Mission Care at Holyoke

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1) who had a diagnosis of dementia with agitation and was looking for assistance from staff, the Facility failed to ensure he/she was treated in a dignified and respectful manner, when on 06/26/26, a staff member witnessed Certified Nurse Aide (CNA) #1 interact with Resident #1 in a demeaning and derogatory manner.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who had been allegedly witnessed by a staff member on 5/10/26 to have been subjected to verbal abuse by another staff member, the Facility failed to ensure staff consistently implemented and followed their Abuse Policy related to the requirement to immediately report an allegation of abuse to Facility Administration when the Director of Nursing was not notified until 06/01/26 about the incident, which had occurred several weeks earlier.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1) who was cognitively impaired and was dependent on staff to meet his/her care needs, the Facility failed to ensure nursing notified the Provider when he/she was observed to have a new area of bruising around the corner of his/her right eye, of unknown origin.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1) the Facility failed to ensure that after being made aware that Resident #1 had an injury of unknown origin on 11/11/25 by the Hospital, that they reported the injury to the Department of Public Health (DPH) within two hours as required, when it was not reported to DPH until 11/17/25, (6 days later).

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1) whose diagnoses included Post Traumatic Stress Disorder (PTSD) and anxiety, with behaviors that included repeatedly entering and exiting his/her room and pacing on the unit when anxious, the Facility failed to ensure that he/she was free from involuntary seclusion by means of confinement, when on 10/14/25 during the evening shift, Nurse #1 prevented Resident #1 from exiting his/her room by physically holding the door shut. Resident #1's anxiety escalated while he/she was confined to his/her room and he/she was heard crying, banging on the door and yelling to be let out.

Inspectors wroteBased on records reviewed and interviews, for two of four sampled residents (Resident #1 and Resident #4), the Facility failed to ensure staff implemented and followed their Abuse Policy related to the need to immediately report an allegation of abuse to Facility administration, when: 1.) On 10/14/25, Nurse #2 and Nurse #3 became aware during the evening shift, of an allegation of involuntary seclusion by means of confinement, when Nurse #1 prevented Resident #1 from exiting his/her room at will, however, neither of them reported the allegation immediately, as required. 2.) Certified Nurse Aide (CNA) #4 reported an allegation of verbal abuse involving Nurse #1 and Resident #4 on 10/02/25 to the Charge Nurse, however, Facility administration was not notified until a few days later, on 10/04/25.

Inspectors wroteBased on records reviewed and interviews, for one of four sampled residents (Resident #4), who was moderately cognitively impaired, the Facility failed to ensure that an allegation of verbal abuse was reported to the Massachusetts Department of Public Health (DPH) as required, when on 10/04/25, the Director of Nurses (DON) was made aware of the allegation made by Certified Nurse Aide #4 against Nurse #1, however, the Facility had not reported the allegation to DPH as of 11/25/25 (52 days later).

