Chicopee Rehabilitation And Nursing Center

F-F692

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 26 225539 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225539 B. Wing 02/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Chicopee Rehabilitation and Nursing 44 New Lombard Road Chicopee, MA 01020

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0637 Assess the resident when there is a significant change in condition

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50563 potential for actual harm Based on interview, and record review, the facility failed to ensure that Significant Change in Status Minimum Residents Affected - Few Data Set [MDS] Assessments (SCSA) was completed for one Resident (#54) out of a total sample of 17 residents.

Specifically, for Resident #54, the facility failed to ensure that a SCSA was completed when the Resident had a decline in activities of daily living (ADLs) and developed a new pressure ulcer.

Findings include:

Review of the facility policy titled Comprehensive Assessment, revised March 2022, indicated the following:

-the SCSA is a comprehensive assessment for a resident that must be completed when the IDT (interdisciplinary team) has determined that a resident meets the significant change guidelines for either major improvement or decline.

Resident #54 was admitted to the facility in November 2024 with diagnoses including Dementia and an intertrochanteric fracture of the right femur.

Review of Resident #54's MDS assessment dated [DATE REDACTED], indicated:

-the Resident required supervision for oral hygiene

-the Resident required partial assistance for upper body dressing

-the Resident required substantial assistance for lower body dressing

-the Resident had no pressure ulcers

Review of Resident #54's MDS assessment dated [DATE REDACTED], indicated the following:

-the Resident required substantial assistance for oral hygiene

-the Resident was dependent for upper and lower body dressing

-the Resident had an unstageable pressure ulcer

Review of Resident #54's medical record indicated that no SCSA was completed between the November 2024 and February 2025 MDS assessments.

During an interview on 2/13/25 at 3:47 P.M., the MDS Nurse said that the January 2025 documentation reflected that Resident #54 had had a decline in ADLs and developed an unstageable pressure ulcer. The MDS Nurse further said that a SCSA should have been completed but was not.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 26 225539 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225539 B. Wing 02/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Chicopee Rehabilitation and Nursing 44 New Lombard Road Chicopee, MA 01020

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Ensure each resident receives an accurate assessment.

Level of Harm - Potential for **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42690 minimal harm Based on interview, and record review, the facility failed to ensure that the Minimum Data Set (MDS) Residents Affected - Some Assessment was coded accurately for one Resident (#35) out of a total sample of 17 residents.

Specifically, the facility failed to ensure that the most recent MDS Assessment was coded accurately relative to weight loss for Resident #35.

Findings include:

Resident #35 was admitted to the facility in July 2024 with diagnoses including Diabetes, small cell lung carcinoma (lung cancer) receiving chemotherapy, Chronic Obstructive Pulmonary Disease (COPD), C-Diff (Clostridium Difficile), Chronic Kidney Disease (CKD), anxiety and depression.

Review of the facility policy titled Weighing and Measuring the Resident, revised March 2011, indicated the following:

a. one month 5% weight loss is significant; greater than 5% is severe.

b. three months 7.5% weight loss is significant; greater than 7.5 is severe

c. six months 10% weight loss is significant; greater than 10% is severe.

Review of Resident #35's Weight Summary from 7/24/24 through 12/1/24 indicated:

-7/24/24: 163 lbs. (pounds)

-11/4/24: 144.4 lbs.

-12/1/24: 136.6 lbs. (5.4% weight loss in 1 month and a 16.20% weight loss in 6 months)

Review of the MDS assessment dated [DATE REDACTED] indicated the facility responded No or unknown to if the Resident experienced a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months.

During an interview on 2/13/25 at 11:07 A.M., the MDS Nurse said that sometimes staff will complete the required sections but not fully sign off on them, so she will go in and complete them. The MDS Nurse said that the Dietician is responsible for completing section K (where the weight information is assessed and documented). The surveyor and the MDS Nurse reviewed the weights documented from 7/25/24 through 12/1/24, and the 12/16/24 MDS Assessments. The MDS Nurse said that judging by the decrease in weight from 7/25/24 through 12/1/24, the Resident experienced a significant weight loss of over 10% in 6 months.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 26 225539 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225539 B. Wing 02/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Chicopee Rehabilitation and Nursing 44 New Lombard Road Chicopee, MA 01020

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 During a follow-up interview on 2/13/25 at 2:20 P.M., the MDS Nurse said to calculate the weight loss, the staff should have used the most recent weight obtained in the last 30 days, closest to the MDS Assessment Level of Harm - Potential for date of 12/16/24. The MDS Nurse said that the MDS assessment dated [DATE REDACTED] should have been coded as minimal harm a weight loss of greater than 5% or 10% but was not.

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 26 225539 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225539 B. Wing 02/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Chicopee Rehabilitation and Nursing 44 New Lombard Road Chicopee, MA 01020

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Ensure services provided by the nursing facility meet professional standards of quality.

Level of Harm - Minimal harm or 42741 potential for actual harm Based on interview, and record review, the facility failed to follow professional standards of practice relative Residents Affected - Few to administering medication for one Resident (#42) out of a total sample of 17 residents.

