Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 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.
Failure to Assess Self-Administration of Bedside Medications: A resident with COPD, weakness, AFTT, and OA was allowed to keep Aspercreme, Ventolin, Systane, and Latanoprost at the bedside for self-administration without a documented self-administration assessment, provider authorization, or care plan documentation. Surveyors observed the medications within reach in the resident’s room, and the resident stated staff permitted self-use and had not taught medication storage requirements. An RN said an assessment and MD order were required, and the UM confirmed the resident had not been assessed before being allowed to keep the medications bedside.
Failure to Arrange Dermatology Follow-Up for a Resident with Upper Lip Lesion: The facility did not schedule a recommended dermatology recheck for a resident with cognitive impairment who was seen for scaly, erythematous upper-lip lesions and treated with topical Hydrocortisone and Ketoconazole. The record showed the treatment was given, but there was no evidence the follow-up visit was arranged or completed, and staff later confirmed the resident had not been seen again by dermatology.
Failure to secure a resident’s suprapubic catheter and document urinary output as ordered. A cognitively intact resident with quadriplegia, urinary retention, and bladder dysfunction had repeated missed urine output entries across multiple shifts, and during observation the catheter was not secured with the ordered leg strap while the resident expressed pain when the tubing was checked. UM acknowledged the strap was needed to prevent pulling and that output should have been documented as ordered.
Failure to Follow Contact Plus and Standard Precautions: A nurse entered a resident’s room where C. diff Contact Plus Precautions were posted without wearing a gown or gloves, touched the resident with bare hands, left without hand hygiene, and then entered another resident’s room without hand hygiene and handled the resident’s bedding with bare hands. The first resident had confirmed C. diff and was receiving Vancomycin, while the second resident was not on TBPs. The nurse acknowledged the lapse, and the IP stated the posted precautions were not followed.
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.
Failure to Assess Self-Administration of Bedside Medications
Penalty
Summary
The facility failed to determine whether self-administration of medications was clinically appropriate for one resident before allowing the resident to keep multiple medications at the bedside for self-administration. The facility’s policy required a self-administration assessment, provider agreement, interdisciplinary team determination of clinical appropriateness and safety, and documentation in the care plan, but the resident’s record did not show that these steps were completed. The record also did not include an order authorizing self-administration of Aspercreme, Ventolin, Systane, or Latanoprost. The resident was admitted with diagnoses including Adult Failure to Thrive, weakness, COPD, and osteoarthritis. Physician orders included Aspercreme lidocaine cream, Latanoprost eye drops, Systane ophthalmic solution, and Ventolin HFA inhaler. Surveyor observations found three bottles of Aspercreme, a prescription Latanoprost eye drop bottle, a unit dose dropper of Systane, and a prescription Ventolin inhaler in the resident’s room and within reach on the bedside table or in open boxes. During interviews, the resident stated staff allowed self-administration of the Aspercreme, eye drops, and inhaler, and said the resident used the Ventolin when feeling short of breath and the eye drops when needed for dry eyes. The resident also stated staff had not instructed him or her on medication storage requirements. A nurse said a resident who wants to self-administer medications must be assessed and have a physician order, but she was unsure whether this had occurred. The unit manager later stated the resident had not been assessed for self-administration before being allowed to keep medications at the bedside.
Failure to Arrange Recommended Dermatology Follow-Up
Penalty
Summary
The facility failed to adhere to professional standards of practice when it did not arrange a recommended follow-up dermatology appointment for Resident #12. The resident was admitted with diagnoses including mild cognitive impairment, dementia, and need for assistance with personal care, and the MDS indicated moderate cognitive impairment with a BIMS score of 12 out of 15, clear speech, and the ability to understand and be understood. A dermatology visit note documented a focused skin exam showing scaly, erythematous papules and plaques on the upper lip, with a differential diagnosis of irritant contact dermatitis, allergic contact dermatitis, or fungal overgrowth. The dermatologist recommended Hydrocortisone 1% cream mixed 50-50 with Ketoconazole cream applied to the upper lip twice daily for two to three weeks and a return visit in about one month for recheck of the rash. The resident’s March 2026 treatment record showed Hydrocortisone 1% and Ketoconazole 2% creams were applied to the upper lip from 3/3/26 through 3/16/26, but the clinical record contained no evidence that the follow-up dermatology appointment was scheduled or completed. A nursing progress note later documented multiple scabbed areas on the resident’s lip, and surveyors observed a scabbed area above the upper lip on 5/17/26 and 5/18/26. During interviews, the resident stated he/she had been told the area above the upper lip was cancer, and the Unit Manager stated she was responsible for ensuring follow-up consults were scheduled, that the resident was supposed to have a dermatology follow-up on 4/2/26, and that no evidence of scheduling was found. The Unit Manager later confirmed the follow-up dermatology appointment had not been scheduled and the resident had not been seen by dermatology since the initial visit.
Failure to Secure Suprapubic Catheter and Document Urinary Output
Penalty
Summary
The facility failed to provide care and services consistent with professional standards of practice for Resident #13’s indwelling suprapubic urinary catheter. Resident #13 was admitted with diagnoses including quadriplegia, urinary retention, and neuromuscular dysfunction of the bladder, and was cognitively intact with a BIMS score of 12 and dependent for all ADLs. The care plan and physician’s orders directed staff to secure the suprapubic catheter with a leg strap, check the site and skin every shift, and document urinary output every shift, with the physician to be notified if output was less than 100 ml. Record review showed multiple missed entries for urinary output documentation across March, April, and May 2026 on day, evening, and night shifts. During observation on 5/18/26, the surveyor and UM #1 observed the catheter tubing being checked, and the resident stated, “Ow, ow, ow, ow!” The surveyor did not observe a securement device or leg strap in place. UM #1 stated the strap was important to prevent the resident from pulling out the catheter and to prevent pain when the catheter is pulled, and later acknowledged that nursing staff should have documented urinary output as ordered and that the securement device should have been in place even though it was documented in the TAR as present.
Failure to Follow Contact Plus and Standard Precautions
Penalty
Summary
The facility failed to adhere to Transmission Based Precautions and Standard Precautions for two residents, including one resident with symptomatic Clostridioides difficile (C. diff) infection who was placed on Contact Plus Precautions and another resident who did not have C. diff and was not on any transmission-based precautions. The facility’s Contact Plus Precautions policy stated that staff entering the room of a resident on these precautions were to perform hand hygiene before entering and upon exiting the room, wear gloves and an isolation gown, remove PPE before exiting, and perform soap-and-water handwashing after caring for residents with confirmed C. diff. Resident #79 was admitted with enterocolitis due to C. diff, had a positive C. diff lab result, and was receiving Vancomycin for C. diff per physician orders and the MAR. CNA flow sheets documented loose and mucus bowel movements in May 2026. On observation, Contact Plus Precautions signage was posted outside the resident’s room and a bin with disposable gowns and gloves was available outside the room. During observation, Nurse #3 entered Resident #79’s room without a gown or gloves, used bare hands to adjust the resident’s legs, exited without performing hand hygiene, and then went directly into Resident #24’s room without hand hygiene. Resident #24 was in bed and did not require TBPs. Nurse #3 then used bare hands to lift the covers and adjust the resident’s sheets. In interview, Nurse #3 acknowledged she did not wear PPE or perform hand hygiene between the two rooms and stated this increased the risk of transmitting C. diff to herself and to residents. The Infection Preventionist stated Nurse #3 should have followed the posted Contact Plus Precautions instructions and performed hand hygiene after touching Resident #79 and before entering Resident #24’s room.
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 August 2026) and official state health department websites.