Chicopee Rehab: Failed Assessment After Pressure Ulcer - MA
The resident, identified in inspection records only as Resident 54, was admitted in November 2024 with dementia and a broken right hip. At that point, according to her Minimum Data Set assessment, she needed supervision for oral hygiene and partial help with her upper body. She could participate in dressing herself, at least in part. She had no pressure ulcers.
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See the Derila PillowBy the time inspectors reviewed her records in February 2025, a later assessment told a different story. She now required substantial assistance just to brush her teeth. She was fully dependent for both upper and lower body dressing. And she had an unstageable pressure ulcer, meaning the wound had progressed to the point where its depth couldn't be determined.
Between those two assessments, nothing had been formally triggered. No Significant Change in Status Assessment, the comprehensive reassessment that the facility's own policy and federal rules require when a resident experiences a major decline, had been completed.
The MDS Nurse, interviewed by inspectors on February 13, said the January 2025 documentation made the decline plain. The resident had lost function across multiple daily activities and had developed the pressure ulcer. The nurse said a Significant Change in Status Assessment should have been completed. It wasn't.
That kind of assessment matters because it forces an interdisciplinary team, nurses, therapists, social workers, dietary staff, to formally re-examine a resident's condition and update the care plan to reflect what's actually happening. Without it, a resident who has slipped significantly can remain on a care plan built around who they were months ago, not who they are now.
Resident 54's decline was not subtle. Moving from partial assistance to full dependence across dressing tasks, and from no wounds to an unstageable ulcer, represents a substantial change in condition by any clinical measure. The facility's own policy, revised as recently as March 2022, defined a Significant Change in Status Assessment as required when the interdisciplinary team determines a resident meets the criteria for major improvement or decline. Inspectors found no evidence the team made that determination or acted on it.
The lapse was identified during a routine inspection completed February 18, 2025, and affected one resident out of a sample of 17. CMS classified the violation at the minimal harm level.
That classification reflects the regulatory framework's assessment of what was documented, not necessarily what the resident experienced. An unstageable pressure ulcer is a serious wound. The failure to formally reassess means the care team may have been operating without an updated, comprehensive picture of her needs during the weeks when her condition was changing most rapidly.
Chicopee Rehabilitation and Nursing is located at 44 New Lombard Road. The facility was given the opportunity to submit a plan of correction to the state survey agency.
Resident 54 arrived in Chicopee with a broken hip and a dementia diagnosis, already dependent on staff for much of her daily life. By winter, she had lost what remained of her independence in basic self-care and was carrying a wound that couldn't be fully assessed. The form that would have required the facility to stop and take stock of all of that was never filled out.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Chicopee Rehabilitation and Nursing from 2025-02-18 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Last verified: November 14, 2026 · Our methodology
CHICOPEE REHABILITATION AND NURSING in CHICOPEE, MA was cited for violations during a health inspection on February 18, 2025.
The resident, identified in inspection records only as Resident 54, was admitted in November 2024 with dementia and a broken right hip.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.