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 Mont Marie Rehabilitation & Healthcare Center during CMS and state inspections, most recent first.
Nursing staff failed to properly operate portable oxygen tanks for a resident with CHF, CKD, and diabetes who developed acute shortness of breath and low O2 saturation. One nurse assessed the resident and directed another nurse to obtain portable oxygen from the unit and then from a second unit, but both tanks were reported as appearing empty based on the regulator gauges. Later inspection showed the tanks were not empty, and it was determined that the nurse who retrieved them did not know to use the metal key to fully open the tank valve so the oxygen would flow and the gauge would display an accurate reading, despite having completed required oxygen administration competencies on hire.
A resident's Health Care Agent, acting under an activated proxy, requested copies of the resident's medical records by submitting a signed release and following facility procedures, but did not receive the requested documentation. The facility's records confirmed the requests were made, but there was no evidence the records were provided, and the administrator could not produce documentation showing compliance.
A resident with severe cognitive impairment and multiple medical conditions did not receive assistance from staff in scheduling a podiatry appointment, despite a request from their Health Care Agent and a physician's order. There was no documentation that podiatry services were provided, and the podiatrist's office confirmed no request was received from the facility.
A resident with Parkinson's disease, ulcerative colitis, and an ileostomy did not receive multiple prescribed bowel and other medications within the required timeframes, with doses often given more than an hour late and after meals instead of before as ordered. This failure to follow physician orders and facility policy resulted in difficulties managing the resident's ileostomy output, as confirmed by the DON and the resident's representative.
A resident with Parkinson's disease was administered incorrect dosages of Carbidopa-Levodopa for several days after admission due to a nurse inaccurately transcribing hospital discharge orders during medication reconciliation. The resident received only half the prescribed dose of both immediate and extended release formulations, and the error was not identified until after multiple administrations.
A resident with multiple mental health diagnoses and on Seroquel did not receive EKG monitoring every six months as recommended by the Behavioral Health Nurse Practitioner. The facility failed to ensure timely follow-up EKGs, with a 14-month gap between tests, despite the known risks associated with the medication and the provider's documented recommendations.
Staff serving breakfast on one unit failed to perform required hand hygiene between handling dirty tableware and serving meals to residents. Despite facility policy and prior education, nurses and CNAs were observed serving food and clearing plates without washing hands or using hand sanitizer, and no staff used the available hand washing sink during the meal service.
Surveyors identified that two residents did not have their MDS assessments accurately completed: one resident's edentulous status and loose dentures were not documented, and another resident's unhealed pressure ulcers were omitted from the MDS, despite clinical records and staff interviews confirming these conditions.
Nursing Staff Lacked Competency in Operating Portable Oxygen Tanks
Penalty
Summary
Nursing staff failed to demonstrate competency in setting up and operating portable oxygen equipment for a resident who experienced acute shortness of breath. The facility’s oxygen administration policy required staff to assemble a portable oxygen cylinder and regulator, turn on the oxygen, and then apply the appropriate delivery device. A resident with diagnoses including congestive heart failure, chronic kidney disease, and diabetes reported being unable to breathe while on room air. Nursing assessment found the resident’s oxygen saturation to be low, and a nurse directed another nurse to obtain a portable oxygen tank from the unit’s code cart. The nurse reported that the regulator gauge on that tank showed it was empty, and a second tank obtained from another unit was also reported as appearing empty. Subsequent review and interviews revealed that neither oxygen tank was actually empty. The Staff Development Coordinator later inspected the tanks and stated that if the tank valve was not fully opened with the metal key on top of the tank, the regulator gauge would not accurately display the remaining oxygen and could falsely appear empty. In an interview, the nurse who retrieved the tanks admitted she did not know she needed to twist the top of the oxygen tank with the metal key to turn the oxygen on so that the gauge would show the true amount of oxygen available. Although facility leadership and the Staff Development Coordinator stated that this nurse had completed all required clinical competencies upon hire, including the steps needed to prepare a portable oxygen tank for use, the incident demonstrated that the nurse was unaware of the need to open the tank valve with the key in order to access and administer oxygen to the resident.
