Mission Care at Holyoke

In the surveyor’s words

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

• Immediate jeopardy, isolatedF656Apr 1, 2025

  Based 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 [DATE] 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. […]

• Immediate jeopardy, isolatedF689Apr 1, 2025

  Based 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 [DATE] 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. […]

• Actual harm, isolatedF603Nov 25, 2025

  Based 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. […]

• Actual harm, isolatedF760Jan 3, 2023

  Based 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. […]

• No harm, potential for more than minimal, patternF756Jun 10, 2025

  Based 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. […]