Chicopee Rehab: Weight Loss, Medication Failures - MA
The patient, identified as Resident 35, dropped from 163 pounds in July 2024 to 129.4 pounds by February 2025. During January alone, he lost nearly 14 pounds while refusing a prescribed protein supplement 31 times out of 55 opportunities. Staff discontinued the supplement on January 28 without implementing alternative nutritional interventions.
"I did not really like the food at the facility, so I ate a lot of soup," the patient told inspectors. He said his family brought chips and snacks, and noted that he "used to get the liquid protein however does not get it anymore and does not know why."
The facility's own policy defines weight loss of more than 10 percent in six months as severe. Resident 35's weight loss reached 20.6 percent over that timeframe.
When the dietician completed a nutritional risk evaluation on January 27, she recommended increasing the ProHeal liquid protein supplement from 30 milliliters twice daily to 60 milliliters twice daily. But the patient had already been refusing the supplement for months, and staff discontinued it the next day.
The dietician told inspectors she was unaware the supplement had been discontinued and didn't know the patient had refused it so frequently. "There are other interventions/options that could be trialed," she acknowledged when shown the medication records documenting the refusals.
The physician assistant said he expected to be notified of significant weight loss but couldn't recall being informed about this patient's condition. "Other options could have been offered, either other food or medication interventions to try and help the situation," he said.
Staff also failed to complete required assessments when another patient's condition declined significantly. Resident 54, admitted with dementia and a fractured right femur, developed an unstageable pressure ulcer and required increased assistance with daily activities between November 2024 and February 2025. The facility never completed a mandated Significant Change in Status Assessment.
The MDS nurse admitted during interviews that the assessment "should have been completed but was not."
Medication timing violations put a diabetic patient at risk when insulin was administered hours outside prescribed timeframes. Resident 42's insulin was given outside the required one-hour window before or after scheduled times in 34 out of 87 administrations over two months.
The violations included bedtime insulin doses and pre-meal sliding scale injections. In January, 15 out of 37 pre-meal insulin doses were given outside the acceptable timeframe. In February, 13 out of 38 doses missed the window.
Nurses told inspectors they understood the timing requirements but acknowledged the violations occurred. The Assistant Director of Nursing said education would be needed about proper medication administration and documentation.
Infection control breakdowns exposed residents and staff to potential contamination across multiple units. A rehabilitation worker entered a patient's room wearing only gloves despite posted signs requiring a gown for Enhanced Barrier Precautions. The patient had a leaking surgical drain that had saturated his shirt.
"I was unaware that Resident 164 was on EBP," the rehabilitation worker said, despite the patient having both a feeding tube and drainage device that required enhanced precautions.
A certified nursing aide entered the room of a patient with C. difficile without following posted Contact Precaution requirements. The aide acknowledged seeing the signs requiring hand sanitizer, gown, and gloves but said she "did not follow the requirements."
During wound care, a nurse used scissors to cut soiled dressing material, placed them on a table, then used the same unsterilized scissors to cut clean gauze. "I should have cleaned and disinfected the scissors before using them to cut the new dressing material," the nurse admitted.
The most serious infection control failure involved a patient with respiratory symptoms awaiting test results for COVID, flu, and RSV. Despite ordering the tests on February 11, staff didn't implement isolation precautions until February 14.
During the delay, inspectors observed the patient moving freely around his room, conversing with his roommate while both coughed intermittently, and positioning himself in the doorway. When isolation was finally implemented, staff lacked required eye protection and the patient remained confused about his status.
"If you are dressed like that, I must have Covid. I'm not stupid. I want information," the patient told a nursing aide wearing full protective equipment.
The Infection Preventionist acknowledged the delay, saying she wasn't notified about the pending test results until late on February 13. "At that time, Isolation/Droplet precautions should have been implemented, but it was missed."
Equipment safety failures left one patient vulnerable to injury when his wheelchair's left armrest went missing, exposing a metal bar with a protruding screw head. The patient, who had suffered a stroke and required total assistance with transfers, used the damaged wheelchair for at least two days before staff reported the problem.
A nurse who observed the wheelchair said "something like this should have been reported to maintenance immediately." The Maintenance Director confirmed he received no work orders about the wheelchair before inspectors discovered the issue.
Missing pharmacy oversight created gaps in medication monitoring when clinical pharmacy reports referenced in progress notes couldn't be located. For Resident 214, pharmacist notes from October and November 2024 indicated recommendations were made, but the facility couldn't produce the reports or evidence that physicians reviewed them.
Hospice coordination failures left critical care plans unavailable when needed. A patient who enrolled in hospice services on February 7 had no hospice plan of care in his facility binder. Staff couldn't identify who was responsible for maintaining hospice documentation or coordinating with hospice providers.
The Director of Nursing said she expected hospice staff to maintain all documentation but acknowledged calling hospice to obtain missing records during the inspection.
Assessment accuracy problems led to incorrect coding of the cancer patient's weight loss on his December 2024 evaluation. Despite documented weight loss exceeding both one-month and six-month thresholds, the assessment indicated no significant weight loss had occurred.
The MDS nurse reviewed the weight records with inspectors and confirmed the resident had experienced "significant weight loss of over 10 percent in 6 months" but said the assessment "should have been coded as a weight loss of greater than 5 percent or 10 percent but was not."
The violations affected multiple aspects of resident care across the 44 New Lombard Road facility, from basic nutrition and medication safety to infection prevention and equipment maintenance. The inspection identified systemic failures in communication, documentation, and clinical oversight that put vulnerable residents at risk of harm.
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: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 18, 2026 · Our methodology
CHICOPEE REHABILITATION AND NURSING in CHICOPEE, MA was cited for violations during a health inspection on February 18, 2025.
The patient, identified as Resident 35, dropped from 163 pounds in July 2024 to 129.4 pounds by February 2025.
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.