Above 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 Life Care Center Of Wilbraham during CMS and state inspections, most recent first.
The facility failed to maintain sanitary conditions in three unit kitchenettes, with surveyors observing toasters laden with crumbs, dried food splatter in cabinets, and unclean refrigerators. The FSD and a dietary aide confirmed that daily cleaning was not occurring, potentially leading to foodborne illness concerns.
A LTC facility failed to adhere to infection control standards, affecting eight residents. Staff improperly used PPE, did not implement necessary precautions for residents with infections, and failed to maintain proper hand hygiene. These actions increased the risk of cross-contamination and infection transmission.
Two residents in a facility were unable to exercise their right to make medical decisions as their Health Care Proxies (HCPs) signed advanced directives and consent forms without being properly invoked. One resident, cognitively intact, had their MOLST form signed by an HCP due to a perceived language barrier, while another resident with severe cognitive impairment had their forms signed before HCP invocation, despite language and communication issues. Facility staff failed to document or communicate the need for HCP involvement appropriately.
The facility failed to respond promptly to call lights, affecting residents' needs and preferences. Several residents experienced long wait times for assistance, leading to incontinence and distress. Observations showed staff did not consistently adhere to the policy of answering call lights within five minutes, particularly during shift changes.
A facility failed to ensure a resident's advanced directives were fully implemented due to a Nurse Practitioner not signing all required areas of the MOLST form. The resident, with acute respiratory failure and COPD, had their health care proxy invoked, but the back page of the MOLST form, indicating no artificial nutrition, was not signed by the NP, rendering it invalid.
A facility failed to adhere to professional standards for a resident with a PICC line, resulting in inaccurate measurement and documentation of the external catheter length and arm circumference. The resident, with a history of severe infections, had discrepancies in recorded measurements, which were critical for ensuring the PICC line's correct placement. This failure placed the resident at risk for catheter-related complications.
The facility failed to adhere to professional standards of practice for skin care management for two residents. One resident, with severe cognitive impairment and on anticoagulant medication, had unexplained scabbed areas on the upper lip with no documentation or investigation conducted. Another resident, at risk for pressure ulcers, did not receive required weekly skin assessments for two weeks. These deficiencies indicate a lapse in the facility's care processes.
A facility failed to ensure necessary respiratory care for a resident using a CPAP machine with oxygen therapy. Despite the resident's care plan documenting the required settings, there were no physician's orders specifying the CPAP pressure settings or oxygen flow rate, as required by facility policy. Staff interviews confirmed the oversight, leading to a deficiency noted by surveyors.
A facility failed to ensure proper care for a resident on hemodialysis by not having a Physician's order for fluid restriction and not documenting the resident's fluid intake. The resident, with End Stage Renal Disease, lacked a documented fluid restriction order, and staff interviews confirmed the absence of daily fluid intake records, making it unclear how much fluid the resident consumed.
A facility failed to implement the Behavioral Health Care Team's recommendations for a resident on antipsychotic medication. The team advised conducting a lipid panel and HbgA1c test after three months of medication use, but these tests were not performed. The Behavioral Health Team's notes were sent to the resident's PCP, who did not order the tests, and facility staff did not ensure the recommendations were followed.
A facility failed to limit the timeframe for a PRN psychotropic medication to 14 days for a resident with Depression and Adjustment Disorder with Anxiety. The resident's Trazodone order, starting in February, lacked an end date and was administered beyond the 14-day limit without a physician's review. Staff interviews confirmed non-compliance with the policy requiring a stop date and physician review for continued use.
A facility failed to securely store medications when an Insulin Lispro Pen was left unattended on a medication cart in the hallway. The assigned nurse was on break, leaving the cart unsupervised for 19 minutes, during which a resident passed by. Nurse #4 later secured the pen, acknowledging the risk of leaving it unattended.
The facility failed to ensure the required members, specifically the DON and IP, were present at a QAPI meeting. The facility's policy requires the QAA Committee to include the DON, Medical Director, IP, and at least three other staff members, including the Administrator. The June 2024 meeting lacked evidence of the DON or IP's attendance, and no representative provided their reports.
