Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
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 Mission Care At Holyoke during CMS and state inspections, most recent first.
A resident with cognitive impairment and multiple comorbidities was found with a new bruise near the right eye, but nursing staff failed to notify the provider as required by facility policy. Instead, internal incident documentation was completed and the Unit Manager was informed, but neither the provider nor the DON were notified. The resident was later hospitalized, where a skull fracture and subarachnoid hemorrhage were discovered. The provider confirmed they were not informed of the injury, and the DON acknowledged the lapse in required notification.
A resident with multiple medical conditions was found with a bruise of unknown origin above the right eyebrow. Nursing staff documented and assessed the injury but did not recognize the requirement to report it to DPH within two hours, resulting in a six-day delay before the incident was reported, contrary to facility policy.
Resident Confined in Room by Nurse: A resident with PTSD, anxiety, and Lewy body dementia was reportedly prevented from leaving his/her room when an RN held the door shut during an episode of agitation. Two residents witnessed the RN holding the door closed while the resident inside yelled, cried, and banged on the door to get out. The DON’s investigation substantiated involuntary seclusion, and the RN’s employment was terminated.
Failure to Immediately Report Abuse Allegations: Staff did not promptly report two abuse allegations to administration as required by policy. In one case, an LPN was alleged to have confined a resident in his/her room by holding the door shut, and in another, a CNA reported that an LPN verbally abused a resident with dementia using a racist slur and derogatory language. Supervisory staff and the DON confirmed the reports were delayed instead of being escalated immediately.
Failure to Report Alleged Verbal Abuse to DPH: A resident with moderate cognitive impairment and diagnoses including dementia, depression, and anxiety was involved in an allegation that an RN used a derogatory slur after the resident refused care. The DON was notified through staff reports and a written statement, but the allegation was not reported to DPH within the required timeframe, and no report had been filed by the time of survey.
Two residents with ESRD did not have pharmacist recommendations addressed in a timely manner. One continued to receive a multivitamin containing Vitamin A and E, which was not recommended, for several months after the pharmacist and physician agreed it should be discontinued. Another resident continued to receive Acetaminophen-Codeine, which should be avoided in dialysis patients, because the medication review was not promptly addressed due to communication lapses.
Surveyors identified multiple failures in hand hygiene, manual ware washing, and cleaning practices by dietary and housekeeping staff, including improper glove use, incorrect utensil sanitization, and unclean kitchenettes with food debris and spills. Staff interviews confirmed lack of training and adherence to protocols, and cleaning logs showed missed or undocumented cleaning in resident care unit kitchenettes.
A resident with severe cognitive impairment and an activated HCP was not provided with effective discharge planning to facilitate transfer to a SNF closer to family, despite repeated requests and documented hardship. The facility failed to make or document ongoing referrals for alternate placement, and staff acknowledged that no further efforts had been made for several months.
A resident with severe cognitive impairment and dependent on staff for dressing was left uncovered in bed with underwear visible from the hallway. Multiple staff, including CNAs and a nurse, observed the situation but did not intervene to cover the resident, despite facility expectations to do so.
A resident with a G-tube for severe dysphagia was found in a room where the feeding pump, IV pole, headboard, wall, and corkboard had dried brownish splatter marks that were not cleaned over several days. Staff interviews revealed confusion about cleaning responsibilities, and the facility's cleaning policy was not followed, resulting in an unclean and non-homelike environment.
A resident with PTSD and Personality Disorder experienced a significant decline in mental health, including new homicidal and suicidal ideation and the initiation of psychotropic medications, but the facility failed to notify the PASRR Office for a required Resident Review as mandated by policy and regulation.
Two residents requiring assistance with eating and prescribed thickened liquids due to dysphagia were not provided with the correct liquid consistencies during meals. Staff failed to follow speech therapy recommendations and physician orders, did not use proper feeding techniques, and did not recognize or report signs of aspiration, resulting in both residents being put at risk.
A resident with significant weight loss and a physician's order for health shakes with meals did not receive the supplement with breakfast due to a failure to update the dietary slip and communicate the order to the kitchen. Staff and the resident confirmed the omission, and the dietician noted the supplement was only provided at lunch and dinner, not breakfast.
A resident with Alzheimer's Disease, who was dependent on staff for oral hygiene and had documented dental issues, did not receive routine dental care despite a signed consent and care plan. Dental services were not scheduled after an insurance issue was resolved, and staff responsible for referrals did not follow up, resulting in the resident not receiving needed dental care.
Staff failed to perform hand hygiene before and after distributing meal trays, handling both clean and dirty trays, and entering and exiting resident rooms. Alcohol-based hand sanitizer was available but not used as required, and gloves were worn in the hallway against policy. Staff interviews confirmed these lapses in infection control practices.
