Chicopee Rehabilitation And Nursing
CHICOPEE REHABILITATION AND NURSING in CHICOPEE, MA — inspection on February 18, 2025.
Found 10 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview on 2/12/25 at 5:00 P.M., the Director of Nursing (DON) said if nursing staff noted a weight loss or gain of three or more pounds from a previous weight, then a reweigh should be done either the same day or the next day.
The DON said Resident #58 was not reweighed until 12/30/24, after the initial significant weight loss was noted on 12/27/24.
During an interview on 2/13/25 at 10:48 A.M., Resident #58's Resident Representative (RR) #1 said he/she thought Resident #58 weighed about 120-130 lbs. when the Resident lived in the community.
During an interview on 2/13/25 at 1:21 P.M., the Dietician said if a Resident has a larger than 5% weight loss or greater, the facility should contact her so she can re-evaluate the Resident.
The Dietician said she could not recall if the facility staff had contacted her when the initial significant weight loss was noted on 12/27/24.
The Dietician further said she would expect the Resident to lose weight, as Resident #58 was being treated with diuretics but she was unsure of what Resident #58's baseline weight should be.
The Dietician said she noted that the initial goal in the Malnutrition Care Plan was 155 lbs or less but she could not comment on what the expected weight range for Resident #58 should be.
The Dietician said she had not been in communication with the Physician or PA regarding Resident #58's initial significant weight loss or continued gradual weight loss and she would expect nursing to update the Physician or PA regarding the weight loss as she provided nursing with weekly notes during the facility's Risk meetings.
The surveyor requested Risk Meeting notes from the Dietician for Resident #58 but no Risk Meeting notes were provided to the survey team by the end of the survey.
During an interview on 2/13/25 at 9:36 A.M., the PA said he would expect Resident #58 to have some weight loss as he/she was on diuretics but he was unaware that the Resident had a significant weight loss since being admitted to the facility.
The PA said no staff at the facility had provided him with specific weight loss percentages for the Resident.
The PA further said that he did not have a specific set of parameters he used for when nursing staff should notify him of changes in a Resident's weight.
During an interview on 2/13/25 at 12:14 P.M., the DON said she was unable to find any documentation that staff had updated the Physician or PA regarding Resident #58's weight loss.
The DON said she would have expected nursing staff to let the Physician or PA know if the Resident had a significant unexpected weight loss.
The DON said the Dietician should be updating the Physician or PA if the Resident continued to have an ongoing gradual weight loss.
Please Refer to F-F641 and F-F692
225539 02/18/2025
Chicopee Rehabilitation and Nursing 44 New Lombard Road Chicopee, MA 01020
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], 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], 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.
225539 02/18/2025
Chicopee Rehabilitation and Nursing 44 New Lombard Road Chicopee, MA 01020
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] 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.
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 date of 12/16/24.
The MDS Nurse said that the MDS assessment dated [DATE] should have been coded as a weight loss of greater than 5% or 10% but was not.
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.
225539 02/18/2025
Chicopee Rehabilitation and Nursing 44 New Lombard Road Chicopee, MA 01020
the Resident had refused the ProHeal Liquid Protein so often.
expected to be notified of Resident #35's significant weight loss.
The PA said that he had been in the
did not recall being 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 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.
225539 02/18/2025
Chicopee Rehabilitation and Nursing 44 New Lombard Road Chicopee, MA 01020
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.
225539 02/18/2025
Chicopee Rehabilitation and Nursing 44 New Lombard Road Chicopee, MA 01020
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.
225539 02/18/2025
Chicopee Rehabilitation and Nursing 44 New Lombard Road Chicopee, MA 01020
During an interview on 2/14/25 at 8:45 A.M., CNA #3 said she did not don eye protection prior to
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.
225539 02/18/2025
Chicopee Rehabilitation and Nursing 44 New Lombard Road Chicopee, MA 01020
Review of Resident #3's Minimum Data Set (MDS) assessment dated [DATE], 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.
225539 02/18/2025
Chicopee Rehabilitation and Nursing 44 New Lombard Road Chicopee, MA 01020
Review of Resident #54's MDS assessment dated [DATE], 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], 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.
225539
Form Approved OMB
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
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.