Regalcare at Holyoke

Inspectors wrote4. Resident #44 was admitted to the facility in August 2023 with diagnoses including Peripheral Vascular Disease, Type 2 Diabetes, and Chronic Kidney Disease. Review of the MDS Assessment, dated 3/19/25, indicated Resident #44 utilized an anticoagulant (blood thinner) medication within the seven day look back period (3/13/25 through 3/19/25). Review of Resident #44's March 2025 Physician's orders failed to indicate any orders for an anticoagulant medication. Review of Resident #44's March 2025 Medication Administration Record (MAR) failed to indicate any documentation that Resident #44 was administered an anticoagulant medication during the month of March 2025. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that one Resident (#34), out of a total sample of 19 residents, was free from significant medication errors. Specifically, for Resident #34, the facility failed to ensure that the medication Ingrezza (Valbenazine Tosylate- a medication to treat Tardive Dyskinesia (TD) used to help reduce uncontrolled body movements) was transcribed accurately as prescribed by the Provider, resulting in missed medication administration for a total of ten occasions out of 47 opportunities, for May 2025 and June 2025, putting the Resident at risk for involuntary movements not being managed appropriately.

Inspectors wroteBased on record review and interview, the facility failed to ensure that a quarterly review assessment was completed as required to ensure critical indicators of gradual status change were monitored for one Resident (#58) out of a total sample of 19 residents. Specifically, for Resident #58, the facility failed to ensure that the Resident was reviewed between comprehensive assessments with respect to the Minimum Data Set (MDS) items specified in the quarterly assessment.

Inspectors wroteBased on record review and interview, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR - preadmission screening to identify residents with mental health disorders or intellectual disabilities) was accurately completed prior to admission for one Resident (#46), out of a total sample of 19 residents.

Inspectors wroteBased on record reviews, and interview, the facility failed to provide services that meet professional standards of quality for one Resident (#34), out of a total sample of 19 residents. Specifically, for Resident #34, the facility failed to administer the medication Ingrezza (Valbenazine Tosylate - medication used to treat tardive dyskinesia (TD) and help reduce uncontrolled body movements) as prescribed: -for increased involuntary movement symptoms when the medication was ordered to be administered daily. -when the medication was discontinued by facility staff, and was being administered without current Physician orders.

Inspectors wroteBased on record reviews, and interviews, the facility failed to ensure the environment remained free of accidental hazards and was safe for one Resident (#27), out of a total sample of 19 residents. Specifically, for Resident #27, the facility failed to ensure that the call bell was placed within reach for the Resident's use and that fall mats were appropriately implemented after the Resident sustained an unwitnessed fall.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services consistent with professional standards of practice for one Resident (#22), of one applicable resident receiving dialysis (process that filters wastes, salts and fluid from your blood when the kidneys are unable to work adequately) services, out of a total sample of 19 residents. Specifically, for Resident #22, the facility failed to ensure: -timely medication administration on the Resident's dialysis scheduled days, when scheduled morning medications were delayed in being administered until after the Resident's return to the facility in the early afternoon on Mondays, Wednesdays, and Fridays. [...]

Inspectors wroteBased on observation, interview and record reviews, the facility failed to ensure complete and accurate medical records were maintained for two Residents (#22, and #91), out of a total sample of 19 residents. Specifically, 1. For Resident #22, the facility failed to ensure accurate documentation of medications scheduled at 8:00 A.M., 8:30 A.M. and 9:00 A.M., were administered, when the Resident was out of the facility receiving dialysis services on Mondays, Wednesdays, and Fridays, and the medications were documented as being administered during the time the Resident was away at dialysis. 2. For Resident #91, the facility failed to ensure accurate documentation on the Skin Observation/ Assessment Tools and Nursing Evaluations when the Resident had a Stage 3 pressure area present on his/her coccyx.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections on one unit (Unit Four), out of three units and for two Residents (#37 and #70) residing on Unit Four. Specifically, the facility failed to implement Enhanced Barrier Precautions (EBP) when providing care on Unit Four: 1. For Resident #37, when the facility staff failed to wear the appropriate Personal Protective Equipment (PPE) when providing direct care for the Resident on EBP due to foot wound and a recent amputation. 2. For Resident #70, when the facility staff failed to don the appropriate PPE while providing high contact care for the Resident on EBP related to an indwelling urinary catheter.