Failure to Provide Medical Records to Resident's Health Care Agent
Penalty
Summary
The facility failed to ensure a resident's rights regarding access to medical records were maintained when the resident's Health Care Agent (HCA), whose authority had been activated, requested copies of the resident's medical documentation. The HCA submitted a signed release form and made multiple requests for the records, both in writing and by phone, but did not receive the requested documentation. The facility's Medical Record Request log confirmed that requests were made on two separate occasions, but there was no indication that the records were provided. The resident involved had significant medical conditions, including Alzheimer's Disease, urinary tract infection, urinary retention, a history of falls, congestive heart failure, and malnutrition, and was assessed as severely cognitively impaired. Despite the facility's policy allowing residents or their representatives to obtain copies of records with proper notice and documentation, there was no evidence that the facility fulfilled the HCA's requests. The administrator confirmed that there was no documentation to support that the records had been provided as required.
Failure to Assist with Scheduling Podiatry Services
Penalty
Summary
The facility failed to provide appropriate foot care for one resident by not assisting in scheduling a podiatry appointment as requested. The facility's policy requires that residents be assisted in making appointments and with transportation to specialists as needed. Documentation showed that the resident's Health Care Agent requested podiatry services upon admission, and a physician's order allowed for a podiatry consult. However, there was no evidence in the clinical record that podiatry services were scheduled or provided. Interviews revealed that the resident had thick and long toenails, and the podiatrist's office confirmed they had not received a request for services from the facility. The DON described the process for scheduling podiatry services but was unable to provide documentation that the process had been followed for this resident. The resident was severely cognitively impaired, dependent on staff for care, and had multiple diagnoses, including Alzheimer's Disease and congestive heart failure.
Failure to Administer Medications Timely for Resident with GI Disorders
Penalty
Summary
Nursing staff failed to administer multiple prescribed medications to a resident with complex gastrointestinal conditions, including Parkinson's disease, ulcerative colitis, and an ileostomy, in accordance with physician orders and professional standards. The medications, which included Diphenoxylate-Atropine, Loperamide HCl, Cholestyramine, and Benefiber, were specifically ordered to be given at set times, often before meals, to manage the resident's loose stools and ileostomy output. Facility policy required medications to be administered within one hour of the prescribed time unless otherwise specified. Audit of medication administration records revealed repeated instances where these medications were given more than an hour late, and in several cases, after meals rather than before as ordered. These delays occurred on multiple dates and involved several scheduled doses, with some medications being administered up to two hours late. The late administration was confirmed by both the medication audit report and the Director of Nursing, who acknowledged that the medications were not given according to the physician's orders. The resident's representative reported that the untimely administration of these medications led to difficulties in managing the consistency and volume of the resident's ileostomy output. The facility's failure to provide timely medication administration did not meet professional standards of nursing care as outlined in facility policy and state regulations, which require nurses to implement prescribed medical regimens and adhere to accepted standards of practice.
Medication Reconciliation Error Leads to Significant Medication Error
Penalty
Summary
A deficiency occurred when a resident with Parkinson's disease was admitted to the facility and experienced significant medication errors due to inaccurate medication reconciliation. Upon admission, nursing staff incorrectly transcribed the resident's hospital discharge orders for Carbidopa-Levodopa, a medication critical for managing the resident's movement disorder. The hospital discharge summary specified that the resident should receive two tablets of both immediate release and extended release Carbidopa-Levodopa at specified times, but the orders entered into the facility's system only provided for one tablet of each formulation. As a result of this error, the resident received only half the prescribed dose of Carbidopa-Levodopa for multiple days. This discrepancy was identified after the resident reported symptoms to their representative, who then inquired about the medication regimen. Review of the Medication Administration Record confirmed that the resident had received the incorrect dosage on several occasions, both for the immediate release and extended release formulations. Interviews with facility staff, including the nurse responsible for the admission and the nursing supervisor, confirmed that the medication reconciliation process was not followed accurately. The nurse failed to correctly transcribe the hospital discharge medication list, and the error was not identified until after the resident had already received the incorrect dosages. The Director of Nursing acknowledged that the orders were entered incorrectly and that the resident was administered the wrong dose until the issue was corrected.