Specifically, for Resident #42, the facility failed to ensure that prescribed Insulin (medication used to treat diabetes) was administered within one hour before or one hour after the ordered time.

Findings include:

Review of the facility policy titled Administering Medications, revised April 2019, indicated the following:

-Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).

Resident #42 was admitted to the facility in January 2025 with diagnoses including Type 2 Diabetes.

Review of the Physician's Order Recap Report, from 1/14/25 through 2/28/25, indicated:

-Lantus SoloStar Subcutaneous Solution 100 unit/milliliter (ml) (Insulin Glargine), Inject 18 units subcutaneously at bedtime (8:30 PM) with a start date of 1/23/25 and end date of 2/6/25.

-Lantus SoloStar Subcutaneous Solution 100 unit/milliliter (ml) (Insulin Glargine), Inject 8 units subcutaneously at bedtime with a start date of 2/6/25.

-HumaLOG KwikPen Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Lispro), Inject as per sliding scale .before meals (7:30 AM, 11:30 AM, 4:30 PM) with a start date of 1/16/25.

Review of the Location of Administration Report from 1/1/25 through 1/31/25 indicated the following:

-1 out of 9 administrations of Lantus Solo Star Solution 100 unit/ml (Insulin Glargine) Inject 18 units subcutaneously at bedtime was administered outside of one hour before and one hour after the ordered time frame.

-15 out of 37 administrations of Humalog KwikPen Subcutaneous Solution Pen - injector 100 unit/ml (Insulin Lispro) Inject as per sliding scale .before meals was administered outside of one hour before and one hour

after the ordered time frame.

Review of the Location of Administration Report dated 2/1/25 through 2/28/25, indicated the following through 2/18/25:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 26 225539 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225539 B. Wing 02/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Chicopee Rehabilitation and Nursing 44 New Lombard Road Chicopee, MA 01020

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 -6 of 12 administrations of Lantus SoloStar Subcutaneous Solution 100 unit/milliliter (ml) (Insulin Glargine) Inject 8 units subcutaneously at bedtime was administered outside of one hour before and one hour after the Level of Harm - Minimal harm or ordered time frame. potential for actual harm -13 out of 38 administrations of Humalog KwikPen Subcutaneous Solution Pen - injector 100 unit/ml (Insulin Residents Affected - Few Lispro) Inject as per sliding scale .before meals was administered outside of one hour before and one hour

after the ordered time frame.

During an interview on 2/18/25 at 8:37 A.M., Nurse #2 said Resident #42 was diabetic and had scheduled and sliding scale Insulin medication administered to him/her. Nurse #2 said the Resident had his/her blood sugars checked at 7:30 A.M., 11:30 A.M., and 4:30 P.M., prior to meals and sliding scale Insulin was administered at those times as ordered and a specific dose of Insulin was administered at bedtime. Nurse #2 said she worked during the day shift so she administered Resident #42's sliding scale Insulin when she was working. Nurse #2 said when she checks Resident #42's blood sugar, she would then draw up the amount of Insulin per his/her sliding scale, administer the Insulin, and then documented in the Resident's electronic medical record that the Insulin was given immediately after administering the medication. Nurse #2 said Resident #42's Insulin should be given around the time ordered by the Physician but can be administered in

the hour before the ordered time or within an hour after the ordered time. Nurse #2 said if she had to administer any residents' Insulin outside of the one hour before or one hour after the ordered time frame, she would update the Physician and document why the Insulin was not administered within the correct time frame.

During an interview on 2/18/25 at 9:19 A.M., the Director of Nursing (DON) said Resident #42's Insulin should be administered within an hour before or an hour after the ordered time. The DON further said medication given outside that time frame should have documentation such as a nursing note as to why it was not administered within the correct time frame.

During an interview on 2/18/25 at 10:55 A.M., the Assistant Director of Nursing (ADON) said medication should be administered within the one hour before or one hour after the ordered time. The ADON further said

she could not be sure if Resident #42's medication had been administered outside the accepted time frame

on the days in question or if nursing staff did not document properly when the medication was given. The ADON said education would need to be provided to the nursing staff about proper medication administration and documentation of when medications were administered.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 26 225539 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225539 B. Wing 02/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Chicopee Rehabilitation and Nursing 44 New Lombard Road Chicopee, MA 01020

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42690 potential for actual harm Based on interview, and record review, the facility failed to maintain acceptable parameters of nutritional Residents Affected - Few status for one Resident (#35) out of a total sample of 17 residents.

Specifically, for Resident #35, the facility failed to address significant weight loss and implement nutritional interventions when the Resident was identified to have greater than 10 percent (%) weight loss.

Findings include:

Resident #35 was admitted to the facility in July 2024 with diagnoses including Diabetes, small cell lung carcinoma (lung cancer) receiving chemotherapy, Chronic Obstructive Pulmonary Disease (COPD), C-Diff (Clostridium Difficile,) Chronic Kidney Disease, anxiety and depression.