A resident with severe cognitive impairment and dysphagia, dependent on staff for eating and prescribed a pureed diet, was given a peanut butter and jelly sandwich and left unsupervised by a CNA who did not check the care plan. The resident was later found unresponsive and pronounced dead. Staff interviews confirmed the resident should not have received the sandwich or been left alone, and the care plan interventions were not followed.
A resident with dysphagia and severe cognitive impairment, who required a pureed diet and one-on-one staff assistance while eating, was given a peanut butter and jelly sandwich by a CNA who did not check the resident's diet order or care card. The CNA left the resident unsupervised, and the resident was later found unresponsive after aspirating on the sandwich. Staff interviews and documentation confirmed the resident's need for supervision and dietary restrictions, which were not followed, resulting in the resident's death.
A Maintenance Assistant in an LTC facility hugged and kissed a cognitively intact resident without consent, making the resident uncomfortable and triggering their PTSD. The resident, with a history of anxiety and PTSD, reported the incident, leading to the Maintenance Assistant's admission of inappropriate behavior and subsequent termination.
The facility failed to ensure staff adhered to infection control standards during a COVID-19 outbreak. Staff did not wear required PPE when caring for COVID-19 positive residents and failed to perform proper hand hygiene between resident contacts. These lapses were observed on two units and confirmed through staff interviews.
The facility failed to provide proper respiratory care for a resident with COPD, Chronic Respiratory Failure, and OSA. The staff did not clean or store the resident's BiPAP mask as required, and the oxygen concentrator filter was found dirty and unmaintained. These lapses placed the resident at risk for infections and impaired oxygen delivery.
The facility failed to provide appropriate dialysis care for a resident with ESRD by not consistently communicating nurse assessments, applying Lidocaine cream, or removing pressure dressings within 24 hours, leading to potential complications and discomfort for the resident.
A resident received an excessive dosage of Abilify due to the facility staff's failure to discontinue a previous 20 mg order before administering a new 25 mg order, resulting in a total daily dose of 45 mg, which exceeded the recommended maximum of 30 mg.
The facility failed to accurately execute Advance Directives for two residents. For one resident, the MOLST form was signed by the HCP without the resident being deemed incapable of making their own medical decisions. Similarly, for another resident, the MOLST form was signed by the HCP without evidence of the resident being deemed incapable by a medical professional.
The facility failed to implement its smoking policy for a resident who was hospitalized on two occasions. Despite the policy requiring smoking evaluations upon re-admission, the resident's medical record showed no documentation of such evaluations. Interviews with staff confirmed that these evaluations should have been completed.
Failure to Notify Provider of New Bruise of Unknown Origin
Penalty
Summary
Nursing staff failed to notify the provider when a cognitively impaired resident, who was dependent on staff for care, was observed with a new bruise of unknown origin near the right eye. The facility's policy required that the physician be notified of any unexpected or substantial change in a resident's condition, including new injuries. Despite this, when the bruise was discovered by a nurse during morning rounds, the nurse only notified the Unit Manager and completed internal incident documentation, but did not contact the physician or the Director of Nursing as required. The Unit Manager, after being informed by the nurse, assessed the bruise and instructed the nurse to complete the necessary incident and skin/bruise reports, but also did not notify the provider or the Director of Nursing. Documentation in the resident's progress notes over several days confirmed the presence of the bruise, but there was no evidence that the provider was informed at any point during this period. The resident, who had diagnoses including vascular dementia, osteoporosis, and a history of stroke, was unable to communicate how the injury occurred. Subsequently, the resident was transferred to the hospital for evaluation of altered mental status and self-removal of a urinary catheter. At the hospital, imaging revealed a right temporal bone fracture and subarachnoid hemorrhage, with no reported trauma. The provider confirmed during an interview that they had not been notified of the bruise and stated that such notification was necessary, as it could have warranted immediate evaluation. The Director of Nursing also acknowledged that the required notifications had not been made when the bruise was first observed.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident to the Department of Public Health (DPH) within the required two-hour timeframe. The resident, who had diagnoses including vascular dementia, depression, osteoporosis, history of stroke, and aphasia, was found by a nurse to have a red-purple, non-tender bruise above the right eyebrow during routine rounds. The nurse did not recall any prior documentation or report of the bruise and immediately notified the Unit Manager, who assisted in assessing the injury and initiating an incident report. Despite these actions, neither the nurse nor the Unit Manager was aware that such an injury of unknown origin required immediate reporting to DPH. The facility's policy mandates that any allegation of abuse, neglect, exploitation, mistreatment, or injury of unknown source must be reported to DPH immediately, but not later than two hours after discovery if it involves abuse or serious bodily injury. In this case, the injury was first identified and documented by nursing staff, but the required report to DPH was not made until six days later, after the hospital notified the facility of additional findings, including a non-displaced fracture and subarachnoid hemorrhage. Interviews with staff revealed a lack of awareness regarding the reporting requirements for injuries of unknown origin. The Director of Nursing confirmed that the facility's policy was not followed, as the nursing staff did not notify her immediately about the injury, and the report to DPH was significantly delayed. The deficiency centers on the failure to recognize and act upon the obligation to report the injury of unknown origin within the mandated timeframe, despite the facility's established policies and procedures.
