting in a deficiency. A nurse reinserted a dislodged and contaminated g-tube for a resident without proper training or physician's order. Additionally, the facility did not verify that agency nurses had completed basic competencies before working.
A facility failed to offer the Influenza Vaccine to a resident with significant health conditions during the 2023-2024 flu season. The resident's medical record lacked documentation of the vaccine being offered, received, or declined. The IP sent a consent form to the resident's legal guardian, but it was not returned, and no follow-up was documented. The DON confirmed that the vaccine should have been offered and that staff should have followed up with the guardian.
Failure to Follow PPE and Hand Hygiene Requirements for Residents on Transmission-Based Precautions
Penalty
Summary
The facility failed to follow infection control practices for residents on Transmission-Based Precautions on Unit B1 and Unit A2. On Unit B1, Resident #60 had a Droplet Precaution sign posted at the doorway, and Social Worker #1 removed gloves, gown, and face shield when exiting the room but did not remove her N95 mask. Resident #121 had active orders for Droplet/Contact Precautions for COVID/Flu, and the Laboratory Technician removed gloves, gown, and face shield when leaving the room but also kept her N95 mask on. Both staff members stated they should have removed all PPE when exiting the rooms. On Unit A2, Resident #122 had orders for Droplet/Contact Precautions related to RSV, and the posted signage indicated Droplet Precautions with instructions to cleanse hands before entering and leaving the room and to remove face protection before exiting. CNA #3 entered the room wearing a surgical mask and gloves but did not don eye protection or a gown. Resident #122 was seated in a wheelchair, was not wearing a mask, and was observed coughing. CNA #3 assisted the resident with dressing, removed and discarded her gloves and mask, removed the breakfast tray, and walked down the hallway. Resident #5 and Resident #15 shared a room on Unit A2 and both had respiratory-related orders, including Tamiflu prophylaxis and, for Resident #5, Droplet/Contact Precautions for upper respiratory symptoms. The room signage indicated Droplet Precautions, but staff repeatedly entered without following the posted PPE instructions. CNA #4 entered with only a surgical mask, later returned with CNA #3, and both entered with only surgical masks and gloves; CNA #4 removed gloves and performed hand hygiene on one occasion but did not remove her mask. CNA #3 later entered with a surgical mask and gloves, sat at the bedside, and assisted Resident #15 with breakfast while Resident #5 was coughing. CNA #2 also entered with only a surgical mask, assisted with the bed, spoke with the resident, collected the breakfast tray, and exited without removing her mask or performing hand hygiene. Laundry Staff #1 entered the room wearing a gown, gloves, and surgical mask but no eye protection, delivered laundry to Resident #15's closet, then removed PPE and put on a new surgical mask without performing hand hygiene. The Infection Preventionist stated that Resident #122 and Resident #5 should have had both Droplet and Contact Precaution signage posted, and that staff should have removed all PPE, including the surgical mask, and performed hand hygiene upon exiting the room.
Failure to Carry Out Ordered Medications and Assessments
Penalty
Summary
The facility failed to provide care and services that met professional standards of quality for one resident by not implementing physician-ordered medications and assessments. The resident had been admitted after hospitalization for pneumonia, acute hypoxic respiratory failure, acute pyelonephritis, type 2 diabetes mellitus, and glaucoma, and the signed admission agreement indicated consent to admission and treatment, including medically necessary routine nursing and other services. Nurse #2 documented that the resident’s consents were not signed and therefore medications could not be given on two shifts, and the medication administration record showed multiple ordered medications were held or not completed. These included amlodipine, ferrous sulfate, docusate sodium, Senna-S, amoxicillin-pot clavulanate, glaucoma eye drops, Humalog insulin, oxygen weaning, pain monitoring, vital signs, and a one-time Tubersol test. The record also showed these orders were held or not completed on more than one day, with the nurse documenting that medications were not given because consent to treat was not signed. Facility interviews confirmed that the admission agreement had been completed with consent for treatment, and the regional clinical director and physician stated the resident should have received the ordered interventions while in the facility. The physician stated the resident and/or representative had agreed to admission following hospitalization with a treatment plan in place, and that the facility should not have held any ordered interventions.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to maintain a medication administration error rate of less than 5% when 3 medication errors occurred out of 41 opportunities, resulting in a 7.32% error rate. During a medication pass for Resident #121, Nurse #4 administered Calcium 600 mg/Vitamin D 10 mcg (400 units) instead of the ordered Calcium 600 mg/Vitamin D 200 units, administered Vitamin B12 500 mcg instead of the ordered 100 mcg, and administered Cefazolin 2 gm in Dextrose 100 ml IV solution instead of the ordered Cefazolin 2 gm in Sodium Chloride 0.9 gm per 100 ml IV solution. Resident #121 was admitted with diagnoses including infection of the left hip prosthesis. The resident’s active orders included Calcium-Vitamin D 600-200 mg-units daily, Vitamin B12 100 mcg daily, and Cefazolin in Sodium Chloride 2 gm IV every 8 hours. The surveyor observed Nurse #4 administer the incorrect Calcium/Vitamin D dose, the incorrect Vitamin B12 dose, and the incorrect Cefazolin IV solution. Nurse #4 later acknowledged the medication errors and stated the medications were not administered per the physician’s orders. The physician stated the expectation was that medications be administered as ordered, and the DON stated nurses were expected to perform the six rights of medication administration before giving a medication.
