Mission Care At Holyoke

F 0603 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

know any better. CNA #2 said she provided care to Resident #1 immediately after the incident and assisted him/her back to bed. CNA #1 said that during care, Resident #1 appeared overwhelmed and very upset.

During an interview on 11/25/25 at 1:33 P.M., Nurse #2 said that she was working from 7:00 A.M. to 7:00 P.M. on Resident #1's unit on 10/14/25. Nurse #2 said that shortly before shift change that evening, she was

on the opposite end of the unit passing medications when she heard Nurse #1 tell Resident #1 to return to his/her room. Nurse #2 said she heard a commotion between Resident #1 and Nurse #1, but siad she was not in a position to see what occurred. Nurse #2 said that approximately 15 minutes later, when she arrived back on that end of the unit, she overheard Resident #2 on his/her cell phone stating that he/she had witnessed a Nurse holding a resident's door shut. During a telephone interview on 11/26/25 at 10:43 A.M., Nurse #1 said that on the evening of 10/14/25, Resident #1 was very anxious, agitated and repeatedly requesting assistance from a CNA to make his/her bed. Nurse #1 said that he informed Resident #1 several times that staff were occupied with providing care to other residents but assured him/her that someone would assist him/her as soon as possible. Nurse #1 said he redirected Resident #1 to go back to his/her room several times; however, he/she continued to leave the room and repeatedly voiced the same concern.

Nurse #1 said that at one point Resident #1 began to exit his/her room through the partially closed door, and that he held the door open to allow him/her to pass safely. Nurse #1 said he did not at any time hold the door closed to prevent Resident #1 from exiting. During an interview on 11/25/25 the Director of Nurses (DON) said that Nurse #1 was suspended on 10/15/25, pending investigation. The DON said that the Facility's investigation substantiated the allegation of involuntary seclusion and as a result and said that Nurse #1 employment with the Facility was terminated.

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Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Mission Care at Holyoke

35 Holy Family Road Holyoke, MA 01040

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

exiting his/her room. During a telephone interview on 12/04/25 at 1:44 P.M., (which also included a review of her written witness statement dated 10/15/24) Nurse # 3 said that while she was the acting Supervisor

during the evening shift on 10/14/25, Resident #2 reported to her that he/she witnessed an altercation between Resident #1 and Nurse #1. Nurse #3 said that around 8:00 P.M., Resident #2 reported that earlier that evening, he/she saw Nurse #1 hold Resident #1's door closed, while he/she (Resident #1) was inside

the room, preventing him/her from leaving the room. Nurse #3 said she observed that Resident #1 was in bed, watching television and appeared safe, therefore she did not further investigate the allegation and did not report it to Facility administration. During an interview on 11/25/25 at 2:00 P.M., the Director of Nurses (DON) said that Nurse #2 and Nurse #3 did not immediately report the allegation to Facility administration as required. The DON further said that she was not notified about the incident until it was reported to her by Resident #2 on the morning of 10/15/25. 2). Resident #4 was admitted to the Facility in April of 2021 with diagnoses including moderate dementia with mood disturbance, major depressive disorder and anxiety disorder.Review of Resident #4's Quarterly MDS assessment, dated as completed 09/07/25, indicated he/she was moderately cognitively impaired with a score of 9 out of 15 on the BIMS. Review of Certified Nurse Aide (CNA) #4's Written Statement, dated 10/04/25, indicated that on the previous Thursday (10/02/25), when CNA #4 attempted to provide care to Resident #4, he/she refused care and was yelling loudly. The Statement indicated that Nurse #1 told Resident #4, You are a faggot racist and that is why you won't let her clean you.During an interview on 11/25/25 at 2:47 P.M., CNA #4 said that one day she had worked in early October 2025, she reported to Nurse #1 that Resident #4 had refused care. CNA #4 said that Nurse #1 responded by confronting Resident #4, accusing him/her of being racist, and called him/her a faggot. CNA #4 said that she reported the incident to the Charge Nurse. CNA #4 further said that although

she could not recall the date of the incident during the interview, it was documented in the written witness statement that she provided to Unit Manager #1.CNA #4 said that (10/02/25) was not the first time she had witnessed Nurse #1 call Resident #4 a faggot racist although she could not recall details or dates for any of

the previous incidents and further said that she had not reported them to her supervisor.During an interview