Resident Confined in Room by Nurse
Penalty
Summary
The Facility failed to ensure that a resident with diagnoses including PTSD, anxiety disorder, and neurocognitive disorder with Lewy bodies was free from involuntary seclusion when a nurse physically held the resident’s room door shut and prevented the resident from leaving. The resident had a behavioral care plan noting that he/she could scream, swear, and have flashbacks related to trauma, and that staff should intervene before agitation escalated, guide the resident away from distress, and if the resident became aggressive, calmly walk away and approach later. The resident was cognitively intact on the most recent MDS and ambulated independently with a walker. According to the resident’s written statement and the Facility’s investigation summary, the resident reported that the nurse shut the room door despite the resident’s preference to leave it open and held it shut when the resident tried to open it. The resident was heard crying, banging on the door, and yelling to be let out while confined inside the room. The investigation summary stated that the allegation was substantiated and that the nurse’s employment was terminated. Two alert and oriented residents reported witnessing the event. One resident said he/she saw the nurse holding the door closed with both hands, bracing himself against it, while the resident inside yelled, cried, and banged on the door trying to get out. The other resident said the nurse instructed the resident to return to the room several times, then closed the door and held it firmly for a few minutes while the resident pulled on the door from inside. A CNA reported hearing the commotion and later seeing the nurse release the door handle, while another CNA said the resident was very upset after the incident. The nurse denied holding the door closed and said he was allowing the resident to pass safely, but the DON stated the Facility substantiated involuntary seclusion.
Failure to Immediately Report Abuse Allegations
Penalty
Summary
The Facility failed to ensure staff immediately reported allegations of abuse to administration, as required by its Resident Abuse policy. The policy prohibited abuse, neglect, exploitation, mistreatment, and misappropriation of resident property, defined involuntary seclusion as separating a resident from others or from his/her room against the resident’s will, and required any staff member who hears, suspects, or witnesses abuse to report it immediately to a supervisor and for the Administrator or on-call designee and DON to be notified immediately. For one incident, Resident #1, who had diagnoses including neurocognitive disorder with Lewy bodies, PTSD, and anxiety disorder, reported that Nurse #1 shut and held the resident’s room door closed while the resident was trying to leave. Two alert and oriented residents said they witnessed Nurse #1 holding the door shut while Resident #1 was inside asking to leave. Nurse #2 heard a commotion and later overheard a resident on the phone describing a nurse holding a resident’s door shut, but did not report the allegation. Nurse #3, acting as supervisor, was told that a resident had witnessed Nurse #1 hold Resident #1’s door closed, but she did not further investigate or report it to administration. The DON stated she was not notified until the next morning when the resident reported it. For another incident, Resident #4 had diagnoses including moderate dementia with mood disturbance, major depressive disorder, and anxiety disorder, and a BIMS score of 9 out of 15. CNA #4 stated that after Resident #4 refused care, Nurse #1 confronted the resident and called him/her a racist slur and a derogatory term. CNA #4 reported the allegation to the Charge Nurse, but Facility administration was not notified until a few days later. Unit Manager #1 stated the Charge Nurse did not report the allegation immediately as required, and the DON said she later learned the incident had occurred two days earlier after reviewing the CNA’s written statement.
Failure to Report Alleged Verbal Abuse to DPH
Penalty
Summary
The Facility failed to ensure that an allegation of verbal abuse was reported to the Massachusetts Department of Public Health (DPH) within the required timeframe. The allegation involved Resident #4, who was admitted in April 2021 with diagnoses including moderate dementia with mood disturbance, major depressive disorder, and anxiety disorder, and whose quarterly MDS assessment dated 09/07/25 showed moderate cognitive impairment with a BIMS score of 9 out of 15. According to the Facility policy, allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown source, and misappropriation of property were to be reported to DPH immediately or within 24 hours depending on the circumstances. On 10/04/25, the DON was notified that CNA #4 had witnessed Nurse #1 direct a derogatory slur at Resident #4 after Resident #4 refused care and was yelling loudly. CNA #4 stated that Nurse #1 confronted Resident #4, accused him/her of being racist, and called him/her a faggot. Unit Manager #1 said she was told that CNA #4 made the allegation and that she instructed CNA #4 to complete a written witness statement and reported the allegation to the DON. The DON stated she reviewed the written statement, felt it conflicted with CNA #4's verbal statement, and did not feel it was specific enough to investigate or report to DPH. The HCFRS showed that no incident involving Nurse #1 and Resident #4 had been reported to DPH as of 11/25/25, 52 days after the allegation was brought to the DON's attention.
