Quabbin Valley Healthcare

Inspectors wroteBased on observation, interviews and records reviewed for one of three sampled residents (Resident #2) who required dressing changes to a wound on his/her coccyx and per facility policy was to be placed on Infection Control precautions, the facility failed to ensure the required level of precautions were put in place and that nursing implemented and followed all necessary precautions during wound care dressing changes.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), whose comprehensive care plan indicated he/she required assistance of two staff members for bed mobility/positioning, the Facility failed to ensure staff consistently implemented and followed interventions in his/her care plan, when on 12/05/25, CNA #1 repositioned Resident #1 in bed without another staff member present to assist her, and he/she fell out of bed.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who required the assistance of two staff members for bed mobility and positioning, the Facility failed to ensure he/she was provided with the necessary level of staff assistance to maintain his/her safety to prevent an incident/accident, when on 12/05/25, during the provision of care, CNA #1 provided care to Resident #1 without having another staff member present to assist her, and Resident #1 fell out of bed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication pass error rate of less than five percent (%) for two Residents (#75 and #54), out of five applicable residents, out of 34 medication pass opportunities. The medication error rate was observed to be 5.88%. Specifically, 1. For Resident #75, the Resident was not encouraged to rinse his/her mouth and spit after the administration of an oral inhalation corticosteroid medication. 2. For Resident #54, the Resident was administered an oral medication that was dropped on the contaminated surface of the medication cart.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide a dignified existence for two Residents (#2 and #64), out of a total sample of 23 residents. Specifically, 1) For Resident #2, the facility failed to ensure privacy was provided before exposing the Resident's buttocks during a dressing change procedure, putting the Resident at risk of having their private parts viewed by others. 2) For Resident #64, the facility failed to ensure that the Resident was dressed in his/her clothing and not a hospital gown while in common spaces in the facility with other residents.

Inspectors wroteBased on interviews, and record reviews, the facility failed to implement abuse prevention policies and procedures relative to alleged incidents of potential abuse for two Residents (#16 and #66) out of a total sample of 23 residents. Specifically, the facility failed to implement their abuse policies and procedures, relative to prohibition, identification, and investigation, to determine whether abuse had occurred:a. For Resident #16, who was allegedly pushed and sworn at by Resident #66, and Nurse #9 as an agent of the facility did not report the incident as required for the investigation of all allegations.b. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide services that met professional standards of quality relative to medication management for two Residents (#75 and #54), out of a total sample of 23 residents. Specifically, the facility failed to: 1. For Resident #75, encourage the Resident to rinse his/her mouth as required after the administration of an oral corticosteroid inhalation medication, placing the Resident at risk of developing fungal infection of the mouth and airways. 2. For Resident #54, ensure that the Resident was not administered medication that was dropped on the medication cart surface, putting the Resident at risk of being administered contaminated medications.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide care consistent with professional standards of practice to prevent deterioration of a pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) for one Resident (#2) of two applicable residents reviewed for pressure ulcer care and services, out of a total sample of 23 residents. Specifically, for Resident #2, the facility failed to ensure that the dressing change for a Stage 4 Pressure Ulcer of the left and right buttocks was completed per Physician's orders, when collagen powder and Calcium Alginate AG were not administered as ordered, placing the Resident at risk for complications related to the pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care consistent with professional standards relative to an indwelling urinary catheter (a thin flexible tube inserted into the bladder to drain urine outside the body) for one Resident (#2), of two applicable residents reviewed for indwelling urinary catheter care and services, out of a total sample of 23 residents. Specifically, for Resident #2, the facility failed to obtain Physician's orders for the use of an indwelling urinary catheter placing the Resident at risk for urinary tract complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care and services for respiratory equipment was maintained in accordance with professional standards of practice related to cleaning, storage, and infection control practices for one Resident (#86) out of a total sample of 23 residents. [...]

Inspectors wroteBased on observation, interview, and record reviews, the facility failed to provide care and services consistent with professional standards of practice for dialysis (process that filters waste, salt, and fluid from your blood when the kidneys are unable to work adequately) services, for one Resident (#6) out of one applicable dialysis resident, out of a total sample of 23 residents. Specifically, for Resident #6, the facility failed to: -Accurately monitor daily fluid intakes as ordered by the Physician, when the Resident was dependent on Renal Dialysis, placing the Resident at risk for fluid status changes, difficulty breathing, edema (swelling caused by a buildup of fluids in the body's tissues) and dehydration (when the body uses or loses more fluid than it takes in).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that medications were stored in a safe and secure manner for one Resident (#123) out of a total of 23 sample residents. Specifically, for Resident #123, the facility failed to ensure that:-two over-the-counter medications were secured and not left at the Resident's bedside and readily accessible to other residents on the unit.-a Physician's order was obtained for the use of two over-the-counter medications brought into the facility by the Resident's family.-an assessment was completed to ensure the Resident was capable of self-administering medications.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to adhere to infection control standards of practice for one Resident (#2) out of a total sample of 23 residents and on one unit ([NAME]) out of four total units observed. Specifically, the facility failed to:1a.for Resident #2, ensure that staff performed hand hygiene as required between glove changes while providing wound care to the Resident.-b. ensure that staff wore the indicated Personal Protective Equipment (PPE: items such as gown and gloves used to mitigate the spread of infection) when providing care for a Resident who required Enhanced Barrier Precautions (EBP: protective barrier gowns and gloves used as an infection control intervention designed to reduce transmission of multi-drug-resistant organisms [MDRO] during high contact resident care).2. [...]