Review of the facility policy titled Weighing and Measuring the Resident, revised March 2011 indicated the following:

a. one month 5% weight loss is significant; greater than 5% is severe.

b. three months 7.5% weight loss is significant; greater than 7.5 is severe

c. six months 10% weight loss is significant; greater than 10% is severe.

Review of the Minimum Data Set (MDS) assessment dated [DATE REDACTED] indicated Resident #35:

-was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15.

-required set up or clean up assistance with eating.

Review of Resident #35's Weight Summary from 7/24/24 through 2/1/25 indicated the following in part:

-7/24/24: 163 pounds (lbs.)

-8/3/24: 155 lbs.

-1/3/25: 143 lbs.

-1/21/25: 134 lbs. (significant weight loss of 17.79 % from 7/24/24 and greater than 10% in 6 months. Significant weight loss of 6.29 % from 1/3/25 and greater than 5% in 1 month).

-2/1/25: 129.4 lbs. (significant weight loss of 16.52% and greater than 10% in 6 months. Significant weight loss of 9.51% from 1/3/25 and greater than 5% in 1 month).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 26 225539 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225539 B. Wing 02/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Chicopee Rehabilitation and Nursing 44 New Lombard Road Chicopee, MA 01020

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Review of the January 2025 Medication Administration Record (MAR) indicated:

Level of Harm - Minimal harm or -ProHeal Liquid Protein, two times a day 30 ml (milliliters) in juice. Start date 10/28/24, Discontinue date potential for actual harm 1/28/25

Residents Affected - Few -Resident #35 refused (coded 15 [Resident refused] per the MAR legend code and initialed by the Nurse) the ProHeal Liquid Protein 31 times out of 55 opportunities.

Review of the Nutritional Risk Evaluation completed on 1/27/25 for the assessment period from 1/16/25 to 1/22/25 indicated the following:

-Weight Loss 5% or more in last month or loss of 10% or more in the last 6 months - YES. Not on a prescribed (weight) loss regimen.

-Goal weight - stable, prevent loss

-Regular house diet

-Supplements - ProHeal increased to 60 ml BID (two times a day) (400 cals)

-Weight status - acute condition resulting in temporary change - loss of 10 pounds, status post fluid gain

-Continue diet

-Recommendation - Increased ProHeal 60 ml in juice BID

-Nutritional Plan - increased diet needs due to decline in appetite with C-Diff infection, and progressive weight loss noted. Increase juice with protein as (Resident) prefers no milky supplement.

Review of Resident #35's Care Plan [sic] indicated the following:

-The Resident is malnourished, evidenced by poor appetite regarding fear of swallowing, chewing difficulty regarding new lung cancer, shortness of breath and fluid weight gain - initiated on 7/24/24 and revised on 1/22/25.

-ProHeal 60 ml in juice BID - initiated on 1/22/25

Further Review of the Care Plan indicated no update to reflect the discontinuation on 1/28/25 of the ProHeal Liquid Protein per the Physician orders on the January 2025 MAR.

During an interview on 2/12/25 at 3:16 P.M., Resident #35 said that he/she did not really like the food at the facility, so he/she ate a lot of soup. Resident #35 said that his/her family would bring in chips and snacks. Resident #35 said that he/she used to get the liquid protein however does not get it anymore and does not know why. Resident #35 could not say whether he/she had been offered other food or dietary supplements.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 26 225539 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225539 B. Wing 02/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Chicopee Rehabilitation and Nursing 44 New Lombard Road Chicopee, MA 01020

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 During an interview on 2/12/25 at 3:18 P.M., Nurse #1 said that Resident #35 was previously prescribed ProHeal Liquid Protein but often refused it, so the facility staff discontinued it on 1/28/25. Nurse #1 said Level of Harm - Minimal harm or Resident #35 had cancer, C-diff, and often refused the ProHeal Liquid Protein, and that the Resident would potential for actual harm have weight loss because of these concerns. Nurse #1 further said that Resident #35 did not have any other nutritional supplements ordered at this time. Residents Affected - Few

During a follow-up interview on 2/12/25 at 4:15 P.M., Resident #35 said that the facility offered Hospice Services however, he/she declined because he/she wanted to continue chemotherapy treatment.

During an interview on 2/12/25 at 4:48 P.M., Dietary Staff #1 said that the facility had protein shakes they could offer the Residents but could not recall if the facility had other types of supplemental or fortified foods (foods with nutrients added to help boost nutritional value). Dietary Staff #1 said when ordering food items,

the staff had to go through a new process that included a predetermined list from the company with acceptable food/dietary items that are available for the staff to choose from. Dietary Staff #1 said that the additional items the staff want to order must be approved by a corporate person. Dietary Staff #1 said that

they had limited control over what could be ordered.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 26 225539 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225539 B. Wing 02/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Chicopee Rehabilitation and Nursing 44 New Lombard Road Chicopee, MA 01020