Failure to Timely Implement Pharmacist Recommendations for Residents with ESRD
Penalty
Summary
The facility failed to implement and address licensed pharmacist recommendations in a timely manner for two residents with end stage renal disease (ESRD). For one resident, the pharmacist recommended discontinuing a multivitamin containing Vitamin A and E, which are not advised for individuals with ESRD, and switching to Nephrocaps. The physician agreed with this recommendation, but the order to discontinue the multivitamin and initiate Nephrocaps was not transcribed or implemented until several months later, resulting in the resident continuing to receive the inappropriate multivitamin for an extended period. For another resident, the pharmacist recommended evaluating the use of Acetaminophen-Codeine, a medication advised to be avoided in dialysis patients, and suggested considering an alternative pain management option. The medication regimen review (MRR) was not addressed by the provider, and the resident continued to receive Acetaminophen-Codeine as ordered. The MRRs for this resident were not reviewed or acted upon until much later due to a breakdown in communication, as the MRRs were sent to a supervisor who was on leave and not seen by facility staff until after the deficiency was identified. Facility policy required that prescribers act upon drug regimen review recommendations within 7-14 days and document their response. In both cases, these requirements were not met, resulting in prolonged administration of medications that were not recommended for residents with ESRD. The failure to timely implement pharmacist recommendations and ensure proper documentation led to the identified deficiencies.
Failure to Maintain Sanitation and Food Handling Standards in Kitchen and Kitchenettes
Penalty
Summary
The facility failed to ensure proper sanitation and food handling practices in the main kitchen and in all three resident care unit kitchenettes. Surveyors observed multiple instances where dietary staff did not maintain appropriate hand hygiene while preparing and serving meals. Staff were seen touching their faces, masks, and beard guards with gloved hands and then continuing to handle food and clean trays without changing gloves or washing hands as required by facility policy. Interviews with staff confirmed a lack of adherence to hand hygiene protocols, and staff acknowledged the importance of these practices to prevent food contamination. In the main kitchen, improper manual ware washing procedures were observed. Dietary aides did not follow the correct sequence for washing, rinsing, and sanitizing utensils, often rinsing sanitized utensils over the garbage disposal or wiping them with paper towels instead of air drying. Some staff were unaware of the required submersion time in sanitizer and had not received proper training on the three-compartment sink process. Additionally, countertops used for food preparation were cleaned with soapy water from the wash sink containing food debris, rather than with sanitizer solution, increasing the risk of cross-contamination. The kitchenettes on all three floors were found to be inadequately cleaned, with dried food splatter, liquid spills, debris, and improper storage of utensils and food items. Cleaning logs indicated missed or undocumented cleaning on several days. Observations included open ceiling tiles with exposed insulation, cracked ice chests, and food and beverage spills, all of which were acknowledged by the Food Service Director and Housekeeping Supervisor as risks for contamination and pest infestation. Housekeeping staff confirmed responsibility for cleaning but failed to consistently document or perform required cleaning tasks.
Failure to Uphold Resident Rights in Discharge Planning
Penalty
Summary
The facility failed to uphold resident rights for one resident by not implementing an effective discharge planning process that considered the goals of the resident's Health Care Proxy (HCP). The resident, who had severe cognitive impairment due to dementia and other psychiatric diagnoses, had an activated HCP, with a family member designated to make decisions. The family's stated goal was to have the resident transferred to a skilled nursing facility closer to them, as the current location posed a significant financial and logistical burden for visits. Documentation in the resident's care plan and social services notes indicated that the facility was aware of the family's preference and the hardship caused by the distance. The care plan included interventions for providing information and referrals to assist with the transfer. However, after an initial referral attempt in early 2025, there was no evidence of further referrals or follow-up calls to other facilities for placement. The social worker acknowledged that no additional referrals had been made in the past six months, despite ongoing requests and discussions with the family. Interviews with the family member and facility staff confirmed that the facility did not consistently pursue alternate placement options or maintain documentation of referral efforts. The administrator and social worker both recognized that more should have been done to assist with the transfer, especially given the family's repeated requests. The facility was unable to provide documentation of referrals or follow-up actions to the survey team at the time of the survey exit.
Failure to Maintain Resident Dignity by Not Covering Unclothed Resident
Penalty
Summary
Staff failed to promote the dignity of a resident with severe cognitive impairment, who was dependent on staff for lower body dressing, by not intervening when the resident was observed uncovered in bed with underwear briefs visible from the hallway. Multiple staff members, including two CNAs and a nurse, walked past the resident's room, looked in, and did not take action to cover the resident, despite being able to see that the resident was uncovered. The resident had diagnoses of dementia and neurosyphilis and was known to frequently remove covers. Staff interviewed at the time acknowledged that the expectation was to cover or offer to cover residents observed to be uncovered, regardless of the resident's tendency to remove blankets. The deficiency was identified through direct observation, interviews, and record review.
