Massachusetts Veterans Home at Holyoke

In the surveyor’s words

From the most serious findings on record at Massachusetts Veterans Home at Holyoke, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF700Jun 9, 2026

  Based on observations, interviews, and record review, the facility failed to ensure assessments which included review of risks including entrapment, were completed as required for six Residents (#62, #40, #4, #10, #3, and #81) of six applicable residents reviewed for bed rails use, and informed consent obtained for the use of bed rails for two Residents (#10 and #4), of the six applicable residents, out of a total sample of 27 residents, in addition to completing bed rail assessment for any resident using bed rails after September 2024. Specifically, the facility failed to: 1. […]

• No harm, potential for more than minimal, patternF585Feb 28, 2025

  Based on observation, interview, and record review, the facility failed to ensure the facility residents and resident representatives were informed on how to file a grievance and that grievance forms were readily accessible and/or available on eight Units (One North, Two North, Two East, Two South, Three East, Four East, Three [NAME] and Three North) out of ten units observed. Findings include: Review of the facility policy titled Grievance Policy, revised March 2021, indicated the following in part: -All veterans residing at the Soldiers Home in [NAME], their families and veteran representatives may voice a complaint or grievance. […]

• No harm, potential for more than minimal, patternF948Feb 28, 2025

  Based on observation, and interview, the facility failed to ensure that individuals who were utilized as paid feeding assistants, completed a State-approved training program. Specifically, the facility failed to ensure the program utilized by the facility to train Activities Staff was approved by the State of Massachusetts, as required. Findings include: During the entrance conference interview on 2/25/25 at 7:44 A.M., the Administrator and Director of Nursing (DON) said that the facility did not utilize paid feeding assistants. On 2/25/25 from 11:18 A.M. through 12:18 P.M., during a lunch meal observation on the Two North Unit, the surveyor observed Activities Assistant (AA) #1 assist in feeding some of the residents in the Unit Dining Room. On 2/27/25 from 11:26 A.M. […]

• No harm, potential for more than minimal, isolatedF921Jun 9, 2026

  Based on observation, record review, and interview, the facility failed to provide a safe, functional environment associated with following the manufacturer's guidelines for maintaining mechanical lift slings for three Residents (#49, #59, and #67) out of a total sample of 27 residents, who required the use of mechanical lift slings for transfers. Specifically, for Resident's #49, #59, and #67, the facility failed to ensure that mechanical lift slings were air dried after laundering, when facility staff did not follow the manufacturer instructions not to tumble dry and used the facility dryer to dry the mechanical lift slings, placing the residents at risk for the use of improper fitting slings shrunk by the dryer and associated discomfort and pain with sling use.Findings include:Review of… […]

• No harm, potential for more than minimal, isolatedF550Feb 28, 2025

  2. Resident #53 was admitted to the facility in December 2024 with diagnoses including Alzheimer's Disease and resided on the Two North Unit. Review of the Nutrition Care Plan, initiated 12/23/24, indicated Resident #53 was at nutrition/hydration risk related to Alzheimer's Disease and included the following interventions: -provide Pureed Diet with thin liquids (double portions) -Resident has slow swallow reflex, take time feeding him/her and allow the Resident to finish swallowing before continuing to feed him/her. -Takes thin liquids well, give small sips at a time. Review of the ADL Fact Sheet (utilized by the CNAs to indicate the Resident's specific care needs), printed on 2/28/25, indicated the following: -required total staff assistance with feeding On 2/25/25, from 11:18 A.M. […]