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 During an interview on 2/13/25 at 8:51 A.M., the Dietician said that Resident #35 was malnourished upon admission and had nausea. The Dietician said the Resident had a concerning weight loss but it was a part of Level of Harm - Minimal harm or the Resident's process. The Dietician said that while it was a significant weight loss it was not unexpected. potential for actual harm The Dietician further said when a Resident had a significant weight loss the Provider should be made aware, but she did not usually document when the Provider was notified. The Dietician said for Resident #35 she Residents Affected - Few just talked to the Director of Nursing (DON) or the Assistant Director of Nursing (ADON). The Dietician said that these conversations are not usually documented. The Dietician was unable to provide any additional information that any conversations had occurred relative to Resident #35's recent weight loss. The Dietician said it had already been acknowledged that the Resident had previous weight loss and was going to continue to have weight loss because of his/her diagnoses. The surveyor requested evidence that the Provider had documented the Resident's previous or current weight loss and that it was to be expected. The facility did not provide any documentation of Resident #35's previous or current weight loss and that weight loss was to be expected by the end of the survey. The surveyor and the Dietician reviewed the Nutritional assessment dated [DATE REDACTED] and the Dietician said Resident #35 had lost 10 pounds because of fluid gain while at the hospital, poor appetite, and that the Resident was not meeting the goals that had been set. The Dietician said because of her assessment of the Resident and noted weight loss, she increased the ProHeal Liquid Protein and directed it to be put into juice because the Resident could not have dairy. The Dietician said when she visited with Resident #35 last week, the Resident said he/she felt like he/she had been eating well and did not want to change anything. When the surveyor asked how the Dietician determined what the appropriate nutrition recommendations would be for a Resident, the Dietician said that she met with the Resident, reviewed the MAR and progress notes and will then determine the next course of action/recommendation. The Dietician reviewed the February 2025 MAR and said that the ProHeal Liquid Protein was not on the MAR, which indicated that it was no longer prescribed for the Resident. The Dietician said that she was unaware that the ProHeal Liquid Protein had been discontinued. The Dietitian reviewed the January 2025 MAR and said that the ProHeal Liquid Protein had been discontinued 1/28/25. The Dietician said that sometimes Resident #35 only took half of the prescribed 30 ml ProHeal Liquid Protein, and that's why a 15 was noted on the MAR. The surveyor and the Dietician further reviewed the MAR and observed an x to be in the ml (how much the Resident consumed) box, with a 15 followed by the Nurses' initials. The Dietician reviewed the legend located at the end of the MAR and said that a 15 indicated the Resident refused the ProHeal Liquid Protein. The Dietician said that it looked like the Resident refused the ProHeal Liquid Protein a lot. When the surveyor asked if increasing the ProHeal Liquid Protein as a new intervention for the most recent assessment (completed on 1/27/24), was an appropriate or effective intervention, based

on the amount of refusals for the month of January, the Dietician said there are other interventions/options that could be trialed. The Dietician said that she did not know the Resident had refused the ProHeal Liquid Protein so often.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 26 225539 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225539 B. Wing 02/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Chicopee Rehabilitation and Nursing 44 New Lombard Road Chicopee, MA 01020

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 During an interview on 2/13/25 at 9:46 A.M., the Physician Assistant (PA) said that he would have expected to be notified of Resident #35's significant weight loss. The PA said that he had been in the facility since the Level of Harm - Minimal harm or Resident experienced the most recent weight loss noted on 1/21/25 and 2/1/25 and did not recall being potential for actual harm notified of the weight loss during those times in the facility. The PA said that he did not recall being made aware that the Resident had refused the nutritional supplement so often, however since it had been Residents Affected - Few discontinued, it was possible he was made aware but could not recall. The PA said that he does not document every conversation or review every resident's weight, he expects the staff to communicate these areas of concerns with him. The PA further said that he could not recall if he had been asked to review Resident#35 for other/new interventions relative to the significant weight loss. The PA said that because this Resident is currently going through chemotherapy and C-Diff treatment it is tough to know if anything would help the Resident stabilize or gain weight. The PA further said that other options could have been offered, either other food or medication interventions to try and help the situation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 26 225539 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225539 B. Wing 02/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Chicopee Rehabilitation and Nursing 44 New Lombard Road Chicopee, MA 01020

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Level of Harm - Minimal harm or potential for actual harm 50563

Residents Affected - Few Based on interview, and record review, 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 for one Resident (#214), of five applicable residents reviewed for unnecessary medications, out of a total sample of 17 residents.

Findings include:

Resident #214 was admitted to the facility in December 2023 with diagnoses including Vascular Dementia.

Review of Resident #214's Pharmacist Progress Notes indicated the following:

-10/4/24: the Pharmacist indicated recommendations made, see Clinical Pharmacy Report

-11/5/24: the Pharmacist indicated recommendations made, see Clinical Pharmacy Report

Review of Resident #214's medical record did not provide evidence of the Pharmacy Recommendations and Clinical Pharmacy Reports indicated in the Pharmacist Progress Notes on 10/4/24 and 11/5/24.

Further review of the medical record failed to indicate that the Physician had reviewed the 10/4/24 and 11/5/24 Pharmacy Recommendations.

During an interview on 2/14/25 at 10:05 A.M., the surveyor requested evidence of the 10/4/24 and 11/5/24 Clinical Pharmacy Reports and Physician review of the Reports from the Director of Nursing (DON).

