Not rated by CMS — ratings are suppressed for new or low-volume facilities.
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 Massachusetts Veterans Home At Holyoke during CMS and state inspections, most recent first.
The facility did not ensure that residents and their representatives were informed about how to file grievances, and grievance forms were not readily accessible or clearly labeled on most units. Multiple residents reported being unaware of the formal grievance process, and staff interviews confirmed that forms were often unavailable or not visible. The Ombudsman also noted a lack of follow-up after grievances were filed.
Activities Assistants were observed assisting residents with feeding after completing a training program that had not been approved by the State of Massachusetts. The DON and Activities Director confirmed that the program was not state-approved and that Activities Staff were assigned to assist with feeding by CNAs or nurses, with uncertainty about licensed nurse supervision during meals.
Multiple residents requiring total assistance with feeding were not provided meals or meal assistance in a timely manner, were left with covered trays for extended periods, and were assisted by staff who stood rather than sat, detracting from a dignified dining experience. Meals were served on trays with disposable cups, and staff reported insufficient staffing to meet residents' needs.
Two residents did not receive care according to professional standards: one continued to receive a discontinued wound treatment without a physician's order and had a topical medication applied without a specified location, while another did not receive the required Glucagon injection during a hypoglycemic event, despite clear physician orders and facility protocol.
A resident with significant weight loss and multiple chronic conditions was not consistently offered a prescribed nutritional supplement (Glucerna) when meal intake was 50% or less, as ordered by the physician. Review of records and staff interviews revealed that the supplement was only documented as offered a few times despite numerous qualifying occasions, with incomplete documentation and inconsistent staff awareness contributing to the deficiency. Direct observation confirmed the supplement was not provided after a missed meal, and both the dietician and DON acknowledged challenges in tracking and ensuring compliance with the order.
A resident with a recent history of C. diff infection developed new symptoms of diarrhea after precautions had been discontinued. Contact Precautions were not immediately re-implemented despite the recurrence of symptoms, resulting in a delay before appropriate infection control measures were restored, contrary to facility policy and CDC guidelines.
Failure to Provide Accessible Grievance Process and Forms
Penalty
Summary
The facility failed to ensure that residents and their representatives were informed about the grievance process and that grievance forms were readily accessible on eight out of ten units. According to the facility's own grievance policy, forms should be easily accessible on all units, and residents, families, and representatives should receive education and written notification about their right to file grievances. However, observations revealed that grievance forms were missing, inaccessible, or not clearly labeled on most units. In some cases, forms were mixed with unrelated materials or placed in locations that were difficult for residents to access, such as behind a resident in a wheelchair or curled up in a file bin. Interviews with residents during a Resident Council meeting indicated that several residents were unaware of how to file a grievance or that a formal process existed. Some residents reported incidents that they felt warranted a grievance but did not know how to proceed. When asked, residents stated they could verbally tell someone about a complaint but did not know they had the right to a formal written process. Staff interviews confirmed that grievance forms were not always made available due to concerns about residents taking them, and that information about the process was not clearly posted or explained. The Ombudsman reported that residents had voiced concerns about the lack of response from the facility after filing grievances, with no follow-up or explanation provided regarding actions taken. Staff acknowledged that the forms should be available and that residents and families needed education on the process. The lack of accessible forms and insufficient education about the grievance process led to residents being uninformed about their rights and unable to formally voice their concerns as outlined in facility policy.
Unapproved Training Program Used for Paid Feeding Assistants
Penalty
Summary
The facility failed to ensure that individuals utilized as paid feeding assistants completed a State-approved training program, as required. During meal observations, Activities Assistants were seen assisting residents with feeding in the dining rooms of two units. Although the Director of Nursing (DON) stated that all Activities Staff had been trained to feed residents, it was later revealed that the training program used by the facility had not been submitted to the State of Massachusetts for approval. The DON was unsure if the program met state requirements and confirmed that an application for approval was only being completed after the surveyor's inquiry. Further interviews indicated that Activities Staff were assigned to assist with feeding by CNAs or nurses, and were instructed not to assist residents with swallowing difficulties. The Activities Director confirmed that all Activities Staff, including herself, had completed the facility's paid feeding assistant training, but could not confirm if a licensed nurse was always present during meals, only that a CNA was always available. The deficiency centers on the use of unapproved training for paid feeding assistants and the lack of assurance that state requirements for such training and supervision were met.
Failure to Provide Dignified and Timely Dining Experience
Penalty
Summary
Surveyors observed multiple deficiencies related to the dining experience and resident dignity across three units. Residents who required total assistance with feeding, including those with Alzheimer's Disease and severe cognitive impairment, were not provided their meals or meal assistance in a timely manner. On several occasions, residents were left seated at tables without meals while others around them were eating or being assisted, leading to visible signs of distress such as fidgeting, reaching for others' trays, and making vocal sounds. In some cases, staff began assisting a resident with a meal but did not complete the assistance, leaving the resident with a covered tray in front of them for extended periods. Meals were consistently served on trays in a cafeteria-style manner, and disposable cups were used for drinks during communal dining. Staff interviews confirmed that this was the standard practice across all units, and that the use of disposable cups and meal trays was institutional in nature. There was no policy in place regarding the dining experience, and the nursing staff were responsible for overseeing communal dining. Staff also reported that there was often insufficient staffing to provide timely and appropriate meal assistance, particularly for residents with higher acuity and total assistance needs. Additionally, staff were observed standing while assisting residents with eating, even when chairs were available, which required residents to turn and tilt their heads to interact with staff. In some instances, food was placed out of the resident's view, further detracting from a dignified and person-centered dining experience. These actions and inactions resulted in a failure to honor residents' rights to a dignified existence, self-determination, and communication during meals.