Failure to Provide Routine Dental Services After Consent Was Obtained
Penalty
Summary
The facility failed to ensure that routine dental services were provided for one resident after dental consent had been obtained from the resident representative in June 2023. The resident was admitted with diagnoses including dementia and anxiety, had a BIMS score of 15, was dependent on staff for oral hygiene, and had no dental issues documented on the MDS. The facility policy stated that routine and emergency dental services were available through the facility dentist, the resident’s personal dentist, community dentists, or other health care organizations, and that dental services were to be recorded in the medical record. The resident later reported tooth pain and difficulty swallowing at times, and the surveyor was unable to visualize the teeth during the interview. Review of the clinical record failed to show evidence that routine dental care had been provided after the signed dental consent. A unit manager reviewed the record and could not find evidence that the resident had been evaluated by a dentist in the prior six months, and the assistant director of nursing also could not find evidence that the resident had received dental care. The resident’s representative stated that dental services had been consented to previously and that, to their knowledge, the resident had never been evaluated by the dentist despite repeated requests for dental care due to discomfort and chewing difficulty. When the resident’s complaint was brought to staff attention, the assistant director of nursing documented tooth pain rated 7 out of 10, two broken teeth, no redness or swelling, and that Tylenol was given with good effect. The diet was changed to mechanical soft and an SLP evaluation was requested. The resident was then seen by the dental provider and was scheduled for extractions of teeth #7, #10, and #11. The regional director of clinical services stated there was no indication the resident had been seen by the dental provider since consent was signed, and the DON stated there was no record that routine dental care had been provided after consent had been obtained in 2023.
Failure to Post Daily Nursing Staffing Data
Penalty
Summary
The facility failed to post nursing staff data daily at the beginning of each shift in a prominent location accessible to residents and visitors, as required by its policy titled "Posting Direct Care Daily Staffing Numbers." The policy stated that daily staffing information should include the number of licensed nurses and unlicensed nursing personnel directly responsible for resident care, and the report specifically noted that the actual hours worked for RNs, LPNs, and CNAs were not posted. On 1/20/26, the surveyor did not observe the nursing staff data available for review in a prominent location in the facility. On 1/21/26 at 9:57 A.M., the surveyor again did not observe the staffing data posted. During interviews, the Receptionist said the information was not kept in the lobby and that a full nursing schedule was kept by the employee time clock in a non-public area. The Scheduler said she was not sure who was responsible for posting the data and believed it might be in the front lobby. The DON said she believed the staffing data was in the lobby enclosed bulletin board, but when the surveyor and DON observed that bulletin board, the nursing staff data was not posted. The DON stated there should be something posted that included the number of hours for nursing staff in the building for that day, but it was not posted as required.
Failure to Execute Valid Advance Directives
Penalty
Summary
The facility failed to accurately execute Advance Directives for a resident, specifically concerning the Massachusetts Medical Order for Life-Sustaining Treatment (MOLST) form. The resident, who was admitted with diagnoses including cerebral infarction and hemiplegia, had a MOLST form signed by their Health Care Proxy (HCP) before the HCP was officially invoked by a physician. This discrepancy was identified during a review of the resident's clinical records, which showed that the HCP activation occurred after the MOLST form was signed. The facility's policy requires that the social services director or designee inquire about the existence of any written advanced directives upon admission. However, the MOLST form for the resident was not valid as it was signed by the HCP before the resident was deemed incapacitated by a physician. This oversight was confirmed during an interview with a social worker, who acknowledged that the MOLST form was invalid due to the premature signing by the HCP.
Failure to Implement Resident-Centered Activity Program
Penalty
Summary
The facility failed to implement a resident-centered, meaningful, and engaging activity program for a resident with severe cognitive impairment and behavioral disturbances. The resident's care plan included preferences for religious services, outdoor activities, and music, but these were not consistently offered or facilitated by the staff. The resident's activity logs showed minimal participation in activities, with only a few recorded instances over several months. Observations by the surveyor revealed that the resident spent significant time alone in their room without access to preferred activities such as television or music. The television was not operational due to a missing remote, and there was no music player or activity materials available. Despite the presence of an activity calendar, the resident was not engaged in any activities during the surveyor's visits. Interviews with the Activity Director and Activity Aide indicated a lack of awareness and follow-through on the resident's activity preferences. The Activity Director was unaware of the non-functional television and the absence of music in the resident's room. The Activity Aide confirmed the accuracy of the activity logs, which showed limited participation, and could not recall the resident attending any religious or musical events. The facility's failure to ensure the resident's engagement in preferred activities led to the deficiency noted in the report.