Inspectors wroteBased on interview and record review, the facility failed to ensure Minimum Data Set (MDS) Assessments were completed and transmitted within 14 days of completion for two Residents (#26, #45) reviewed, out of a total of three residents reviewed for MDS records over 120 days, and for one Resident (#25) reviewed, out of a total of three resident reviewed for closed records. Specifically, the facility failed: 1. For Resident #26, to complete a Discharge MDS Assessment. 2. For Residents #45 and #25, to complete Death in the Facility Tracking Records resulting in inaccurate resident tracking.

Inspectors wroteBased on interviews and records reviewed for one of three sampled residents (Resident #1), who back in June 2024, alleged that during care by a staff member, he/she was physically abused, the Facility failed to ensure they reported the final results of their abuse investigation to the Department of Public Health (DPH) within five working days, when although an allegation of abuse, involving Resident #1 and Certified Nurse Aide (CNA) #1, was reported on 06/06/24, the final results of the investigation however, were not reported to the DPH until 10/01/24, almost four months later.

Inspectors wroteBased observations, interviews, policy and record review the facility failed to ensure that there was sufficient nursing staff to assist residents in attaining and maintaining the highest practicable physical, mental, and psycho-social well-being on three (Unit Two, Unit Three and Unit Four) out of three observed units. Specifically, the facility failed to: 1)Ensure sufficient staff as determined by the Facility Assessment 2)Ensure call bells were responded to timely for Residents #83 & Resident #22

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and implement policies, in accordance with applicable Federal, State and local laws and regulations regarding smoking for two Residents (#82 and #244) out of four applicable residents out of a total sample of 21 residents. Specifically, the facility failed to: 1. Ensure their smoking policy addressed what preventative measures were in place in the event of a fire emergency. 2. The facility failed to ensure they implemented their smoking policy relative to two Residents (#82 and #244) relative to possession of smoking materials.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure precautions are taken for the resident's individual safety relative to smoking. Specifically, the facility failed to: 1. Ensure fire prevention equipment was readily available in the smoking area to ensure a safe smoking environment. 2. Ensure the smoking plan of care was implemented for two Residents (#82 and #244) out of four applicable residents out of a total of 21 sampled residents relative to resident possession of smoking materials (Resident #82 and #244) and providing a safety intervention (smoking apron) (Resident #244 and #245) assessed to require one. 3. Ensure staff, who accompanied residents outside to smoke, were educated as to what safety interventions to implement in the event of an emergency relative to resident smoking.

Inspectors wroteBased on observations, interviews, and test tray results, the facility failed to serve palatable food at an appetizing temperature, to all residents, on three Units (Unit Two, Unit Three, and Unit Four) of three units observed as well as in the Main Dining Room.

Inspectors wroteBased on observation and interview the facility failed to ensure two Unit (Unit #3 and Unit #4) kitchenettes were maintained in a clean and sanitary manner out of three Unit kitchenettes observed.

Inspectors wroteBased on observations and interviews, the facility failed to ensure Administration and/or the Governing Body provided residents in the facility with appropriate care and services in order to maintain their highest practicable physical, mental, and psychosocial well-being. The facility failed to identify and implement plans to address numerous facility wide concerns, failed to fully assess the facility staffing needs in order to meet resident needs, and failed to ensure supplies for resident care were available and accessible.

Inspectors wroteBased on record review and interviews the facility failed to implement their grievance policy and assist one Resident (#56) to file a grievance out of a total sample of 21 residents. Specifically, the facility staff failed to follow up and investigate a report of a missing electric razor.

