Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Holden Rehabilitation & Nursing Center during CMS and state inspections, most recent first.
A resident with dementia and moderate cognitive impairment was improperly restrained by a CNA who used a locked wheelchair to prevent the resident from getting out of bed. Despite the resident's ability to stand independently and the presence of a bed alarm, the CNA placed the wheelchair against the bed, which was confirmed by a nurse to be inappropriate and a restraint. This action was not in line with the resident's care plan or facility policies.
A facility failed to notify the State PASRR Office after a resident experienced a significant change in mental health, including a new diagnosis of auditory hallucinations and treatment with antipsychotic medication. Despite the requirement for a Resident Review, the facility did not submit a request, as confirmed by the Social Worker overseeing the PASRR process.
A resident with Multiple Sclerosis and Neurogenic Bladder had a Foley catheter with a 30 ml balloon instead of the ordered 10 ml balloon. The facility lacked the correct size catheter, and the discrepancy was not documented. Interviews revealed that the facility did not have the correct catheter size in stock, and an order to reflect the change was not written.
A resident with Major Depressive Disorder and Mild Cognitive Impairment did not receive timely psychotherapeutic counseling or a Psychiatric Evaluation as recommended. Despite consent for therapy, no follow-up sessions were conducted, and a Psychiatric Evaluation ordered in December was delayed until June. The resident experienced increased paranoia and auditory hallucinations during this period, and facility staff cited a system glitch and staffing changes as contributing factors.
A facility failed to accurately code MDS Assessments for a resident who received Aspirin, an antiplatelet medication, as ordered for heart health. Despite receiving Aspirin during the observation periods, the MDS did not reflect this due to the MDS Coordinator's misunderstanding that Aspirin should not be coded as an antiplatelet medication.
Resident Restrained by Locked Wheelchair
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints, as evidenced by the actions of a Certified Nurses Aide (CNA) who used a locked wheelchair to prevent the resident from getting out of bed. The resident, who was moderately cognitively impaired with a Brief Interview for Mental Status (BIMS) score of nine, was admitted with diagnoses including dementia, muscle weakness, and glaucoma. The resident's care plan included interventions for fall prevention, such as a bed sensor alarm, non-skid footwear, and a well-lit environment free of clutter. On the day of the survey, the resident was observed lying in bed with half side rails up and a bed sensor alarm in place. A manual wheelchair with the left brake locked was positioned against the mattress, blocking the lower quarter of the resident's bed. During an interview, CNA #1 admitted to placing the wheelchair in this position to prevent the resident from getting out of bed independently, despite the resident's ability to stand independently and the presence of a bed alarm to alert staff if the resident attempted to get up. Nurse #1 confirmed that the locked wheelchair was inappropriate, as it inhibited the resident's ability to get out of bed and acted as a restraint. The facility's policy on physical restraints clearly defines such actions as restraints and requires a physician's order for their use, which was not present in this case. The use of the wheelchair as a restraint was not in line with the resident's care plan or the facility's policies, leading to the deficiency noted by the surveyor.
Failure to Notify State PASRR Office of Significant Change in Resident's Mental Health
Penalty
Summary
The facility failed to notify the state mental health authority for a resident review after a significant change in the mental health condition of a resident. The resident, who was admitted with diagnoses including Major Depressive Disorder and Mild Cognitive Impairment, was newly diagnosed with auditory hallucinations and began treatment with antipsychotic medication, Seroquel. Despite these significant changes, the facility did not refer the resident to the State PASRR Office for a Resident Review, as required by federal regulations to ensure appropriate placement and care for individuals with mental disorders or intellectual disabilities. The deficiency was identified during a review of the resident's clinical records and interviews with facility staff. The Social Worker, responsible for overseeing the PASRR process, acknowledged that the resident should have been referred for a review following the new diagnosis and treatment initiation. However, no request for a Resident Review was submitted to the State PASRR Office between the time of diagnosis and the survey date, indicating a lapse in compliance with the necessary notification procedures.
Failure to Provide Correct Catheter Size for Resident
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling urinary catheter. The resident, who was admitted with diagnoses including Multiple Sclerosis, Quadriplegia, and Neurogenic Bladder, had a physician's order for a Foley catheter size 20 French with a 10 ml balloon. However, during an observation, it was found that the resident had a catheter with a 30 ml balloon instead of the ordered 10 ml balloon. This discrepancy was not documented, and the facility did not have the correct size catheter in stock until the day of the surveyor's visit. Interviews with the Unit Manager, Director of Nursing, Nurse Practitioner, and Central Supply Staff revealed that the facility lacked the correct size catheter for an unspecified period. The Central Supply Staff was responsible for ordering supplies based on a list from the nursing staff, but there was no evidence of how long the facility had been without the correct catheter size. The Nurse Practitioner stated that an order should have been written to reflect the change in catheter size, but this was not done. The incorrect catheter size could cause irritation and increase the risk of bleeding, as noted by the Unit Manager.
Failure to Provide Timely Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident, leading to a deficiency in maintaining the highest practicable mental and psychosocial well-being. The resident, who was admitted with diagnoses including Major Depressive Disorder and Mild Cognitive Impairment, did not receive psychotherapeutic counseling after a Psychotherapy Evaluation recommended it. Despite the resident consenting to psychotherapy services, there was no evidence of follow-up counseling sessions being conducted. Additionally, a Psychiatric Evaluation ordered by a Nurse Practitioner to assess the resident for auditory hallucinations was not completed in a timely manner. The evaluation was ordered in December but was not conducted until June of the following year, approximately six months later. During this period, the resident experienced increased paranoia and auditory hallucinations, which were documented in various progress notes by nursing and social services staff. Interviews with facility staff revealed that the psychotherapist who initially evaluated the resident was no longer providing services, and there was a delay in finding a replacement. The facility's contracted Behavioral Health Agency did not provide the necessary follow-up services, and there was a lack of communication and documentation regarding the resident's behavioral health needs. The Behavioral Health Manager acknowledged a glitch in the system that resulted in the resident not being scheduled for necessary services, contributing to the deficiency.
Inaccurate MDS Coding for Antiplatelet Medication
Penalty
Summary
The facility failed to accurately code three consecutive Minimum Data Set (MDS) Assessments for a resident regarding the administration of an antiplatelet medication. The resident, who was admitted with diagnoses including Hyperlipidemia and Atherosclerotic Heart Disease, had an active physician order for Aspirin, which was to be administered daily for prophylactic heart health. Despite the resident receiving Aspirin as ordered during the observation periods for the MDS Assessments dated May 2, 2024, November 1, 2024, and January 31, 2025, the assessments did not reflect that the resident had received an antiplatelet medication. The MDS Coordinator, during an interview, stated that she did not code the resident's MDS Assessments to indicate the receipt of antiplatelet medication because she believed Aspirin is never coded as such on MDS assessments. This oversight led to the inaccurate coding of the resident's medication administration, as the facility's records, including the Medication Administration Records (MARs), clearly indicated that the resident received Aspirin daily during the relevant observation periods.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Holden
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Jewish Healthcare Center | 3.6 mi | ★★★★★ | 9 | 0 |
| Odd Fellows Home Of Massachusetts | 4.4 mi | ★★★★★ | 10 | 0 |
| Holy Trinity Eastern Orthodox N & R Center | 4.5 mi | ★★★★★ | 2 | 0 |
| Oakdale Rehabilitation & Skilled Nursing Center | 4.5 mi | ★★★★★ | 0 | 0 |
| Knollwood Nursing Center | 4.6 mi | ★★★★★ | 9 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.