Failure to Implement Smoking Safety Measures for Resident
Penalty
Summary
The facility failed to ensure an environment free from accidental hazards for a resident who was identified as needing a smoking apron during smoking activities. The resident, who was admitted with chronic obstructive pulmonary disease (COPD) and was cognitively intact, had a care plan and smoking evaluation that recommended supervision and the use of a smoking apron while smoking. Despite these recommendations, the resident was observed smoking on the patio without wearing a smoking apron on multiple occasions. Interviews with staff revealed a lack of awareness and implementation of the safety measures outlined in the resident's care plan. The smoking supervisor stated that no residents required specialized equipment while smoking, and the unit manager confirmed that the recommendations from the smoking evaluations should be followed. The resident reported not using a smoking apron for three to four weeks, and the smoking monitor admitted to never having seen or provided a smoking apron to the resident. This oversight indicates a failure to adhere to the facility's smoking policy and procedure, which mandates the use of safety precautions based on assessments.
Failure in G-Tube Management and Protocol
Penalty
Summary
The facility failed to provide appropriate care and management for a resident with a gastrostomy tube (g-tube) in accordance with professional standards of practice. Specifically, the facility did not have a physician's order or care plan in place for the replacement of the g-tube should it become dislodged. This deficiency was identified for a resident who was admitted with a diagnosis of gastrostomy and cerebral infarction. The resident's clinical record lacked instructions or interventions for staff to follow in the event of a g-tube dislodgment. An incident occurred where the resident's g-tube became dislodged during a shower. The nurse on duty cleaned and reinserted the g-tube without consulting a physician, as there were no supplies or orders available for such an event. The Director of Nursing was not informed of the incident, and it was noted that the resident should have been sent to the hospital for a new g-tube replacement. Interviews with nursing staff revealed a lack of awareness and protocol for handling g-tube dislodgment, contributing to the deficiency.
Failure to Ensure Nursing Competencies for Resident Care
Penalty
Summary
The facility failed to ensure that licensed nurses had the necessary competencies to care for residents, leading to a significant deficiency. Specifically, Nurse #1 did not complete competency training for the care and management of a gastrostomy tube (g-tube) before providing care to Resident #19, who had a g-tube in place. During shower care, the g-tube became dislodged, fell on the floor, and was re-inserted by Nurse #1 without proper sanitization, despite the facility's policy requiring a physician's order and competency in the procedure. The Director of Nursing (DON) acknowledged that the resident should have been sent to the hospital for g-tube replacement. Additionally, the facility did not verify that Nurses #3, #4, #5, and #6, who were provided by a staffing agency, had completed basic nursing competencies before working at the facility. The DON admitted that the facility assumed the staffing agency had completed these competencies but did not confirm this before the nurses began their duties. Interviews with the DON and Nurse #1 revealed that the facility did not ensure that agency nurses had the required competencies, which was an expectation that was not met.
Failure to Offer Influenza Vaccination to Resident
Penalty
Summary
The facility failed to offer the Influenza Vaccination to a resident during the 2023 through 2024 flu season, as required by their policy. The policy mandates that the vaccine be offered to residents between October 1st and March 31st each year, with any refusal documented in the resident's medical record. However, for one resident with significant health conditions, including Chronic Obstructive Pulmonary Disease and Tracheostomy Status, there was no indication in the medical record that the vaccine was offered, received, or declined. The resident had a legal guardian appointed in October 2022, and the Infection Preventionist (IP) stated that a consent form was sent to the guardian but was not returned. Despite this, there was no documentation in the resident's medical record to confirm that the vaccine was offered. The Director of Nursing (DON) acknowledged that all residents should be offered the vaccine and that the staff should have followed up with the guardian when the consent form was not returned.
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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 Wilbraham
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Life Care Center Of Wilbraham | 1.3 mi | ★★★★★ | 0 | 0 |
| Palmer Healthcare Center | 4.8 mi | ★★★★★ | 6 | 0 |
| Sixteen Acres Health And Rehabilitation Center Llc | 5.8 mi | ★★★★★ | 10 | 0 |
| Loomis Lakeside At Reeds Landing | 6.2 mi | ★★★★★ | 0 | 0 |
| Chicopee Rehabilitation And Nursing | 6.2 mi | ★★★★★ | 0 | 0 |
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