Regalcare at Holyoke

In the surveyor’s words

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

• Actual harm, isolatedF656Oct 12, 2023

  Based 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… […]

• Actual harm, isolatedF686Oct 12, 2023

  Based 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). […]

• No harm, potential for more than minimal, widespreadF725May 24, 2024

  Based 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 Findings include: Review of the facility policy titled Emergency Staffing Strategies, dated September 2020, indicated but was no limited to the following: -In the event that sufficient staff is not available from the individual SNF's (Skilled Nursing Facility) workforce, the facilities… […]

• No harm, potential for more than minimal, widespreadF926May 24, 2024

  Based 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. […]

• No harm, potential for more than minimal, patternF641Jun 25, 2025

  4. 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. […]