Inspectors wroteBased on interviews, records review and policy review, the facility failed to implement their abuse policies and procedures. Specifically; 1) The facility failed to investigate an allegation of abuse according to policy and procedure for one Resident (#30), out of a total of 21 sampled residents resulting in potential for psychological harm. 2) The facility failed to implement their employee screening procedures to ensure new employees have no previous abuse, neglect or mistreatment findings for one staff member (CNA #4) out of 5 staff members reviewed.

Inspectors wroteBased on observation, interviews, records review and policy review, the facility failed to prevent the potential for further abuse for one Resident (#30) out of a total of 21 sampled residents. Specifically, the facility failed to follow their policy and take steps to protect the Resident and prevent him/her from the potential of further abuse during an investigation of an allegation of abuse.

Inspectors wroteBased on record review and interview, the facility failed to provide recommended specialized services from the Preadmission Screening and Resident Review (PASRR- a federal and state-required process that is designed to, among other things, identify evidence of serious mental illness (SMI) and/or intellectual or developmental disabilities (ID/DD) in all individuals (regardless of source of payment) seeking admission to Medicaid- or Medicare-certified nursing facilities) Level II Evaluation (an evaluation conducted to determine if an individual who screened positive for an SMI or ID/DD requires specialized services), for one Resident (#21) out of 21 total residents sampled. Specifically, the facility failed to provide Resident #21 with individual psychotherapy as recommended by the Department of Mental Health (DMH) based on the PASRR Level II Evaluation.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure an intervention was implemented as recommended by the Wound Physician's Assistant (PA) for one Resident (#48) out of a total sample of 21 residents. Specifically, the facility failed to ensure a protective boot was obtained for Resident #48 as recommended by the Wound PA to protect the Resident's foot where he/she had a transmetatarsal amputation (TMA-surgical removal of part of the foot).

Inspectors wroteBased on record review an interview the facility failed to ensure one Resident (#12) out of a total of 21 residents sampled received proper treatment and assistive devices to maintain vision abilities. Specifically, for Resident #12 the facility failed to coordinate follow-up services relative to vision, after communicating his/her vision concerns.

Inspectors wroteBased on record review, policy review and interview, the facility failed to provide care and services consistent with professional standards for one Resident (#1) out of one applicable resident, out of a total sample of 21 residents. Specifically, the facility staff failed to coordinate delivery of medications with Resident #1's dialysis (procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) treatment schedule to ensure the Resident received all medication as ordered by the Physician.

Inspectors wroteBased on interviews, record review and review of the Facility Assessment (an assessment completed by the facility to identify what resources are necessary for competent care of residents on a day-to-day or emergency basis), the facility failed to ensure annual performance appraisals for Certified Nurse Aides (CNAs) were completed every 12 months. Specifically, the facility failed to ensure that two CNAs (#4 and #5) out of 2 applicable CNAs reviewed had an annual performance appraisal completed and ensured regular in-service education was completed based on the result of the performance appraisals.

Inspectors wroteBased on record review and interview, the facility failed to provide the necessary Behavioral Health care and services to attain or maintain the highest practicable mental, and psychosocial well-being for one Resident (#56), out of a total sample of 21 residents. Specifically, the facility staff failed to provide Behavioral Health Services for Resident #56 when he/she displayed symptoms of Depression (a common and serious mood disorder that may include symptoms of fatigue, sleep and appetite disturbances, agitation, and expressions of guilt, difficulty concentrating, apathy, withdrawal, and suicidal ideation).

Inspectors wroteBased on record review and interviews, the facility failed to provide specialized rehabilitation services for one Resident (#78) out of 21 total residents sampled. Specifically, for Resident #78 the facility failed to obtain specialized services relative to speech-language pathology for a Resident experiencing ongoing difficulty swallowing putting him/her at an increased risk of experiencing an adverse effect such as aspiration pneumonia (a type of lung infection that is due to a relatively large amount of material from the stomach or mouth entering the lungs) or choking.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff accurately coded Minimum Data Set (MDS) Assessments for three Residents (#9, #50, and #56) out of a total sample of 21 residents. Specifically, 1. For Resident #9 the facility failed to ensure the MDS Assessments were coded accurately related to the use of an anticoagulant medication (medication that thins blood), 2. For Resident #50 the facility failed to ensure the MDS Assessments were coded accurately related to the use of a pressure relieving device (mattress that assists in reducing the likelihood of a resident developing pressure ulcers) on the Resident ' s bed and the use of a restraint., 3. For Resident #56 the facility failed to ensure the MDS Assessments were coded accurately related to the use of an anticoagulant medication.