Failure to Maintain Clean and Homelike Environment for G-Tube Dependent Resident
Penalty
Summary
The facility failed to maintain a clean and homelike environment for one resident who was dependent on a G-tube for nutrition due to severe dysphagia and other medical conditions. Multiple observations revealed that the resident's room, specifically the area around the G-tube feeding equipment, was not properly cleaned. The EnteraFlo pump, IV pole, corkboard, wall, and headboard near the resident's bed all had dried brownish colored splatter marks, indicating a lack of cleaning following a spill of nutritional supplement. The facility's policy required spot cleaning of vertical surfaces and IV poles, but these areas remained visibly soiled over several days. Interviews with nursing staff, housekeeping, and the administrator confirmed that the soiled areas should have been cleaned either immediately by staff or by housekeeping, but this was not done. There was also confusion among staff regarding responsibility for cleaning the G-tube pump and surrounding areas. The deficiency was identified through direct observation, record review, and staff interviews, all of which confirmed that the environment was not maintained in accordance with facility policy and resident rights.
Failure to Notify PASRR Office After Significant Change in Mental Condition
Penalty
Summary
The facility failed to notify the state mental health authority (PASRR Office) of the need for a Resident Review when a resident experienced a significant change in mental condition from their initial Level I PASRR. The resident was admitted with diagnoses including Post-Traumatic Stress Disorder (PTSD) and Personality Disorder, but the initial PASRR screening did not document any mental illness or disorder, and a Level II PASRR evaluation was not indicated at that time. Upon admission, there were no psychotropic medications ordered for the resident. Over the following months, the resident exhibited escalating behavioral and psychiatric symptoms, including aggressive behavior, refusal of medications, physical altercations with residents and staff, sexually inappropriate behavior, and exit-seeking. The resident also began expressing both homicidal and suicidal ideation, including specific threats to harm themselves and others. Psychiatric assessments documented these changes, and the resident was eventually started on psychotropic medications, including Lamotrigine and later Sertraline, to address mood instability and depressive symptoms. Despite these significant changes in mental status and the initiation of psychotropic medication, the facility did not refer the resident to the PASRR Office for a Resident Review as required by policy and regulation. Interviews with facility staff confirmed that no referral was made, even though the social worker acknowledged that the resident's change in behavior and need for medication constituted a significant change in mental condition that should have triggered a PASRR Resident Review.
Failure to Provide Safe Feeding Assistance and Ordered Liquid Consistencies
Penalty
Summary
The facility failed to provide safe feeding assistance for two residents who required help with eating, resulting in both being put at risk for aspiration. For one resident with severe cognitive impairment, dysphagia, and a recent diagnosis of aspiration pneumonia, staff did not follow the speech therapist's recommendations for honey-thick liquids to be given by teaspoon. During a meal observation, the certified nursing assistant (CNA) provided large sips of milk directly from a cup, did not verify the correct liquid consistency, and gave multiple heaping spoonfuls of food in rapid succession without ensuring the resident had swallowed each bite. The CNA also mixed applesauce with other foods without authorization and failed to recognize or report signs of aspiration, such as coughing and gulping, during the meal. Another resident, also dependent on staff for eating and with a history of recurrent pneumonia and dysphagia, was not provided with the ordered nectar-thick beverages during a breakfast meal. The CNA assisting this resident failed to add thickener to the cranberry juice and was unsure if thickener had been added to other beverages. The CNA admitted to forgetting to thicken the cranberry juice and only realized the omission after the meal was completed. The nurse and nurse consultant confirmed that staff are responsible for ensuring liquids are thickened according to physician orders and acknowledged that providing incorrect liquid consistency could pose a risk for aspiration. Both incidents were observed and confirmed through interviews and record reviews. The facility's policies required staff to check diet slips, provide appropriate food and liquid consistencies, and monitor for signs of aspiration. However, these protocols were not followed, and staff demonstrated a lack of understanding of the specific feeding techniques and precautions required for residents with dysphagia. The deficiencies were directly related to staff actions and inactions during meal assistance, as well as a lack of adherence to individualized care plans and physician orders.