Inspectors wroteBased on interviews, and record reviews, the facility failed to address and implement licensed Pharmacist recommendations in a timely manner for two Residents (#106 and #117) of five applicable residents, out of a total sample of 24 residents. Specifically: 1. For Resident #106, the facility failed to implement the licensed Pharmacist's recommendation, which the Physician agreed with, to discontinue administration of a Multivitamin and initiate the use of Nephrocaps (vitamins for individuals with renal failure) when the Resident had a diagnosis of End Stage Renal Disease (ESRD) and administration of the Multivitamin was not recommended for use for individuals with an active ESRD diagnosis, increasing the Resident's risk for renal toxicity. 2. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure proper sanitation and food handling practices in the facility main kitchen and cleaning in three (Floor One, Two and Three) out of the three kitchenettes on the resident care units. Specifically, the facility failed to: 1. ensure that dietary staff maintained and performed appropriate hand hygiene practices while preparing and serving meals for residents in the facility main kitchen. 2. ensure that cooking utensils, dishes, and countertops were properly cleaned and sanitized in the facility main kitchen. 3. ensure that the kitchenettes on Floors One, Two and Three were properly cleaned, and that utensils were stored in accordance with food service standards, putting the residents at risk for foodborne illness, cross-contamination, and food contamination.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide a dignified existence by recognizing the individuality of one Resident (#1), out of a total sample of 24 residents. Specifically, for Resident #1, the facility failed to promote the dignity of the Resident when staff walked by, looked into the Resident's room, and failed to intervene and cover the Resident's lower body when he/she was observed from the hallway to be uncovered in bed with his/her underwear briefs clearly visible.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure a clean and homelike environment was maintained for one Resident (#48) out of a total sample of 24 residents. Specifically, for Resident #48, the facility failed to maintain a clean and homelike environment relative to G-tube (gastrostomy tube: medical device inserted into the abdomen to deliver food, fluids, medications) feeding equipment and the surrounding space in the Resident's room.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to notify the state mental health authority (Pre-admission Screening and Resident Review [PASRR] Office) promptly of the need for Resident Review for one Resident (#107) out of a total sample of 24 residents,when the Resident experienced a significant change in his/her mental condition from his/her initial Level I PASRR. Specifically, the facility failed to notify the PASRR Office of the need for Resident Review when Resident #107: -had diagnoses of Post Traumatic Stress Disorder (PTSD) and Personality Disorder. -newly expressed homicidal ideation (HI) and suicidal ideation (SI). -had psychotropic medication that was newly ordered and administered to the Resident to stabilize his/her mood.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to safely provide feeding assistance for two Residents (#14 and #5), out of a total sample of 24 residents, when both Residents required assistance for eating, putting both residents at risk for aspiration. Specifically, 1. For Resident #14, the facility failed to ensure that safe swallow strategies recommended by the Speech Therapist (ST) were implemented and that liquids provided to the Resident were the ordered consistency. 2. For Resident #5, the facility failed to ensure the Resident was provided with nectar (mildly) thick beverages during the breakfast meal.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide nutrition and hydration services as required for one Resident (#75) out of a total sample of 24 residents. Specifically, for Resident #75, the facility failed to provide health shakes as ordered at the breakfast meal, putting the Resident at risk for compromised nutritional status.

Inspectors wroteBased on observation, record review, and interview, the facility failed to assist one Resident (#89), out of a total sample of 24 residents, in obtaining routine dental services. Specifically, the facility failed to schedule dental appointments when consent was given, to ensure that Resident #89 received routine dental services as requested.

Inspectors wroteBased on observations, and interviews, the facility failed to adhere to infection control standards of practice while serving meals to residents on one Unit (3rd Floor) out of three Units observed. Specifically, the facility failed to ensure that staff distributing food during the lunch meal service on the 3rd Floor Unit performed appropriate hand hygiene to prevent contamination and the spread of foodborne illnesses.

Inspectors wroteBased on interview, and record review, the facility failed to uphold Resident Rights for one Resident (#70), out of a total sample of 24 residents, relative to rights exercised by the Resident's Representative. Specifically, for Resident #70, the facility failed to implement an effective discharge planning process including documentation of referrals made and response from referrals that focused on the Resident Representative's goals of discharging the Resident to a skilled nursing facility closer to involved family members, putting the Resident at risk of decreased family visits.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), whose care plan interventions included dependent with staff member assistance while eating, and that all food items were required to be pureed in consistency due to dypshagia (difficulty swallowing), the Facility failed to ensure nursing consistently implemented and followed interventions identified in his/her care plan related to eating. On 03/12/25 around 7:45 P.M., Certified Nurse Aide (CNA) #1 delivered Resident #1 a peanut butter and jelly sandwich as an evening snack to him/her in his/her room, CNA #1 did not remain with Resident #1 to assist him/her while he/she ate the sandwich, and left Resident #1 unsupervised with the sandwich, which was not the correct conisistency per his/her care plan. [...]