The facility failed to provide Bed-Hold Notices to residents or their representatives upon hospital transfer, affecting multiple residents. Staff interviews revealed confusion over departmental responsibilities, leading to the oversight. This deficiency involved residents with conditions such as dementia and COPD.
Facility Fails to Maintain Sanitary Conditions in Unit Kitchenettes
Penalty
Summary
The facility failed to maintain three unit kitchenettes in a safe and sanitary condition, as observed by surveyors. In the Hampden Garden Unit kitchenette, a toaster was found laden with crumbs, and the inside of a cabinet storing snacks had dried dark brown splatter on the shelves and door. The [NAME] Terrace Unit kitchenette also had a toaster with crumbs and dried pieces of bread stuck inside, which the Food Service Director (FSD) acknowledged could pose a fire risk. Additionally, the refrigerator in the [NAME] Terrace Unit had dried yellow material on the floor. The Hampshire Woods Unit kitchenette had thick dried brown material on the refrigerator floor. During interviews, the FSD and Dietary Aide #1 confirmed that the kitchenettes should be cleaned daily, but this was not occurring. The FSD was unsure who was responsible for cleaning the toasters regularly, and Dietary Aide #1 stated that afternoon dietary aides were supposed to clean the kitchenettes while stocking snacks. The FSD acknowledged that the lack of cleaning could lead to foodborne illness concerns, as dried food or liquid materials were not being removed from the refrigerators and cabinets as required.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to infection control standards on one of its units, affecting eight residents. For one resident, a nurse improperly donned a gown that touched the floor, failed to clean and disinfect a table before setting up treatment supplies, and used scissors that were not disinfected between uses, increasing the risk of contamination and infection. Another resident had dressing materials brought into their room that were then returned to the treatment cart, posing a risk of cross-contamination. In another case, a resident with suspected Clostridium Difficile (C. Diff) infection was not placed on Contact Precautions while awaiting test results, and the facility did not implement Special Contact/Droplet Precautions for two residents diagnosed with Influenza. Additionally, Enhanced Barrier Precautions were not implemented for two residents at high risk for contracting infections, and a resident diagnosed with C. Diff was not placed on Contact Plus Precautions. The facility's infection prevention and control program was found lacking in several areas, including the improper use of personal protective equipment (PPE), failure to implement appropriate transmission-based precautions, and inadequate hand hygiene practices. These deficiencies were observed during interactions with residents, where staff either did not follow proper procedures or were unaware of the necessary precautions, leading to potential cross-contamination and increased risk of infection transmission.
Failure to Invoke Health Care Proxies Appropriately
Penalty
Summary
The facility failed to ensure that two residents were able to exercise their right to make decisions regarding their medical care, as their Health Care Proxies (HCPs) were not invoked, yet the HCPs signed advanced directives and consent forms. For the first resident, who was admitted with a cerebrovascular accident and diabetes, the facility allowed the HCP to sign a Medical Order for Life-Sustaining Treatment (MOLST) form despite the resident being cognitively intact and able to communicate in English. The resident's clinical record did not indicate that the HCP was invoked, and the resident confirmed they could communicate their needs and had no difficulty with the staff. The second resident, admitted with cognitive communication deficit and dementia, had their MOLST form and consents for psychotropic medications and vaccinations signed by the HCP before the HCP was officially invoked. The resident was severely cognitively impaired and primarily spoke Portuguese, yet there was no documented evidence that the HCP was invoked due to language barriers. The resident's communication care plan did not reflect the need for HCP involvement, and the staff failed to provide information in the resident's native language before the HCP was invoked. Interviews with facility staff, including the Assistant Director of Nurses (ADON) and the Director of Nursing (DON), revealed that there was a lack of documentation and communication regarding the invocation of HCPs. The ADON acknowledged that if residents deferred to their HCPs for signing paperwork, there should be a note in the clinical record. The DON was made aware of the concerns regarding the improper signing of paperwork by HCPs without proper invocation.