Inspectors wroteBased on observation, records reviewed and interviews, for one of three sampled residents (Resident #3), who was readmitted to the Facility with a reddened area to the coccyx (lower back), and was assessed by nursing as being at high risk for skin breakdown, the Facility failed to ensure that a comprehensive person-centered care plan based on his/her individual wound care needs for the promotion of healing or the prevention of worsening of wounds, which included and identified interventions, measurable objectives and desired outcomes was developed, and that interventions that were in place were consistently implemented by nursing, as a result Resident #3's wound deteriorated to an unstageable pressure injury (full-thickness skin and tissue loss that is obscured by eschar and slough- dead tissue). Findings Include: [...]

Inspectors wroteBased on observation, records reviewed and interviews, for one of three sampled residents (Resident #3), who was readmitted to the Facility with a reddened area to the coccyx (lower back), and was assessed by nursing as being at high risk for skin breakdown, the Facility failed to ensure Resident #3 received care and services consistent with professional standards of practice related to the promotion of healing or the prevention of worsening of his/her wound, when treatment orders were not implemented as ordered by the physician, the wound was not adequately assessed by nursing, and the wound deteriorated to an unstageable pressure injury (full-thickness skin and tissue loss that is obscured by eschar and slough- dead tissue). Findings Include: Review of the Facility's Policy, Pressure Ulcers/Injuries Overview, dated 03/2022, indicated the following: [...]

Inspectors wroteBased on interview and records reviewed, for two of three sampled residents (Resident #3 and #1), the facility failed to ensure they maintained a completed and accurate medical record (1) for Resident #3, Nursing documentation in his/her Treatment Administration Record (TAR) related to the application of Optifoam Dressing was inaccurate and the Certified Nurse Aide Activity of Daily Living (ADL) Flow sheet during the month of October 2023, was incomplete, (2) for Resident #1 his/her weekly skin observation tools were not completed by Nursing, as ordered by the Physician during the months of May 2023 and June 2023. Findings Include: Review of the Facility's policy, Pressure Ulcer/Injury Risk Assessment, dated 03/2022, indicated the type of skin care provided and the condition of the resident's skin (i.e. [...]

Inspectors wroteBased on records reviewed and interviews, the facility failed to ensure two Residents (#4 and #2) in a total sample of five residents were up to date with their Pneumococcal (name for any infection caused by bacteria called Streptococcus pneumoniae) Vaccinations, according to National standards for Pneumococcal Vaccination and the facility's policy. Specifically, the facility failed to: 1. Offer a Pneumococcal Vaccination to Resident #4 when the Resident had previously received one dose of the vaccine, but was not up to date with the Pneumococcal Vaccination series. 2. Determine whether Resident #2 was eligible to receive an additional dose of Pneumococcal Vaccine when staff failed to obtain the date Resident #2 received his/her first dose.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure its staff implemented the plan of care for two Residents (#44, and #174) out of 18 sampled residents. Specifically, failure to implement: 1. a) monitoring meal intake while transitioning from NPO (does not receive fluid or solids by mouth) to PO (does receive fluid or solids by mouth), b) monitoring weights, and c) fall safety interventions for Resident #44, 2. initiated the bowel regimen protocol as care planned for Resident #174, and 3. ensure Oxygen (O2) was delivered at the ordered flow rate for Resident #15.