The facility was unable to provide any additional information pertaining to the Clinical Pharmacy Reports and Physician Review of the Pharmacy Recommendations to the survey team at the time of survey exit.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 26 225539 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225539 B. Wing 02/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Chicopee Rehabilitation and Nursing 44 New Lombard Road Chicopee, MA 01020

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0849 Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Level of Harm - Minimal harm or potential for actual harm 42741

Residents Affected - Few Based on record review, and interview, the facility failed to provide continuity of care related to Hospice Services for one Resident (#42) out of a total sample of 17 residents.

Specifically, for Resident #42, the facility failed to:

-designate a member of the interdisciplinary team (IDT) responsible for working with Hospice Representatives to coordinate care provided by the facility staff and Hospice staff.

-obtain the most recent Hospice Plan of Care and ensure that it was readily available.

Findings include:

Review of the Hospice Nursing Facility Services Agreement dated May 31, 2023, indicated:

-Nursing facility and Hospice shall develop procedures regarding communications and the documentation of such communications to ensure that the needs of the patient are addressed and met 24 hours a day.

-Hospice will supply the facility a copy of the patient's plan of care which will specify the inpatient services to be provided.

-The facility will have patient care policies consistent with those of hospice and agrees to abide by the palliative care protocols and plan of care established by the Hospice.

-The facility shall identify an individual who is responsible for implementation of the agreement.

Review of the facility policy titled Palliative/End of Life Care - Clinical Protocol, revised March 2018, indicated

the following:

-If Hospice becomes involved, both the attending physician and staff will retain an active role in the resident/patient's care and will not simply defer everything to the Hospice staff and practitioner.

Resident #42 was admitted to the facility in January 2025 with diagnoses including cerebral infarction (stroke).

Review of the Hospice Long Term Care Status Form dated 2/7/25, indicated Resident #42 signed onto Hospice Services on 2/7/25.

Review of Resident #42's Hospice binder (binder used to store all Hospice documentation), indicated that no Hospice Plan of Care was on file in the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 26 225539 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225539 B. Wing 02/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Chicopee Rehabilitation and Nursing 44 New Lombard Road Chicopee, MA 01020

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0849 During an interview on 2/18/25 at 8:45 A.M., the Social Worker (SW) said each resident in the facility who was on Hospice Services had a Hospice binder that contained all the pertinent Hospice documentation for Level of Harm - Minimal harm or that resident. The SW further said she was unaware of who from the IDT at the facility was responsible to potential for actual harm make sure Hospice documentation was maintained in the binder.

Residents Affected - Few During an interview on 2/18/25 at 9:02 A.M., with the Administrator and the Director of Nursing (DON), the DON said she was unsure if the facility had a designated staff member who ensured that all Hospice documentation was in each resident's hospice binder. The DON said she thought Hospice Staff needed to ensure that all Hospice documentation was in each resident's Hospice binder. The DON further said she was unsure if Resident #42's Hospice Plan of Care was readily available in his/her Hospice binder.

During an interview on 2/18/25 at 9:08 A.M., Nurse #2 said she thought Hospice Staff maintained the Hospice binder for each resident. Nurse #2 said she was unsure if there was a staff member at the facility who ensured all Hospice documentation was readily available and could be reviewed whenever it was needed. The surveyor and Nurse #2 observed Resident #42's Hospice binder and Nurse #2 said she would expect there to be more documentation in the Resident's binder including nursing notes and Home Health Aides (HHA) notes as she knew both these Hospice disciplines had been in to see Resident #42 since he/she signed onto Hospice a few weeks ago. Nurse #2 further said she was unsure about the specifics of

the Hospice Plan of Care outside of knowing a Nurse and HHA came into the facility to see the Resident regularly during the week.

During a follow-up interview on 2/18/25 at 9:08 A.M., the DON said the facility had not designated a specific member from the facility's IDT to be the facility representative to communicate with Hospice and ensure Hospice documentation including the Hospice Plan of Care was readily available. The DON said she expected Hospice staff to maintain all this information. The DON further said she had called Hospice to get Resident #42's Hospice documentation because it was not available in the Resident's Hospice binder.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 26 225539 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225539 B. Wing 02/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Chicopee Rehabilitation and Nursing 44 New Lombard Road Chicopee, MA 01020

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42741 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure that infection control Residents Affected - Few practices were implemented to prevent the spread of infection on two Units (North Unit and [NAME] Unit) of two units observed.

Specifically, the facility failed to:

1. For Resident #164 who resided on the North Unit, ensure that staff utilized proper Enhanced Barrier Precautions (EBP - set of infection control practices that uses Personal Protective Equipment (PPE) such as gowns and gloves to reduce the spread of multidrug resistant organism to residents who are at risk due to having a wound or indwelling medical device).

2. For Resident #35 who resided on the North Unit, ensure that staff utilized proper Contact Precautions (set of infection control practices that are used when a resident is diagnosed with a condition that can spread from person to person by touch or by direct contact with contaminated objects and surfaces) when entering

the Resident's room.