Delayed Response to Call Lights in LTC Facility
Penalty
Summary
The facility failed to provide reasonable accommodations for the needs and preferences of several residents, as evidenced by delayed responses to call lights. Residents #98 and #75 reported waiting 15 to 30 minutes for assistance during early morning shift changes, leading to incidents of incontinence and increased anxiety. Resident #101 also experienced incontinence due to prolonged wait times for toileting assistance, a condition that was new since admission to the facility. These delays were particularly noted during shift changes and were corroborated by observations and resident interviews. On the [NAME] Terrace Unit, call lights were not answered promptly, with one instance where a call light remained on for eight minutes while staff passed by without responding. Another resident reported waiting an hour for assistance, and Resident #169's call light was observed to be lit for 19 minutes before a nurse responded. This resident required assistance with mobility and transfers due to a history of falls and muscle weakness, highlighting the critical need for timely staff response. Resident #72, who required assistance with personal care and toileting, was observed waiting for assistance for over 20 minutes, during which time the resident repeatedly called for help. Despite the call light being audible at the nursing station, staff did not respond promptly, resulting in the resident's distress. The facility's policy requires call lights to be answered within five minutes, yet observations and resident reports indicate this standard was not consistently met, contributing to the deficiencies noted in the survey.
Failure to Implement Resident's Advanced Directives
Penalty
Summary
The facility failed to ensure that a resident had the opportunity to formulate advanced directives and that their wishes regarding these directives were implemented. Specifically, the deficiency involved a resident who was admitted with acute respiratory failure and chronic obstructive pulmonary disorder. The resident's health care proxy was invoked, and a Medical Order for Life Sustaining Treatment (MOLST) form was completed. However, the Nurse Practitioner (NP) did not sign all required areas of the MOLST form, specifically the back page, which indicated no artificial nutrition. During a review of the MOLST form, it was found that while the front page was signed by both the resident's health care proxy and the NP, the back page was only signed by the health care proxy. The absence of the NP's signature on the back page rendered it invalid, as confirmed by the Assistant Director of Nursing during an interview with the surveyor. This oversight resulted in the facility's failure to fully implement the resident's advanced directives as required by their policy.
Inaccurate PICC Line Measurements and Documentation
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for a resident with a Peripherally Inserted Central Catheter (PICC) line. The deficiency involved the inaccurate measurement and documentation of the external catheter length and arm circumference for a resident receiving IV antibiotics. The facility's policy required accurate measurement of the external catheter length and arm circumference to ensure the PICC line had not migrated, which was not adhered to in this case. The resident, admitted with multiple diagnoses including Metabolic Encephalopathy, Sepsis, and MSSA infection, had a PICC line placed in the upper right extremity. The hospital records indicated the external catheter length was 2 cm, and the arm circumference was 36 cm at the time of insertion. However, facility records showed discrepancies in these measurements, with the external catheter length documented as 41 cm on one occasion and 4 cm on another, and the arm circumference documented as 36 cm initially and then 12 cm later. During the survey, the Assistant Director of Nurses (ADON) re-measured the resident's arm circumference and external catheter length, finding a significant difference from the initial measurements. The Infection Preventionist confirmed that the external catheter length was not consistent with the initial 2 cm measurement. The failure to accurately measure and document these parameters placed the resident at risk for potential catheter-related complications, as the PICC line's position in the superior vena cava was critical for safe medication administration.
