Another resident witnessed the October 14 incident and immediately called family to report seeing "a Nurse holding a resident's door shut," according to the November 25 inspection report.
The trapped resident had been asking staff throughout the evening to help make their bed. Nurse #1 repeatedly told them that staff were busy with other residents but assured them someone would help soon, the nurse told inspectors during a phone interview.
But the resident kept leaving their room and voicing the same concern.
When the resident tried to exit through the partially closed door, Nurse #1 said he held it shut. During the phone interview, the nurse claimed he "held the door open to allow him/her to pass safely" and denied preventing the resident from leaving.
Two nursing assistants who provided care immediately after the incident told a different story. CNA #1 said the resident "appeared overwhelmed and very upset" during care afterward. CNA #2 helped get the resident back to bed.
Nurse #2, who was working the 7 a.m. to 7 p.m. shift that day, was passing medications on the opposite end of the unit when she heard Nurse #1 tell the resident to return to their room. She heard "a commotion" between them but couldn't see what happened.
Fifteen minutes later, when Nurse #2 returned to that end of the unit, she overheard Resident #2 on a cell phone telling someone about witnessing a nurse holding a resident's door shut.
The facility suspended Nurse #1 the next day, pending investigation.
The Director of Nurses told inspectors the facility's investigation "substantiated the allegation of involuntary seclusion." Nurse #1 was fired.
Federal inspectors cited the facility for failing to ensure residents were free from involuntary seclusion, finding the violation caused actual harm to few residents.
The resident who was trapped had been anxious and agitated that evening, seeking help with something as basic as making their bed. Instead of receiving assistance or appropriate redirection, they were physically prevented from leaving their room by a nurse who later denied the action despite witness accounts.
The incident occurred during evening shift change, when the nurse said staff were occupied providing care to other residents. But holding a door shut to confine an anxious resident seeking help violates federal regulations protecting residents' freedom of movement.
Mission Care at Holyoke, located at 35 Holy Family Road, terminated the nurse's employment after determining the involuntary seclusion allegation was substantiated through their internal investigation.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mission Care At Holyoke from 2025-11-25 including all violations, facility responses, and corrective action plans.