Failure to Provide Ordered Nutritional Supplement at Breakfast
Penalty
Summary
A deficiency occurred when a resident with a history of dysphagia, dementia, significant weight loss, and a therapeutic diet order did not receive prescribed health shakes with breakfast as ordered by the physician. The resident had experienced a 13.5-pound weight loss over four months, and the care plan included the addition of health shakes to increase calorie intake. Despite this, observations on multiple occasions showed that the health shake was not present on the resident's breakfast tray, and the resident confirmed not receiving the supplement at breakfast. Interviews with nursing staff and a CNA revealed that the health shake order was not reflected on the resident's dietary slip for breakfast, although it was present for lunch and dinner. Staff indicated that the process for ensuring supplements are provided involves entering the order into the electronic medical record and completing a Diet Requisition and Dietician Communication Form, which should be submitted to the kitchen. However, this process was not followed for the breakfast meal, resulting in the omission of the health shake. The dietician confirmed that the recommendation for health shakes had been made due to the resident's weight loss, but the kitchen had only included the supplement for lunch and dinner, not breakfast. The failure to update the dietary slip and communicate the order to the kitchen led to the resident not receiving the prescribed nutritional supplement with breakfast, as required by the care plan and physician's order.
Failure to Provide Routine Dental Services After Consent and Care Plan Initiation
Penalty
Summary
A resident with Alzheimer's Disease was admitted to the facility in April 2023 and was noted to have broken natural teeth and cavities upon admission. The resident's representative signed a request for dental services in May 2023, and a physician's order authorized dental, vision, auditory, podiatry, and wound consults. The resident's care plan included coordination for dental care due to the observed dental issues. The Minimum Data Set (MDS) assessment indicated the resident was severely cognitively impaired, fully dependent on staff for oral hygiene, and had obvious dental problems. Despite the signed consent and care plan directives, the facility failed to schedule and provide routine dental services for the resident. According to interviews, the medical records staff member responsible for dental referrals did not arrange for dental care after an initial insurance issue was resolved approximately six months post-admission. The administrator confirmed that the resident should have received dental services but was not aware that the services had not been provided, and no alternative arrangements were made.
Failure to Perform Hand Hygiene During Meal Service
Penalty
Summary
Staff on the 3rd Floor Unit failed to adhere to infection control standards during lunch meal service. Four staff members, including two nurses and two CNAs, were observed removing meal trays from the meal truck and distributing them to residents without performing hand hygiene before or after entering resident rooms. Staff were seen entering rooms, handling bedside tables, and positioning trays for residents, then exiting rooms and continuing to distribute trays without using the alcohol-based hand sanitizer available in the hallway. Additionally, staff were observed handling both clean and dirty meal trays without performing hand hygiene in between, and one nurse was seen exiting a resident's room wearing gloves, which is against facility policy for hallway conduct. Interviews with staff confirmed that the expectation was to use alcohol-based hand sanitizer before entering and after exiting resident rooms, and that gloves should not be worn in the hallway. Staff acknowledged forgetting to perform hand hygiene and not following the established procedures. The Infection Control Nurse reiterated the facility's policy and expectations regarding hand hygiene and glove use, confirming that the observed practices did not align with infection prevention protocols.
Failure to Follow Care Plan for Resident with Dysphagia Results in Fatal Incident
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, diagnosed with dementia, dysphagia, and schizophrenia, was not provided care in accordance with their established care plan. The resident was dependent on staff for eating and required a pureed diet due to difficulty swallowing, as documented in the care plan, physician's orders, and CNA care card. The care plan also specified that the resident needed one-on-one staff assistance during meals and snacks to ensure safety and prevent aspiration. On the evening of the incident, a CNA delivered a peanut butter and jelly sandwich to the resident as an evening snack, which was not consistent with the prescribed pureed diet. The CNA did not check the resident's care card for dietary restrictions or required supervision level before providing the snack. After delivering the sandwich, the CNA left the resident unattended in their room and continued distributing snacks to other residents. The resident was later found unresponsive and without a pulse, and was subsequently pronounced dead at the facility. Interviews with facility staff, including the rehabilitation director, dietician, and nursing supervisor, confirmed that the resident should not have been given a sandwich or left unsupervised while eating. The failure to follow the care plan interventions, including providing the correct food consistency and required staff assistance, directly led to the deficiency identified during the survey.
Failure to Provide Required Supervision and Diet Consistency Results in Resident Death
Penalty
Summary
A resident with diagnoses including dysphagia, dementia with agitation, and schizophrenia was on a physician-ordered pureed diet (NDD1) and was dependent on staff for eating due to severe cognitive impairment and hand tremors. The resident's care plan specified the need for one-on-one staff assistance during meals and snacks, as well as strict adherence to the prescribed pureed diet to prevent aspiration. The resident's Minimum Data Set (MDS) and care plans consistently documented the need for dependent-level assistance and close supervision while eating. On the evening of the incident, a Certified Nurse Aide (CNA) delivered a peanut butter and jelly sandwich to the resident as a snack, without checking the resident's diet orders or care card for required assistance. The CNA did not remain with the resident while he ate and left him unsupervised in his room. Approximately fifteen minutes later, the resident was found unresponsive, and resuscitation efforts were unsuccessful. Witness statements and interviews confirmed that the resident was typically provided with pudding or yogurt for snacks and that staff were aware of the resident's dietary restrictions and need for supervision. Interviews with facility staff, including the Speech Language Pathologist, Dietician, and Director of Nursing, confirmed that the resident required a pureed diet and one-on-one supervision during meals and snacks due to his dysphagia and cognitive impairment. The CNA involved admitted to not checking the care card or diet order before providing the snack and acknowledged leaving the resident unattended. Facility policies required staff to follow diet orders and provide the necessary level of assistance, which was not done in this case, resulting in the resident's death after aspirating on the sandwich.