Failure in Skin Care Management for Two Residents
Penalty
Summary
The facility failed to provide appropriate treatment and care according to professional standards of practice related to skin care for two residents. For Resident #22, the facility did not identify a new skin alteration or conduct an investigation to determine its cause. The resident, who was severely cognitively impaired and on anticoagulant medication, was observed with bilateral scabbed areas on the upper lip. Despite multiple observations and interviews, there was no documentation in the resident's medical record regarding the origin or timing of these injuries. Staff members, including a CNA and a nurse, speculated that the injuries might have been caused by shaving, but no formal assessment or documentation was completed. For Resident #62, the facility failed to conduct weekly skin checks as required by the resident's comprehensive care plan. The resident, who had moderate cognitive impairment and was at risk for pressure ulcers, did not have documented weekly skin assessments for two consecutive weeks. The Director of Nursing confirmed that the assessments were not completed as scheduled, despite being set up in the electronic medical record system. This oversight left the resident without the necessary monitoring for potential skin integrity issues. The deficiencies highlight a lack of adherence to the facility's policy on basic skin management, which mandates regular skin inspections and prompt documentation of any changes. The failure to document and investigate skin alterations for Resident #22 and to perform scheduled skin assessments for Resident #62 indicates a gap in the facility's care processes, potentially compromising the residents' health and safety.
Lack of Physician's Orders for CPAP and Oxygen Therapy
Penalty
Summary
The facility failed to ensure that necessary respiratory care and services were in place for a resident, specifically regarding the use of a Continuous Positive Airway Pressure (CPAP) machine and oxygen therapy. The resident, who was admitted with a diagnosis of Complex Sleep Apnea, was observed using a CPAP machine with oxygen every night. However, there were no physician's orders specifying the CPAP pressure settings or the oxygen flow rate, which are required according to the facility's policy. The resident's care plan did include these settings, but the absence of a formal physician's order constituted a deficiency. Interviews with nursing staff and the unit manager confirmed that the resident used the CPAP with oxygen nightly, and they acknowledged the lack of physician's orders for the CPAP settings and oxygen flow rate. The facility's policy mandates that such orders must be in place, including details like mode, pressure setting, mask type, and oxygen liters per minute. Despite the care plan documentation, the failure to have a physician's order in place for these treatments was a clear oversight, leading to the deficiency noted by the surveyors.
Failure to Document Fluid Restriction for Dialysis Resident
Penalty
Summary
The facility failed to implement professional standards of care for a resident requiring hemodialysis, specifically by not having a Physician's order for fluid restriction and not maintaining documentation of the resident's fluid intake. The resident, who was admitted with End Stage Renal Disease (ESRD) and received dialysis services three times a week, did not have a documented fluid restriction order in their March 2025 Physician's orders. Additionally, the resident's care plan encouraged fluid intake up to 1200 cc per day, but there was no evidence in the medical record that nursing staff documented the resident's daily fluid intake. Interviews with facility staff revealed that there was an expectation for a Physician's order to be in place for fluid restriction and for nursing staff to document daily fluid intake. However, both Nurse #6 and Unit Manager #1 confirmed that there was no documentation of the resident's fluid intake, making it unclear how much fluid the resident consumed each day. The Dialysis Unit Manager from the dialysis facility also indicated that the nursing facility should provide fluid intake information if requested, as it could be important for addressing unexpected weight changes in the resident.
Failure to Implement Behavioral Health Recommendations
Penalty
Summary
The facility failed to implement the recommendations made by the Behavioral Health Care Team for a resident diagnosed with multiple mental health disorders, including generalized anxiety disorder, psychotic disorder, depression, and dementia with psychosis. The resident was started on antipsychotic medication, and the Behavioral Health Physician Assistant recommended a lipid panel and Hemoglobin A1C (HbgA1c) lab work to be drawn after three months of medication use. However, the facility did not ensure these tests were conducted as recommended. Interviews with facility staff revealed that the Behavioral Health Team's notes and recommendations were faxed to the resident's Primary Care Provider (PCP), who was responsible for reviewing and implementing any necessary orders. Despite this process, there was no documentation indicating that the PCP ordered the recommended tests, and the facility staff did not verify whether the recommendations were followed. This oversight resulted in the failure to monitor the resident's health condition as advised by the Behavioral Health Team.