Failure to Follow Physician Orders and Protocols for Wound and Hypoglycemia Care
Penalty
Summary
Facility staff failed to provide care and services according to professional standards of practice for two residents. For one resident with Type Two Diabetes Mellitus and Alzheimer's Disease, a fluid-filled blister was observed on the right heel. The facility's policy required a physician's order for wound treatments and clear documentation of treatment locations. However, staff continued to apply Skin Prep to the resident's right heel after the physician's order for this treatment had been discontinued. Additionally, Ammonium Lactate 12% was applied without specifying the body location in the physician's order, and this lack of clarification was acknowledged by the Director of Nursing and the Wound Nurse. For another resident with diabetes mellitus who was cognitively intact and dependent on insulin, the facility failed to follow the hypoglycemic protocol and physician's orders during a hypoglycemic event. When the resident's fingerstick blood sugar was recorded as less than 39 mg/dL and the resident was confused, staff administered oral dextrose, which was only indicated for blood sugar between 50-70 mg/dL. The required administration of 1 mg Glucagon HCL by injection, as specified in both the hypoglycemic protocol and the physician's order for blood sugar below 50 mg/dL, was not performed. Interviews with nursing staff, the DON, and the physician confirmed that the facility's protocols and physician's orders were not followed in both cases. The DON and Wound Nurse acknowledged that treatments were provided without current physician orders or without proper clarification of treatment locations. The physician confirmed that the resident experiencing severe hypoglycemia should have received Glucagon HCL as ordered.
Failure to Consistently Provide Ordered Nutritional Supplement for Resident with Weight Loss
Penalty
Summary
The facility failed to ensure that a therapeutic dietary supplement, Glucerna, was consistently offered to a resident with significant weight loss and multiple medical conditions, as ordered by the physician. The physician's order specified that Glucerna should be provided if the resident consumed 50% or less of their meal, with the care plan and nutrition assessments reinforcing this protocol. However, review of meal intake logs, medication administration records, and nursing progress notes revealed that the supplement was not offered on the majority of occasions when the resident's intake was below the threshold, with documentation missing or incomplete for most instances. The resident, who had diagnoses including hypertensive heart disease with heart failure, dysphagia, type 1 diabetes, and chronic kidney disease, experienced significant weight loss over a six-month period. Despite the care plan's directive to monitor intake and provide supplements as prescribed, records showed that out of numerous meals where intake was 50% or less, the supplement was only documented as offered a handful of times. Staff interviews confirmed inconsistent offering and documentation of the supplement, with some staff unaware of the requirement or relying on incomplete records to determine when to provide Glucerna. Direct observations by the surveyor further confirmed that the resident was not offered the supplement after not consuming a meal, and staff interviews revealed confusion about the protocol and lack of awareness of the resident's actual intake. The dietician and DON acknowledged the importance of documentation and adherence to the physician's order, but also noted the difficulty in tracking whether the supplement was offered due to poor record-keeping. The deficiency was substantiated by both documentation review and direct observation, showing a failure to implement the prescribed nutritional intervention for the resident.
Failure to Timely Implement Contact Precautions for C. diff Symptoms
Penalty
Summary
The facility failed to implement transmission-based precautions (TBPs) in a timely manner for a resident who had a recent history of Clostridium difficile (C. diff) infection. The resident was initially placed on Enteric Contact Precautions after experiencing diarrhea and testing positive for C. diff. These precautions were discontinued after the resident's last loose bowel movement, as documented in the nursing progress notes. Eight days after the discontinuation of precautions, the resident began experiencing symptoms of diarrhea again, including multiple episodes of loose, foul-smelling stools with mucus. Despite these symptoms, Contact Precautions were not immediately re-implemented. Nursing notes indicate that the supervisor and on-call physician were notified, and a new order for Vancomycin was obtained, but Enteric Contact Precautions were only reinstated after a delay. The facility's policies and CDC guidelines require immediate implementation of Contact Precautions for residents exhibiting symptoms of infectious diarrhea, including C. diff. The Infection Preventionist confirmed that staff are educated to initiate precautions as soon as symptoms appear and that precautions should remain in place until infectious diarrhea or C. diff is ruled out. The delay in re-implementing precautions for the symptomatic resident constituted a failure to follow established infection control protocols.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 254 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Holyoke
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Day Brook Village Senior Living | 0.7 mi | ★★★★★ | 3 | 0 |
| Regalcare At Holyoke | 1 mi | ★★★★★ | 0 | 0 |
| Renaissance Manor On Cabot | 1.1 mi | ★★★★★ | 3 | 0 |
| Mission Care At Holyoke | 1.6 mi | ★★★★★ | 5 | 0 |
| Care One At Holyoke | 1.9 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Massachusetts Veterans Home At Holyoke.
100% money-back within 48 hours.
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.