Inspectors wroteBased on interview, and record review, the facility failed to provide education on the benefits and risks of Pneumococcal Vaccination for one Resident (#15) of five applicable residents reviewed for vaccination, out of a total sample of 23 residents. Specifically, the facility failed to provide evidence that education was provided to the Resident #15's invoked Health Care Proxy (HCP) when the Resident was offered the Pneumococcal Vaccine and refused administration of the vaccine.

Inspectors wroteBased on record review, and interview, the facility failed to ensure that discharge tracking Minimum Data Set (MDS) Assessments were completed as required for three Residents (#25, #27, and #82) of four applicable residents, out of a total sample of 23 residents. Specifically, the facility failed to ensure that Discharge MDS Assessments were completed when Residents #25, #27 and #82 were discharged from the facility to the community. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to post required nurse staffing information daily that included the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift: registered nurses, licensed practical nurses or licensed vocational nurses, and certified nurse aides. Specifically, the facility failed to post the required nurse staffing information and the actual hours worked by licensed and unlicensed nursing staff on 8/6/25, 8/7/25, and 8/8/25.

Inspectors wroteBased on observations, records reviewed, and interviews, for two of three sampled residents (#3 and #1), who required the use of a wheelchair for mobility, the facility failed to ensure each residents room was equipped with or located near toilet/commode that they can access quickly, both residents ability to quickly access their bathrooms were restricted because the bathroom door size was smaller than the wheelchair.

Inspectors wroteBased on observation, interviews and record reviews, for 14 resident rooms that housed two residents per room, located on two of four nursing units, the facility failed to ensure each resident room measured the required square footage of 80 square feet per resident in a multi-bed bedroom.

Inspectors wroteBased on records reviewed, interviews, and observations, for one of three sampled residents (Resident #3), who resided on a secure unit, had a history of wandering on the evening shift, and staff said they needed to have their eyes on Resident #3 while he/she was ambulating on the unit, the Facility failed to ensure he/she was provided an adequate level of staff supervision in an effort to maintain his/her safety and prevent a fall resulting in an injury, when on 08/25/24, although Resident #3 was out of bed and ambulating in the hallway, he/she was not being supervised by unit staff, Resident #3 fell in the hallway, complained of pain, was transferred to the Hospital Emergency Department (ED) and diagnosed with intertrochanteric (hip) fracture of the left femur, which required surgical intervention to repair.

Inspectors wroteBased on interviews and records reviewed, for one of three sampled residents (Resident #1) whose behaviors included disrobing and unsafe rising, the Facility failed to ensure Resident #1 was treated in a dignified respectful manner which included being free from the use of a physical restraint imposed for the purpose of staff, when on 07/04/24 during the overnight shift, Certified Nurse Aide #1 placed a sheet across Resident #1's waist and tied it in the back of his/her reclining chair, to prevent Resident #1 from disrobing, while she left to provide care to other residents.

Inspectors wroteBased on interview and record review, the facility failed to obtain Physician's orders prior to obtaining laboratory testing for three Residents (#25, #103, and #112) out of a total sample of three residents. Specifically, the facility failed to: -For Residents #25, #103, and #112, obtain a Physician's order for COVID-19 rapid testing prior to administering a COVID-19 Rapid Test (type of COVID-19 testing which provides rapid test results) for each of the Residents. Findings Include: 1. Resident #25 was admitted to the facility in May 2024. Review of the Nursing Progress Note dated 6/7/24, indicated that Resident #25 was administered a COVID-19 rapid test. Review of Resident #25's June 2024 Physician's orders indicated no documentation that Resident #25 had an order for COVID-19 rapid testing. 2. Resident #103 was admitted to the facility in October 2023. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure the required transfer documentation was completed and that the transfer documentation communicated the appropriate information to the receiving health care institution for one Resident (#16), out of a total sample of 25 residents. Specifically, the facility failed to ensure Resident #16 was transferred to the emergency room with a form that included important information relative to the Resident's medical history and the reason for transfer, putting the Resident at risk for complications and adverse events upon transfer to the hospital.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary respiratory care and services in accordance with professional standards of practice for two Residents (#12 and #54) out of a total sample of 25 residents. Specifically, the facility failed to ensure that: 1. -Resident #12 was administered the appropriate liter per minute (LPM - flow rate of supplemental Oxygen [O2] ) of Oxygen as ordered by the Physician. -Resident #12's oxygen equipment was appropriately maintained in a safe and functional manner. 2. Resident #54's nebulizer set/tubing (drug delivery device used to administer medication in the form of a mist inhaled into the lungs) was changed weekly as ordered by the Physician.