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who had a diagnosis of dysphagia (difficulty swallowing), with diet orders for pureed foods only and was dependent on staff to provide assistance when eating, the Facility failed to ensure he/she was provided with the necessary level of staff assistance while eating to maintain his/her safety to prevent an incident of choking. On 03/12/25 at around 7:45 P.M., Certified Nurse Aide (CNA) #1 delivered Resident #1 an evening snack which consisted of a peanut butter and jelly sandwich, to him/her in his/her room. CNA #1 did not remain with Resident #1 to assist him/her while he/she was eating, and left Resident #1 unsupervised with the sandwich. [...]

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1) who was cognitively intact, the Facility failed to ensure he/she was treated in a dignified and respectful manner, when on 12/09/24 during the day shift, Maintenance Assistant #1 hugged Resident #1 and kissed him/her on the mouth, without his/her consent, which made him/her feel uncomfortable.

Inspectors wroteBased on observation, interview, record and policy review, the facility failed to ensure that staff adhered to infection control standards for transmission-based precautions for two Residents #61 and #79, and on two Units (Unit One and Unit Three) out of three units observed to stop the spread of infection in the facility. Specifically, the facility failed to ensure: 1. On Unit One, for Residents #61 and #79, that staff wore the required personal protective equipment (PPE) when caring for COVID-19 positive residents, to mitigate the spread of infection during a COVID-19 outbreak in the facility. 2. On Unit Three, that staff performed hand hygiene after caring for a COVID positive resident, between contact with multiple residents to prevent contamination and mitigate the spread of infection during a COVID-19 outbreak in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide respiratory care and services consistent with professional standards of practice for one Resident (#44) out of a total sample of 24 residents. Specifically, the facility staff failed to: -Implement a schedule for cleaning and storage of Resident #44's BiPAP mask (a mask used in conjunction with a BiPAP device [non-invasive ventilation machine that is capable of generating two adjustable pressure levels ), placing the Resident at risk for nosocomial (healthcare associated) infections. -Clean and maintain the Resident's oxygen concentrator (medical device that uses air in the atmosphere, filters it, and delivers air that is 90 - 95% oxygen concentrated) filter in accordance with professional standards and placing the Resident at risk for impaired oxygen delivery and equipment malfunction.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide dialysis services consistent with professional standards of practice for one Resident (#94) out of a total sample of 24 residents. Specifically, the facility failed to: -consistently communicate the facility Nurse's assessment of the Resident prior to him/her going to dialysis. -collaborate with applying EMLA (Lidocaine) cream to the dialysis access site prior to the Resident leaving the facility to prevent pain when the dialysis site is accessed in the dialysis facility. -implement recommendations made by the dialysis center to remove pressure dressings within 24 hours of dialysis treatments to prevent clotting of the dialysis access site.

Inspectors wroteBased on record review and interview, the facility failed to ensure that one Resident (#96) out of a total sample of 24 residents was free from a significant medication error. Specifically, the facility staff failed to: -discontinue an order for an antipsychotic medication (medication used to treat certain types of mental health problems whose symptoms include psychotic experiences) dosage of 20 milligrams (mg) of Abilify, before administering the newly ordered dosage of 25 mg of Abilify resulting in the Resident receiving an excessive dosage (45 mg) of the medication, which was greater than the recommended maximum dosage of 30 mg daily.

Inspectors wroteBased on record review and interview, the facility failed to accurately execute Advance Directives (written documents that tells your health care providers who should speak for you and what medical decisions should be made, if you become unable to speak for yourself) for two Residents (#30 and #79) out of a total sample of 24 residents. Specifically, the facility failed to ensure that the MOLST (Massachusetts Medical Order for Life-Sustaining Treatment) decisions were made by: 1. Resident #30, who had not been deemed as lacking capacity for informed decision making by the facility's Physician instead of their Health Care Proxy (HCP-a legally designated person who can make medical decisions for a person deemed by a medical professional to be unable to make their own medical decisions). 2. [...]