Failure to Limit PRN Psychotropic Medication to 14 Days
Penalty
Summary
The facility failed to adhere to the regulatory requirement of limiting the timeframe for a PRN psychotropic medication to 14 days for a resident. Specifically, the resident was admitted with diagnoses of Depression and Adjustment Disorder with Anxiety and had a physician's order for Trazodone, an antidepressant medication, to be administered as needed. The order, which began on February 23, 2025, did not include an end date, and the medication was administered on March 2 and March 10, 2025, exceeding the 14-day limit without a physician's review. Interviews with facility staff revealed a lack of compliance with the policy that requires PRN psychotropic medications to be reviewed and renewed by a physician after 14 days. Nurse #9 confirmed that such medications should have a stop date and require a physician's review for continued use. The Unit Manager acknowledged that the PRN order for Trazodone should have been reviewed by March 9, 2025, but was not, resulting in the deficiency.
Unattended Insulin Pen on Medication Cart
Penalty
Summary
The facility failed to ensure that medications were stored securely, as observed with the Hampden Garden Long Hall medication cart. An Insulin Lispro Pen was left unattended on top of the medication cart in the hallway, accessible to residents. This occurred when the nurse assigned to the cart left the floor for a break, leaving the cart unsupervised for approximately 19 minutes. During this time, a resident was observed wheeling past the unattended cart and into their room. Nurse #4, upon returning to the area, acknowledged that the Insulin Lispro Pen should not have been left unattended due to the risk of a resident taking it. The nurse then removed the pen to store it securely until the assigned nurse returned. The Assistant Director of Nursing confirmed that no medications should be left unsupervised on top of the medication cart, indicating a lapse in adherence to the facility's policy on medication storage.
QAPI Committee Meeting Attendance Deficiency
Penalty
Summary
The facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) Committee with the required members during one of the four quarterly meetings reviewed. Specifically, the Director of Nursing (DON) and the Infection Preventionist (IP) or a designated representative were not present at the June 2024 quarterly QAPI meeting. The facility's policy mandates that the QAA Committee must include the DON, the Medical Director or designee, the IP, and at least three other staff members, including the facility's Administrator. A review of the meeting attendance sign-in sheet for the QAPI meeting held on June 17, 2024, showed no evidence of the DON or IP's attendance. During an interview on March 12, 2025, the Administrator confirmed the absence of documented evidence that the DON or IP attended the June 2024 QAPI meeting. The Administrator acknowledged the requirement for the DON or IP to be present or for a representative to provide an updated report on their behalf to the QAPI committee. However, there was no documented evidence that such reports were presented by a designee as required.
Failure to Provide Bed-Hold Notices Upon Hospital Transfer
Penalty
Summary
The facility failed to provide a Notice of Bed-Hold Policy and Return in writing to residents or their representatives upon transfer to the hospital. This deficiency was identified for two residents out of a sample of 22 and one resident out of three closed records reviewed. The facility's policy requires that the Bed-Hold policy be given upon admission and upon transfer to the hospital, ensuring residents and their representatives are informed about the bed-hold and reserve bed payment policy. However, the facility did not adhere to this policy, as evidenced by the lack of documentation in the medical records of the affected residents. Interviews with facility staff revealed a lack of clarity and responsibility regarding who was tasked with providing the Bed-Hold Notices. The Admissions Assistant, Social Worker, and Business Office Manager each believed that another department was responsible for sending out these notices. Consequently, no department took responsibility, resulting in the failure to provide the necessary documentation to the residents' representatives. This oversight affected residents with various medical conditions, including dementia, COPD, and influenza, who were transferred to the hospital without the required notification being issued.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 265 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Wilbraham
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hampden Post Acute | 1.3 mi | ★★★★★ | 9 | 0 |
| Sixteen Acres Health And Rehabilitation Center Llc | 4.8 mi | ★★★★★ | 10 | 0 |
| Loomis Lakeside At Reeds Landing | 5 mi | ★★★★★ | 0 | 0 |
| Chicopee Rehabilitation And Nursing | 5 mi | ★★★★★ | 0 | 0 |
| Palmer Healthcare Center | 6.1 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.