3. For Resident #54 who resided on the [NAME] Unit, ensure that staff use proper infection control practices to clean and disinfect scissors used to remove a soiled dressing before reusing the scissors to cut clean dressing materials.

4. For Resident #60 who resided on the North Unit: 1) initiate Transmission Based Precautions (TBP- measures implemented for patients who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission) when the Resident was symptomatic of infection and was awaiting laboratory results for a potential transmissible infection, and 2) adhere to Isolation/Droplet Precautions (used for diseases spread in tiny droplets caused by coughing and sneezing) increasing the risk for the potential spread of infection.

Findings include:

1. Review of the facility policy titled Enhanced Barrier Precautions, revised March 2024, indicated:

-Enhanced Barrier Precautions (EBPs) are used as an infection prevention and control intervention .

-EBPs are indicated .for residents with wounds and/or indwelling medical devices .

Resident #164 was admitted to the facility in February 2025 following surgery to place a Jejunostomy (J) Tube (tube surgically placed directly into the small intestine for the delivery of nutrition) and right sided Jackson Pratt (JP) drain (an indwelling medical device that is inserted through the skin into the body cavity allowing excess fluid to drain through a tube to a collection bag outside the body).

Review of the Nursing Progress Notes dated 2/9/25, 2/10/25, and 2/11/25, indicated Resident #164's JP drain was leaking from the tube incision site.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 26 225539 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225539 B. Wing 02/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Chicopee Rehabilitation and Nursing 44 New Lombard Road Chicopee, MA 01020

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 On 2/12/25 at 7:57 A.M., the surveyor observed signs posted outside Resident #164's door indicating Enhanced Barrier Precautions (EBP): Use gloves and gown for high contact care including dressing. The Level of Harm - Minimal harm or surveyor observed Resident #164 was sleeping in bed, and his/her shirt was saturated with fluid on the right potential for actual harm side of his/her body.

Residents Affected - Few On 2/12/25 at 9:10 A.M., the surveyor observed Rehabilitation Staff Member #1 in Resident #164's room assisting the Resident with direct care. The surveyor observed Rehabilitation Staff Member #1 was only wearing gloves and no other PPE. During an interview at the time, Rehabilitation Staff Member #1 said she was unaware that Resident #164 was on EBP and thought Resident #164's roommate was on EBP. When

the surveyor asked why a resident would be on EBP, Rehabilitation Staff Member #1 said any resident who has a catheter, drain, or wound would be on EBP. Rehabilitation Staff Member #1 further said Resident #164 had a JP drain and she was assisting him/her with changing his/her shirt as the JP drain had leaked. Rehabilitation Staff Member #1 said she had only been wearing gloves and should have also been wearing a gown.

42690

2. Resident #35 was admitted to the facility in July 2024 with diagnoses including Diabetes, small cell lung carcinoma (lung cancer) receiving chemotherapy, Chronic Obstructive Pulmonary Disease (COPD), and C-Diff (Clostridium difficile, a spore forming toxin that can develop in the intestines after antibiotic use and causes watery diarrhea. C-Diff can be spread from person to person by touch or by direct contact with contaminated objects and surfaces).

On 2/13/25 at 10:54 A.M. the surveyor observed the following:

-A Contact Precaution sign posted outside the Resident's door indicating:

>everyone must clean their hands before entering and when exiting the room

>provider and staff must also put on gloves before room entry

>provider and staff must put on gown before room entry

-PPE located outside of the Resident's door

-Resident #35's call bell to be on

-CNA #4 knock on the Resident's door and enter the room

-CNA#4 did not perform hand hygiene or don (put on) the required PPE as indicated on the signage located outside of the Resident's door.

During an interview at the time, CNA #4 said that the signage indicated to use hand sanitizer before and after entering the Resident's room and to don a gown and gloves when entering the Resident's room. CNA #4 said that she did not follow the requirements as listed on the Contract Precautions sign.

50563

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 26 225539 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225539 B. Wing 02/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Chicopee Rehabilitation and Nursing 44 New Lombard Road Chicopee, MA 01020

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 3. Resident #54 was admitted to the facility in November 2024 with diagnoses including Dementia and an intertrochanteric fracture of the right femur. Level of Harm - Minimal harm or potential for actual harm Review of Resident #54's Minimum Data Set (MDS) assessment dated [DATE REDACTED], indicated the Resident was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 0 out of a Residents Affected - Few possible score of 15.

