Care One at Holyoke

In the surveyor’s words

From the most serious findings on record at Care One at Holyoke, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF880Apr 5, 2023

  Based on observation, interview, and policy review, the facility failed to ensure its staff used proper hand hygiene techniques on one unit (Deerfield) out of four units observed, and for one Resident (#66) out of a total sample of 32 residents. Specifically, Nursing staff failed to: 1. properly handle medications in a way as to reduce the risk for the spread of possible contaminates from bare hands to pills being distributed to residents on the Deerfield unit, and 2. properly don (put on), doff (take off), and perform hand hygiene per facility policy when providing wound care treatments for Resident #66 who had multiple wounds and a diagnosed wound infection. Findings include: 1. […]

• No harm, potential for more than minimal, patternF761Aug 2, 2021

  Based on policy review, observations and interviews, the facility failed to 1.) Ensure one medication cart on two of four units observed were clean and orderly and 2.) The facility failed to ensure one of two medication refrigerators inspected were at the required temperature setting. Findings include: Review of the facility Storage of Medications Policy, revised November 2020, included: - The facility stores all drugs and biologicals in a safe, secure and orderly manner. - Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. […]

• No harm, potential for more than minimal, patternF842Aug 2, 2021

  Based on observations, record reviews and interviews, the facility failed to ensure accurate and/or complete medical records for four sampled Residents (#23, #66, #57 and #35), out of a total sample of 30 residents. Findings include: 1. For Resident #23, the facility failed to ensure an accurate medical record relative to the administration of oxygen therapy. Resident #23 was admitted to the facility in March of 2016 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD- condition involving constriction of the airways and difficulty or discomfort in breathing). On 7/27/21 at 9:27 A.M., the surveyor observed Resident #23 seated in a wheelchair in his/her room. […]

• No harm, potential for more than minimal, isolatedF761Sep 17, 2025

  Based on observation, and interview, the facility failed to ensure that the medication storage room was locked when unattended for one unit ([NAME] Unit), out of four medication storage rooms observed. Specifically, the facility failed to ensure:-For the [NAME] Unit, that the medication storage room was locked when not in use and was under direct supervision of authorized personnel when unlocked, when facility staff permitted unauthorized Maintenance Personnel access to the medication storage room which contained medications and treatments that were not secured and easily accessible, and the Maintenance Personnel was observed to prop open the medication storage room door and leave it unattended and unsecured on two occasions. […]

• No harm, potential for more than minimal, isolatedF551Apr 5, 2023

  Based on interviews and record review, the facility failed to ensure its staff: 1) received consent from the activated Health Care Proxy (HCP- person designated to make health care decisions on behalf of a person determined to not be able to make those decisions) for one Resident (#129) out of a total sample of 32 residents, prior to administering a medication used to treat mood and behavior, and 2) have the designated HCP sign required written consents. Findings include: Review of the facility policy titled Psychotropic Medication Use, edited 2/2/23, included the following: -a psychotropic medication is any medication that affects brain activity associated with mental processes and behavior -categories of medications that affect brain activity such as antihistamines (medications used… […]