Inspectors wroteBased on observations, interviews and policy review, the facility failed to ensure its staff stored and prepared food in accordance with professional standards for food service and safety. Specifically, they failed to ensure a sanitary environment in the facility main kitchen, as well as in three out of three unit kitchens.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure its staff maintained an infection prevention program to prevent the transmission of a communicable disease for one Resident (#223), out of a total sample of 18 residents. Specifically, they failed to: 1) utilize the appropriate personal protective equipment (PPE) while providing care to the Resident, and 2) initiate precautions appropriate to the Resident's condition.

Inspectors wroteBased on observation, interview, and record review, the facility and its staff failed to provide a dignified existence for two Residents (#8 and #174), out of a total sample of 18 residents. Specifically, the facility staff failed to: 1. provide a urinary catheter bag privacy cover (covers a catheter bag so urine is not visible) for Resident #8, and 2. provide activities of daily living (ADL) care that included removal of unwanted facial hair for Resident #174. Findings Include: 1. Resident #8 was admitted in April 2022 with a diagnosis of urine retention (the inability for a person to voluntarily release urine from the bladder). Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #8 had an indwelling foley catheter (tubing that is inserted into the bladder to help drain urine). [...]

Inspectors wroteBased on interview and record review, the facility and its staff failed to provide a notice of rights and services to residents during the residents stay.

Inspectors wroteBased on observations and interviews, the facility failed to ensure its staff provided a safe, clean, comfortable homelike environment on one (Unit Four) out of three units.

Inspectors wroteBased on interview and record review, the facility failed to ensure its staff referred one Resident (#2), out of a total sample of 18 residents, for a Level II evaluation (an evaluation to determine if a resident needs specialized services to address his/her Mental Illness (MI)) once it was identified post admission that the Resident had a diagnosis of MI. Findings Include: Resident #2 was admitted the facility in March 2022. Review of the Resident's Level I Preadmission Screening and Resident Review (PASRR-an evaluation to determine if a Resident has MI or Intellectual or Developmental Disability (ID/DD) and needs an additional Level II evaluation) dated 4/19/22, indicated Resident #2 did not have any diagnosis of MI. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure that its staff provided care and services in accordance with professional standards for one Resident (#46) with an intravenous line out of a total sample of 18 residents. Specifically, the facility failed to ensure staff developed and implemented measures to ensure the peripherally inserted central catheter (PICC: an intravenous line that is inserted in the arm, threaded through the veins and ends in the larger vein of the heart) was assessed for migration (movement), flushed to maintain patency and that the needleless connection caps were changed per facility policy and professional standards.

Inspectors wroteBased on interview and record review, the facility and its staff failed to ensure: 1. development of a policy that provided time frames for the different steps of the Medication Regime Review (MRR-review done by the facility Pharmacist that provides recommendations monthly for each resident regarding their medications), and 2. the attending Physician reviewed and documented they accepted and/or declined the MRR for one Resident (#43), out of a total sample of 18 residents. Findings Include: Review of the facility policy titled Medication Regimen Review (MRR), revised December 2019, indicated the following: -Recommendations are acted upon and documented by the facility staff and/or the prescriber. -Prescriber accepts and acts upon suggestion or rejects and provides an explanation for disagreeing. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure its staff limited a PRN (as needed) antipsychotic medication order to 14 days for one Resident (#43), out of a total sample of 18 residents. Findings Include: Resident #43 was admitted to the facility July 2022 with diagnoses including Vascular Dementia, Major Depressive Disorder, Anxiety Disorder, and was on Hospice Services. Review of the January 2023 Order Summary Report indicated the following order: -ABH gel (a topical gel used to treat terminal restlessness at the end of life made from the combination of Lorazepam (an antianxiety medication), Diphenhydramine (an antihistamine), and Haloperidol (an antipsychotic) . every four hours PRN with a start date of 10/17/22 and no stop date indicated. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure its staff provided specialized rehabilitative services relative to Speech and Language Pathology (SLP) for one Resident ( #44) out of a sample of 18 residents.

Inspectors wroteBased on observation and interview, the facility staff failed to ensure a secure handrail was in place on one Unit (Unit Three) out of three total Units.