Inappropriate Conduct by Maintenance Assistant
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect, as required by their policy on Resident Rights and Responsibilities. On a specific day, a Maintenance Assistant hugged and kissed a cognitively intact resident without consent, which made the resident feel uncomfortable and triggered their PTSD. The resident, who had a history of anxiety disorder, PTSD, major depressive disorder with psychotic symptoms, and schizoaffective disorder, reported feeling uncomfortable and afraid of the incident recurring. The Maintenance Assistant admitted to the inappropriate behavior, stating that he hugged and kissed the resident to comfort them after they expressed feeling depressed. The incident was reported to the facility's Social Worker and Administrator, and the resident expressed fear and reluctance to discuss the details. The Maintenance Assistant acknowledged that his actions were wrong and that he had crossed a line, leading to his suspension and eventual termination.
Infection Control Deficiencies During COVID-19 Outbreak
Penalty
Summary
The facility failed to ensure that staff adhered to infection control standards for transmission-based precautions for two residents and on two units during a COVID-19 outbreak. Specifically, on Unit One, staff did not wear the required personal protective equipment (PPE) when caring for COVID-19 positive residents. For instance, a CNA entered a resident's room with only a surgical mask instead of the required N95 mask. Additionally, another staff member entered a different resident's room without the necessary eye protection. Both instances were observed despite clear signage and available PPE supplies outside the rooms, and staff acknowledged their failure to comply with the PPE requirements during interviews immediately following the observations. On Unit Three, staff failed to perform proper hand hygiene after caring for a COVID-19 positive resident and between contacts with multiple residents. A CNA was observed exiting a COVID-19 positive resident's room, doffing PPE, and then entering another resident's room without performing hand hygiene. This CNA admitted to not following the required hand hygiene protocols after removing PPE and before interacting with another resident. The facility's policy on hand hygiene clearly indicated the need for hand hygiene after removing gloves and before entering and exiting residents' rooms, which was not adhered to in this case. The deficiencies were observed during a survey, and interviews with staff confirmed the lapses in following the facility's infection control policies. The facility's policies on droplet and contact precautions, as well as hand hygiene, were not followed, leading to potential risks of contamination and spread of infection during the COVID-19 outbreak. The staff's failure to use appropriate PPE and perform hand hygiene as required by the facility's policies were the primary actions leading to the identified deficiencies.
Failure to Maintain Respiratory Equipment
Penalty
Summary
The facility failed to provide respiratory care and services consistent with professional standards of practice for a resident diagnosed with Chronic Obstructive Pulmonary Disease (COPD), Chronic Respiratory Failure with Hypoxia, and Obstructive Sleep Apnea (OSA). The staff did not implement a schedule for cleaning and storing the resident's BiPAP mask, which was observed multiple times laying face down on the bed without a protective bag. The resident reported that the BiPAP mask had never been cleaned by the staff, and the mask was found with dried yellow and white debris inside it. Additionally, the storage bag for the BiPAP mask was dirty and undated, indicating it had not been changed as required. The facility also failed to clean and maintain the resident's oxygen concentrator filter according to professional standards. The oxygen concentrator filter was observed to be coated with a thick, gray, fibrous layer of dust. The resident's oxygen concentrator was connected to a nasal cannula, and the dirty filter posed a risk of impaired oxygen delivery and equipment malfunction. The IC Nurse confirmed that the filter was dirty and expressed concern about the air quality the resident was inhaling. The IC Nurse also mentioned that a representative from the oxygen and respiratory supply company indicated that a dirty filter could cause the concentrator to overheat and shut off, stopping the oxygen flow to the resident. Interviews with the nursing staff revealed that the night shift nurse was responsible for cleaning the oxygen concentrator filters weekly, but this task had not been performed. The IC Nurse confirmed that the nursing staff was responsible for cleaning the resident's BiPAP mask and oxygen concentrator filter, but these tasks were not being carried out. The failure to adhere to the facility's policy on respiratory equipment maintenance placed the resident at risk for nosocomial infections and impaired respiratory function.