on 11/25/25 at 3:44 P.M., Unit Manager #1 said that while she was acting as the weekend supervisor on 10/04/25, a Charge Nurse reported that CNA #4 told her that Nurse #1 had called Resident #4 a faggot racist. Unit Manager #1 said that the Charge Nurse did not report the allegation to Facility administration immediately as required.Unit Manager #1 said that both the Charge Nurse and CNA #4 should have reported the allegation to Facility administration immediately. During an interview on 11/25/25 at 4:28 P.M.,

the Director of Nurses (DON) said that on 10/04/25 Unit Manager #1 reported CNA #4's allegation involving Nurse #1 and Resident #4, and that CNA #4 could not recall the exact date of the incident. The DON said that it wasn't until she reviewed CNA #1's written statement, dated 10/04/25, that she noticed the incident had occurred on the previous Thursday, (two days earlier).During an interview on 11/25/25 at 4:45 P.M. the Administrator said the expectation is for all allegations of suspected abuse to be reported to Facility administration immediately.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Mission Care at Holyoke

35 Holy Family Road Holyoke, MA 01040

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Based on records reviewed and interviews, for one of four sampled residents (Resident #4), who was moderately cognitively impaired, the Facility failed to ensure that an allegation of verbal abuse was reported to the Massachusetts Department of Public Health (DPH) as required, when on 10/04/25, the Director of Nurses (DON) was made aware of the allegation made by Certified Nurse Aide #4 against Nurse #1, however, the Facility had not reported the allegation to DPH as of 11/25/25 (52 days later).Findings include:Review of the Facility Policy titled Resident Abuse (Screening, Training, Prevention, Reporting, Investigation)-MA, dated as effective 11/03/20, indicated it is the policy of the Facility that abuse, neglect, exploitation, and/or mistreatment of residents or misappropriation of resident property is prohibited. Further

review of the Policy indicated allegations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of property are to be reported to the Massachusetts Department of Public Health:a. Immediately but not later than two hours after the allegation is made if the allegations involve abuse or result in serious bodily injury or if there is reasonable suspicion of a crime as defined by

the Elder Justice Act.b. No later than 24 hours if it does not involve abuse or serious bodily injury.Resident #4 was admitted to the Facility in April of 2021 with diagnoses including moderate dementia with mood disturbance, major depressive disorder and anxiety disorder.Review of Resident #4's Quarterly Minimum Data Set (MDS) assessment, dated as completed 09/07/25, indicated he/she was moderately cognitively impaired with a score of 9 out of 15 on the Brief Interview for Mental Status (BIMS, scores indicate: 0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, and 13-15 cognitively intact). Review of Certified Nurse Aide (CNA) #4's Written Statement, dated 10/04/25, indicated that on the previous Thursday (10/02/25), when CNA #4 attempted to provide care to Resident #4, he/she refused care and was yelling loudly. The Statement indicated that Nurse #1 told Resident #4, You are a faggot racist and that is why you won't let her clean you. During an interview on 11/25/25 at 2:47 P.M., CNA #4 said that in early October 2025, she had reported to Nurse #1 that Resident #4 had refused care. CNA #4 said that Nurse #1 responded by confronting Resident #4, accusing him/her of being racist, and called him/her a faggot. CNA #4 said that she reported the incident to the Charge Nurse. CNA #4 further said that although she could not recall the date of the incident during the interview, it was documented in the written witness statement that

she provided to Unit Manager #1.Review of the Health Care Facility Reporting System (HCFRS), indicated that between 10/02/25 and up to the date of survey (11/25/25) the Facility had not reported any incidents involving Nurse #1 and Resident #4.During an interview on 11/25/25 at 3:44 P.M., Unit Manager #1 said that while she was acting as the weekend supervisor on 10/04/25, a Charge Nurse reported that CNA #4 had alleged that when she told Nurse #1 that Resident #4 had been combative during care, Nurse #1 had confronted Resident #4, accused him/her of being racist, and called him/her a faggot. Unit Manager #1 said that when she spoke to Resident #4, he/she was unable to recall any incidents with Nurse #1, and only told her, That Nurse (#1) doesn't like me. Unit Manager #1 said she instructed CNA #4 to complete a written witness statement about the incident, and she reported the allegation to the Director of Nurses (DON).During an interview on 11/25/25 at 4:28 P.M., the Director of Nurses (DON) said that on 10/04/25,

she was notified that CNA #4 had witnessed Nurse #1 direct a derogatory slur at Resident #4, and that CNA #4 said she could not recall the exact date the incident occurred. The DON said that when she reviewed CNA #4's Written Witness Statement, she felt it conflicted with her (CNA #4's) verbal statement, and that she (the DON) did not feel it was specific enough to investigate or to report to DPH.

Event ID:

Facility ID:

If continuation sheet