On 2/14/25 at 11:10 A.M., the surveyor observed the following during wound care provided to Resident #54 by Nurse #2:

-Nurse #2 gathered needed supplies, performed hand hygiene, donned gloves, and entered Resident #54's room

-Nurse #2 disinfected the overbed table

-Nurse #2 doffed (removed) gloves, performed hand hygiene, draped the overbed table with a barrier and set up supplies

-Nurse #2 performed hand hygiene, donned a gown and gloves

-Nurse #2 cut off the soiled bandage with scissors and placed the scissors on the overbed table to the side of

the barrier

-Nurse #2 used wound cleanser to loosen and remove dressing from the wound bed

-Nurse #2 doffed gloves, performed hand hygiene and donned new gloves

-Nurse #2 cleansed the wound with wound cleanser and gauze

-Nurse #2 doffed gloves, performed hand hygiene and donned new gloves

-Nurse #2 applied skin prep to the peri-wound, Santyl to the wound bed followed by Dakins 1/4 strength soaked gauze

-Nurse #2 doffed gloves, performed hand hygiene and donned new gloves

-Nurse #2 covered the area with an abdominal pad and wrapped it with rolled gauze

-Nurse #2 used the scissors that were used to cut off the soiled dressing to cut the rolled gauze to size without cleaning and disinfecting the soiled scissors

-Nurse #2 taped the dressing to secure it

During an interview on 2/14/25 at 11:30 A.M., Nurse #2 said that she should have cleaned and disinfected

the scissors before using them to cut the new dressing material because the scissors were considered dirty

after use on the soiled dressing, but she had not cleaned and disinfected the scissors.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 26 225539 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225539 B. Wing 02/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Chicopee Rehabilitation and Nursing 44 New Lombard Road Chicopee, MA 01020

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During an interview on 2/18/25 at 7:59 A.M., the Infection Control Preventionist (ICP) said that after scissors are used to cut off a dressing they should be cleaned and disinfected before being used to cut new dressing Level of Harm - Minimal harm or materials. The ICP further said that the old dressing is considered contaminated and using scissors that cut potential for actual harm off an old dressing without cleaning and disinfecting them to cut new dressing materials could contaminate

the new dressing. Residents Affected - Few 37400

4. Resident #60 was admitted to the facility in January 2025 with diagnoses including Acute Respiratory Failure with hypoxia (low levels of oxygen in the blood) and Respiratory Syncytial Virus (RSV - contagious virus that affects the respiratory system and has cold-like symptoms such as a runny nose and cough).

Review of the Minimum Data Set (MDS) Assessment, dated 1/31/25, indicated Resident #60:

-was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of 15

-had no behaviors

-required substantial/maximum assistance from staff with bathing, dressing and toileting needs

-was not on Isolation or Quarantine for active infectious disease

Review of the facility Matrix provided by the facility on 2/12/25 did not indicate Resident #60 was on TBP.

Review of the Resident #60's clinical record indicated the following:

-Nursing Note dated 2/10/25, Resident requesting cough medication, the Provider was made aware and new orders were obtained.

-Skilled Nurse Note dated 2/10/25, Resident continued to have non-productive cough.

-Nursing Note dated 2/11/25, Resident received chest X-ray today and results were normal. Nasal swab for Covid/Flu and RSV completed and will be picked up on 2/12/25.

Review of the February 2025 Physician's orders included the following:

-Flu/Covid-19/RSV viral swab - discontinue when specimen obtained, initiated 2/11/25 and discontinued 2/13/25

-chest X-ray for cough - discontinue when test completed, initiated 2/11/25 and discontinued 2/13/25

-Isolation Precautions, initiated 2/14/25

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 26 225539 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225539 B. Wing 02/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Chicopee Rehabilitation and Nursing 44 New Lombard Road Chicopee, MA 01020

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 On 2/13/25 at 2:00 P.M., the surveyor observed Resident #60 dressed and seated in a wheelchair in his/her room. The surveyor did not observe TBP signage posted outside of the Resident's room. Level of Harm - Minimal harm or potential for actual harm On 2/14/25 from 8:05 A.M. through 8:14 A.M., the surveyor observed the following:

Residents Affected - Few -8:05 A.M., Isolation Droplet/Contact Precaution signage posted outside of Resident #60's room which included the following instructions:

*Stop. In addition to Standard Precautions, Staff and Providers must:

>clean hands when entering and exiting

>put on a gown and change (the gown) between each resident

>put on an N95 respirator or facemask if N95 respirator is not available

>put on eye protection (goggles or face shield)

>put on gloves and change (the gloves) between each resident

-a bin containing Personal Protective Equipment (PPE) which contained N95 masks, gowns and gloves. No eye protection was observed in the PPE bin.

-8:06 A.M., Certified Nurses Aide (CNA) #2 opened the door to the room (from inside of the room) and was observed to be wearing an N95 mask and a gown while holding a bag with soiled items with her gloved hands. CNA #2 did not have eye protection on. CNA #2 doffed her gown, put it in a bag, and exited the room to discard the soiled items. CNA #2 did not discard her gloves or N95 mask after exiting the room. The door of the Resident's room was left open, and the surveyor observed Resident #60 dressed and seated in a wheelchair.

-8:09 A.M., Resident #60 was observed to self-propel to the middle of the room, and position the wheelchair next to his/her roommate while having a conversation. Neither Resident had face masks on, and both Residents were observed to have intermittent coughing.

-8:14 A.M., the surveyor observed Resident #60 seated in a wheelchair in the doorway to his/her room.

During an interview at the time, Resident #60 said he/she had a cough.