Inspectors wroteBased on interview, policy and record review, the facility failed to implement the facility smoking policy one Resident (#22) out of a total sample of 24 residents. Specifically, for Resident #22 the facility failed to ensure that staff completed re-admission smoking evaluations after the Resident was hospitalized on two occasions.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure its staff prevented significant medications errors for two Residents (#29 and #111), out of 24 sampled residents. Specifically, 1) Nurse #9 administered 80 units of Humulin-N insulin (an intermediate acting Insulin that lowers blood sugar, its effect typically starts in 90 minutes and lasts 24 hours) to Resident #29 without a Physician's order and the Resident was subsequently transferred to the hospital for evaluation, and 2) Nursing staff omitted the administration of Insulin as ordered by the Physician for Resident #111.

Inspectors wroteBased on interview and record review, the facility failed to ensure its staff managed and monitored the psychotropic (a drug that affects brain activities associated with mental processes and behavior) medication regimen to promote and maintain the highest practicable mental, physical, and psychosocial well-being of four Residents (#36, #113, #272, and #41) out of 24 sampled residents. Specifically, facility staff failed to: 1) ensure residents (#36, #113, #272) were consistently monitored for medication side effects and that, 2) ensure an as needed (PRN) psychotropic medication was time limited and reevaluated as required (Resident #41).

Inspectors wroteBased on observation and interview, the facility failed to ensure its staff promoted care for residents in a manner and environment that maintained and enhanced each resident's dignity and respect, by neglecting to sit with residents while providing dining assistance on one unit (Unit Three) out of three units observed. Findings Include: Review of the facility policy Feeding (Dependent Feeding), revised 6/5/19, indicated the following: -Give resident your complete attention, sit so you are at the same level of the resident. During an observation on 12/27/22 at 9:55 A.M., during the breakfast meal on Unit Three, the surveyor observed Nurse #1 standing while assisting a resident with the breakfast meal. The surveyor noted there were multiple empty chairs throughout the dining area available for the Nurse to use. During an observation on 12/28/22 from 9:23 A.M. [...]

Inspectors wroteBased on observations and interview, the facility failed to provide reasonable and needed accomodations for one Resident (#19), out of a sample of 24 residents. Specifically, the facility staff failed to place a call bell within reach, making it impossible for the Resident to summon help when needed and placing him/her at increased risk for falls.

Inspectors wroteBased on interview and record review, the facility failed to ensure one Resident's (#40) personal care choices were honored, out of a total sample of 24 residents. Specifically, the facility failed to provide showers for the Resident per his/her request.

Inspectors wroteBased on interview and record review, the facility failed to ensure that its staff provided Physician notification when insulin (a medication that controls the amount of sugar in the bloodstream) was not available to be administered as ordered for one Resident (#111), out of 24 sampled Residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure its staff provided a clean home-like environment for two Residents (#21 and #36), out of a sample of 24 Residents. Specifically, the facility housekeeping staff failed to adequately clean wheelchairs so there was not a build up of food and other debris, that could potentially become a sanitary and safety concern. Findings Include: 1. Resident #21 was admitted to the facility in March 2021. During an observation on 12/28/22 at 8:23 A.M., the surveyor observed Resident #21 seated in his/her wheelchair. The surveyor observed the wheelchair to be filthy and appeared to not have been cleaned. The wheelchair had areas covered in a crusty white dried material, as well as a thick pink gummy substance. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that its staff assessed, monitored and evaluated the use of a physical restraint for one Resident (#79), out of a sample of 24 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its staff developed and implemented the plan of care for three Residents (#17, #21 and #52), out of a sample of 24 residents. Specifically, the facility staff: 1) failed to complete weekly skin checks for three Residents (#17, #21 and # 52), and 2) failed to provide an intervention intended to prevent a pressure injury for one Resident (#21), placing them at increased risk for acquired pressure injuries (injury to skin and underlying tissue resulting from prolonged pressure on the skin).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary treatment and services consistent with professional standards of practice, to promote healing of existing pressure ulcers (wounds caused by prolonged pressure on the skin) for one of four applicable residents (Resident #14), out of a total sample of 24 residents. Specifically, the facility failed to ensure that ordered wound care treatments and skin checks to identify new areas of concern were completed as ordered.