Failure to Provide Appropriate Dialysis Care
Penalty
Summary
The facility failed to provide dialysis services consistent with professional standards of practice for a resident with End Stage Renal Disease (ESRD). The facility did not consistently communicate the nurse's assessment of the resident prior to dialysis, apply EMLA (Lidocaine) cream to the dialysis access site to prevent pain, or implement the dialysis center's recommendations to remove pressure dressings within 24 hours to prevent clotting of the dialysis access site. These failures were observed and documented multiple times, with the dialysis center repeatedly noting the lack of communication and the presence of pressure dressings beyond the recommended time frame. The resident, who was cognitively intact, had specific physician orders for dialysis treatments and the application of Lidocaine cream to the fistula site. Despite these orders, the facility's nurses often left the pressure dressings on the resident's arm for more than 24 hours, citing concerns about excessive bleeding due to the resident's blood-thinning medication. This practice was contrary to the dialysis center's instructions and led to indentations and deep pits on the resident's arm, as well as a scant amount of bleeding observed during a surveyor's visit. Interviews with the facility's staff, including the Unit Manager and Director of Nurses, revealed a lack of proper communication and adherence to the dialysis center's guidelines. The staff admitted to not consistently completing the Dialysis Communication Form and not removing the pressure dressings in a timely manner. The Director of Nurses acknowledged that a proper assessment of the dialysis site for infection or complications could not be conducted with the pressure dressing in place, highlighting a significant communication issue between the dialysis facility and the nursing facility.
Failure to Discontinue Previous Medication Order
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors. Specifically, the staff did not discontinue an order for a 20 mg dose of Abilify before administering a newly ordered 25 mg dose, resulting in the resident receiving an excessive dosage of 45 mg daily. This dosage exceeded the recommended maximum of 30 mg daily. The resident, who was admitted with a diagnosis of Schizophrenia, received both doses from March 6, 2024, through March 10, 2024, due to a transcription error by a nurse who was distracted and forgot to discontinue the old order. The error was discovered by the Unit Manager after reviewing a Consultant Pharmacist's recommendation and clarifying the order with the Psychiatric Nurse Practitioner. The Unit Manager found that the resident's chart, Medication Administration Record (MAR), and Nursing Progress Notes indicated the resident had been receiving both doses. The nurse responsible for the error was unavailable for an interview during the survey, but it was confirmed that the resident should have only been taking a 25 mg daily dose of Abilify.
Failure to Accurately Execute Advance Directives
Penalty
Summary
The facility failed to accurately execute Advance Directives for two residents, specifically regarding the completion of the MOLST forms. For Resident #30, who was admitted with diagnoses including Frontotemporal Neurocognitive Disorder, Major Depressive Disorder, Bipolar Disorder, and Delusional Disorder, the MOLST form was signed by the Health Care Proxy (HCP) on 8/9/23 without the resident being deemed incapable of making their own medical decisions by a medical professional. There was no documentation indicating that the resident was involved in the decision-making process for the MOLST form. The Social Workers confirmed that the HCP had not been activated until January 2024, meaning the HCP did not have the authority to complete the MOLST form at the time it was signed. Similarly, for Resident #79, who was admitted with diagnoses including Dementia and catatonic disorder, the MOLST form was signed by the HCP on 7/17/23. The clinical record did not indicate that the resident had been deemed by a Physician or Nurse Practitioner as lacking the capacity to make their own health care decisions. The Social Worker confirmed that there was no evidence of the HCP being activated by a medical professional, and thus the HCP should not have signed the MOLST form. These actions led to the deficiency in accurately executing Advance Directives for the residents involved.
Failure to Implement Smoking Policy for Resident
Penalty
Summary
The facility failed to implement its smoking policy for one resident out of a sample of 24. Specifically, the facility did not complete re-admission smoking evaluations for a resident who was hospitalized on two occasions. The facility's policy requires smoking evaluations upon admission, re-admission, and after significant changes in resident status. However, the resident's medical record showed no documentation of smoking evaluations upon their return from the hospital on two separate dates. The resident in question was admitted to the facility with diagnoses including dementia with severe mood disturbance and a history of traumatic brain injury. Despite being identified as a smoker and having a care plan that included smoking evaluations, the facility did not perform these evaluations after the resident's hospitalizations. Interviews with staff confirmed that smoking evaluations should have been completed per facility policy, but they were not done in this case.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 313 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.
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A prioritized, do-first checklist
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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) |
|---|---|---|---|---|
| Mont Marie Rehabilitation & Healthcare Center | 0.4 mi | ★★★★★ | 3 | 0 |
| Mary's Meadow At Providence Place | 1 mi | ★★★★★ | 4 | 0 |
| Vantage At West Springfield Llc | 1.4 mi | ★★★★★ | 10 | 0 |
| Massachusetts Veterans Home At Holyoke | 1.6 mi | — | 0 | 0 |
| Regalcare At Holyoke | 2.2 mi | ★★★★★ | 0 | 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.