During an interview on 2/14/25 at 8:17 A.M., Nurse #2 said Resident #60 was placed on Isolation Precautions today because he/she had a laboratory test which was pending results.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 26 225539 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225539 B. Wing 02/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Chicopee Rehabilitation and Nursing 44 New Lombard Road Chicopee, MA 01020

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During an interview on 2/14/25 at 8:27 A.M., CNA #2 said the Isolation/Droplet Precaution signage posted outside of Resident #60's room was added today, and it was because the Resident had an RSV infection. Level of Harm - Minimal harm or CNA #2 said prior to entering Resident #60's room, she had put on an N95 mask, a gown and gloves. The potential for actual harm surveyor and CNA #2 reviewed the Isolation/Droplet Precaution signage posted. CNA #2 said the Isolation/Droplet Precaution signage indicated she was supposed to put on eye protection prior to entering Residents Affected - Few the Resident's room. CNA #2 said she didn't put eye protection on, and she knew she should have. CNA #2 looked in the PPE bin located outside of Resident #60's room and said there was no eye protection available

in the PPE bin. CNA #2 further said there should be extra PPE supplies at the nurses station. The surveyor and CNA #2 walked to the nurses station, and were able to locate gowns, gloves and face masks, but were unable to find eye protection.

On 2/14/25 from 8:35 A.M. through 8:44 A.M. the surveyor observed the following during the breakfast meal pass:

-8:35 A.M., CNA #3 donned a gown, gloves and N95 mask prior to entering Resident #60's room to deliver

the breakfast trays to his/her roommate. Resident #60 was observed dressed and seated in a wheelchair near the entrance of the room. After delivering the breakfast tray, CNA #3 stood at the entrance to Resident #60's room and requested Resident #60's breakfast meal while in close proximity to the Resident.

-8:42 A.M., the Infection Preventionist (IP) was observed to restock the PPE bin outside of Resident #60's room with eye protection and then assisted CNA #3 with donning eye protection.

-8:44 A.M., CNA #3 was observed to deliver and set up Resident #60's breakfast meal and Resident #60 was observed to say if you are dressed like that- I must have Covid .I ' m not stupid .I want information.

During an interview on 2/14/25 at 8:45 A.M., CNA #3 said she did not don eye protection prior to entering Resident #60's room because there was no eye protection in the PPE bin. CNA #3 said she should have contacted the Director of Nursing (DON) or the IP to request more eye protection prior to entering the Resident's room but she did not.

During an interview on 2/14/25 at 8:55 A.M., the IP said that she was not made aware until late on 2/13/25 about the RSV/Covid/Flu test that was pending for Resident #60. The IP said the testing was ordered by the Physician on 2/11/25, and at that time, Isolation/Droplet precautions should have been implemented, but it was missed. The IP said the facility had plenty of PPE available, that extra PPE supplies were located off the unit, and if the staff needed more, they knew to ask, and it would be restocked.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 26 225539 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225539 B. Wing 02/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Chicopee Rehabilitation and Nursing 44 New Lombard Road Chicopee, MA 01020

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 Keep all essential equipment working safely.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50563 potential for actual harm Based on observation, and interview, the facility failed to ensure that patient care equipment was maintained Residents Affected - Few in a safe operating condition for one Resident (#3) out of a total sample of 17 residents.

Specifically, for Resident #3, the facility failed to ensure that his/her wheelchair was maintained in safe condition when the left cushioned armrest of the Resident's wheelchair was missing leaving a metal bar and exposed screw and placing the Resident at risk of injury.

Findings include:

Resident #3 was admitted to the facility in May 2024 with diagnoses including Cerebral Infarct (Stroke) and Rheumatoid Arthritis.

Review of Resident #3's Minimum Data Set (MDS) assessment dated [DATE REDACTED], indicated:

-the Resident had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status score of 9 out of a total possible score of 15

-the Resident was dependent for transfers to and from the chair

During an observation on 2/12/25 at 2:00 P.M., the surveyor observed Resident #3 sitting up in his/her wheelchair in the facility dining room. The surveyor observed that the left armrest of the wheelchair was missing and the head of a screw where the armrest would be attached was sticking up from the metal bar.

During an observation and interview on 2/13/25 at 11:51 A.M., the surveyor and Nurse #5 observed Resident #3's wheelchair to be missing the left armrest with an exposed screw head sticking up from the metal bar where the armrest would be attached. Nurse #5 said the armrest should not be like that. Nurse #5 said that something like this should have been reported to maintenance immediately through the facility online work order system. Nurse #5 further said she would notify maintenance and the therapy department immediately.

During an interview on 2/13/25 at 12:49 P.M., the Maintenance Director said that the employee handbook indicated that all staff are responsible to report any broken equipment immediately to maintenance or their supervisor. The Maintenance Director further said that the facility used an electronic system to send work orders directly to his phone and/or computer. The Maintenance Director said he had not received any work order before today (2/13/25) that Resident #3's wheelchair required repair. The surveyor and the Maintenance Director reviewed a photograph taken of Resident #3's wheelchair's missing armrest. The Maintenance Director said the missing armrest was a concern due to the potential for the Resident to be injured.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 26 225539