Inspectors wroteBased on observation, interview, and record review, the facility and its staff failed to ensure that the appropriate equipment and assistance to maintain and improve mobility were provided for two Residents (#1 and #41), out of 24 sampled residents with limited mobility. Specifically, the facility staff failed to ensure devices were applied as ordered to prevent and limit contractures (deformity and rigidity of joints resulting in decreased function).

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that its staff provided appropriate care and services for three Residents (#14, #112, and #75), out of three applicable residents, with urinary catheters (tubes that drain urine from the bladder to a collection device outside the body) out of a total sample of 24 residents. Specifically, the facility staff failed to indicate: A) catheter care had been performed, B) evidence of drainage bag changes and urinary output recording, C) that dignity was provided relative to catheter drainage bags, and D) follow infection control practices to prevent contamination and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its staff provided respiratory care consistent with professional standards of practice for one Resident (#1) with a tracheostomy tube (trach: a surgically created opening (stoma) from the neck to the trachea to create an airway for those unable to breathe through the nose or mouth), out of one applicable residents with tracheostomies, out of a total sample of 24 residents. Specifically, facility staff failed to keep a spare tracheostomy tube (trach tube: a tube inserted into the tracheostomy to maintain an open airway) at the bedside in the event of an emergency, and document trach tie changes as ordered.

Inspectors wroteBased on interviews and record review, the facility failed to ensure its staff provided care consistent with professional standards of practice for one Resident (#91), out of 4 residents receiving dialysis in a total sample of 24 residents. Specifically, the facility staff failed to communicate effectively with the dialysis center by sending the Resident with incomplete, pertinent clinical information.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its staff: 1) acquired and dispensed medication as ordered for one Resident (#111), out of 24 sampled residents, and 2) replaced an Insulin Emergency Kit (E-Kit) on one out of one unit where the Insulin Emergency kits were stored.

Inspectors wroteBased on interview and record review, the facility failed to ensure its staff responded to medication regime reviews (MRRs-pharmacy recommendations) timely and documented within the clinical record for two Residents (#113 and #41), out of a total sample of 24 residents. Findings Include: 1. Resident #113 was admitted to the facility in June 2022 with diagnoses including Bullous Pemphigoid (skin condition that can cause large blisters which can result in pain and itching), Vascular Dementia, antisocial personality disorder, and delusional disorder. Review of the Resident's medical record indicated MRRs were done by the Pharmacist on 7/20/22, 9/21/22, and 10/20/22 and recommendations had been made on each date. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that its staff stored drugs and biologicals in accordance with currently accepted professional principles on two of three units. Specifically, the facility failed to ensure: A) an unattended medication cart was locked, B) expired patient specific medications were removed from the medication cart and medication storage room, and C) that medication refrigerator temperatures were monitored to ensure vaccines was kept under appropriate temperature controls.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff obtained Physician's orders for COVID-19 testing prior to testing being conducted on two Residents (#12 and #88), out of a total sample of three residents. Findings Include: Review of the Centers for Medicare and Medicaid (CMS) Memo QSO-20-38-NH titled Interim Final Rule (IFC), CMS-3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements, revised 9/23/22, indicated the following: [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure that its staff accurately documented the use of a Continuous Positive Airway Pressure (CPAP) device (a machine that uses positive pressure to keep breathing airways open during sleep). Specifically, the facility staff failed to document the Resident's refusal of wearing the device.