Failure to Implement Behavioral Health EKG Monitoring Recommendations
Penalty
Summary
The facility failed to implement the Behavioral Health Care Team's recommendation for a resident diagnosed with Parkinson's Disease, Obsessive Compulsive Disorder, and Dementia with psychotic disturbance. The resident was prescribed Seroquel, an antipsychotic medication known to have the potential to cause heart arrhythmias, which requires regular monitoring through an EKG to check for changes in the QTc interval. The Behavioral Health Nurse Practitioner recommended that an EKG be performed every six months to monitor for these potential side effects. Despite this recommendation, the resident's medical record showed that after a baseline EKG was completed prior to admission, the next EKG was not performed until 14 months later, rather than the recommended six-month interval. The Director of Nursing confirmed that a physician order for a follow-up EKG should have been implemented after the recommendation was made, but this did not occur, resulting in a failure to provide the appropriate monitoring for the resident while on Seroquel.
Failure to Perform Hand Hygiene During Meal Service
Penalty
Summary
During a breakfast meal observation on the 3rd Floor Unit, seven staff members, including nurses, CNAs, and a dietary aide, were involved in serving meals to ten residents in the dining room. The staff were observed serving food, pouring beverages, and clearing dirty tableware without performing appropriate hand hygiene between these tasks. Specifically, one CNA was seen handling dirty plates, cups, and utensils with bare hands and did not perform hand hygiene before serving other residents. Although a hand washing sink was available behind the steam table, none of the staff were observed using it for hand hygiene during the meal service. The facility's policy requires all food and nutrition services staff, including nursing personnel, to wash their hands before serving food and after handling soiled plates and food waste. However, staff did not adhere to these guidelines during the observed meal service. Interviews with staff and the Director of Nursing confirmed that the expectation is for staff to perform hand hygiene between serving each resident, and that staff have previously been educated on these practices. Despite this, no staff were observed following the required hand hygiene protocols during the meal service.
Inaccurate MDS Assessments for Dental Status and Pressure Ulcers
Penalty
Summary
The facility failed to accurately complete Minimum Data Set (MDS) assessments for two residents, resulting in deficiencies in the documentation of dental status and pressure ulcer presence. For one resident, who was admitted with cachexia, dysphagia, and malignant neoplasm, the clinical record and dental consult indicated the presence of full upper and lower dentures, both of which were loose fitting. The resident was edentulous and only wore the upper dentures for eating, while the lower dentures were never worn due to poor fit. Despite these findings, the MDS assessments consistently failed to document the resident's edentulous status and the presence of loose dentures, instead indicating no dentures or dental concerns. Interviews with staff confirmed the resident's dental status and the inaccuracies in the MDS coding. For another resident with diagnoses including diabetes mellitus type II, acute kidney failure, and dependence on renal dialysis, the care plan and treatment records showed the presence of an unstageable right heel pressure injury and a stage 2 pressure injury on the left foot. Wound care treatments were documented for both sites during the relevant observation period. However, the most recent MDS assessment did not reflect the presence of any unhealed pressure ulcers, contrary to the clinical documentation and wound assessment report. The MDS Coordinator acknowledged that the assessment should have been coded to indicate the pressure ulcers present during the look-back period. These deficiencies were identified through record review, direct observation, and staff interviews, which revealed discrepancies between the residents' clinical conditions and the information recorded in the MDS assessments. The failure to accurately code for dental status and pressure ulcers resulted in incomplete and inaccurate resident assessments.
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What surveyors actually found near you
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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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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) |
|---|---|---|---|---|
| Mission Care At Holyoke | 0.4 mi | ★★★★★ | 5 | 0 |
| Mary's Meadow At Providence Place | 0.7 mi | ★★★★★ | 4 | 0 |
| Vantage At West Springfield Llc | 1 mi | ★★★★★ | 10 | 0 |
| Massachusetts Veterans Home At Holyoke | 2 mi | — | 0 | 0 |
| Renaissance Manor On Cabot | 2.5 mi | ★★★★★ | 3 | 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.