Inspectors wroteBased on observation, record review and interview, the facility failed to maintain accurate medical records in accordance with professional standards and practices for one Resident (#54) out of a total sample of 25 residents. Specifically, for Resident #54 the facility staff inaccurately documented that a nebulizer (drug delivery device used to administer medication in the form of a mist inhaled into the lungs) set/tubing was changed as ordered.

Inspectors wroteBased on interview and record review, the facility failed to maintain infection control measures to prevent the development and transmission of communicable diseases and infections for one Resident (#25) and implement procedures for prevention of infection of one Resident (#111), out of nine applicable residents that had an indwelling urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag), out of a total sample of 25 residents. Specifically, the facility failed to: 1. For Resident #25, implement COVID-19 protocol for the Resident on Transmission Based Precautions (infection control precautions taken to prevent the spread of disease), to ensure that COVID-19 testing was done immediately during an outbreak once it was identified Resident #25 had possible signs and symptoms of COVID-19. 2. [...]

Inspectors wroteBased on interview, record and policy review, the facility failed to ensure that the Pneumococcal (any infection caused by bacteria called Streptococcus pneumoniae, or pneumococcus that can range from ear and sinus infections to pneumonia and blood stream infections) Vaccination was administered to two Residents (#16 and #23) for five applicable residents, out of a total sample of 25 residents, increasing the Resident's risk for facility acquired Pneumococcal infections. Specifically, the facility failed to: 1. offer and administer the Pneumococcal Vaccine to Resident #16 when he/she became eligible. 2. ensure that staff offered and administered an updated Pneumococcal Vaccination to Resident #23 within the appropriate timeframe as indicated by CDC (Centers for Disease Control) guidelines.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure 15 resident bedrooms measured the required square footage of 80 square feet per resident in a multi-bed bedroom. Specifically, Rooms 101 - 105, 107, 118 - 122, 124 - 126, and 128, were found to measure 75 square feet per resident, and not the required 80 square feet.

Inspectors wroteBased on record reviewed and interviews, for two of three sampled residents (Resident #1 who was severely cognitively impaired and required assistance from staff for mobility and Resident #2 who was cognitively intact and dependent on his/her call light to alert staff of his/her needs), the Facility failed to ensure they were free from abuse by a staff member when: A). On 03/28/24 at approximately 6:00 P.M., Certified Nurse Aide (CNA) #1, was witnessed by Visitor #1 as she forcefully transferred Resident #1 to his/her bed. CNA #1 was then witnessed by both Visitor #1 and Nurse #1, as she forcefully pushed Resident #1 down on his/her bed when he/she tried to get up. [...]

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #2), who was dependent on staff for all aspects of personal care including bed mobility and transfers, the Facility failed to ensure staff implemented and followed their Abuse Policy related to the need to immediately report an allegation of abuse to the Administrator and/or designee, when on 04/03/24, during the provision of morning care, Nurse Aide #A witnessed Certified Nurse Aide (CNA) #3 place Resident #2's call light out of his/her reach, and then tell Resident #2 that he/she was in a time-out however, Nurse Aide #A did not report the incident to the Director of Nurses (DON) until the end of his/her shift, at approximately 4:30 P.M. that day (approximately eight hours after witnessing the incidents).

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #2), the Facility failed to ensure that an allegation of abuse, was reported to the Department of Public Health (DPH) within two hours, as required, per Federal Regulations and Facility Policy. When on 04/03/24 at approximately 4:30 P.M. the Director of Nurses (DON) became aware of an incident that occurred earlier that day on the 7:00 A.M. to 3:00 P.M. shift, where the call light was deliberately removed from Resident #2's reach by Certified Nurse Aide (CNA) #3 who told Resident #2 that he/she could not have it because he/she was in a time-out, however the incident was not reported by the facility to the DPH until the following day on 04/04/24 at 8:16 A.M., more than 16 hours after they became aware of the allegation.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), whose Physician's Orders included the administration of an as needed (PRN) antidepressant medication (Trazodone), the Facility failed to ensure they maintained a complete and accurate medical record when nursing failed to accurately transcribe the medication order in to Resident #1's Medication Administration Record, by adding parameters not included in the the telephone order, which resulted in the medication being discontinued and unavailable for PRN use.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who was cognitively intact, the Facility failed to ensure staff implemented and followed their Abuse Policy when :1) on 11/08/23, Resident #1 reported to Nurse #2 that Nurse #1 had acted in a sexually inappropriate manner towards him/her, and although Nurse #2 became aware of the allegation on 11/08/23, she did not report the allegation to administration until the following day, and 2) a Massachusetts Nurse Aide Registry (NAR) check was not conducted on Nurse #1 (agency staff) prior to his date of employment at the Facility, in accordance with Facility Abuse Policy.

Inspectors wroteBased on observation, document review, and interview, the facility failed to provide a resident environment free of accidental hazards relative to accessibility of microwave ovens on resident units. Specifically, the facility failed to ensure its staff kept three out of three microwaves in common areas on resident units locked after it was determined by the interdisciplinary team (IDT) that all microwaves on resident units were to be locked for resident safety.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure its staff adhered to sanitary standards of practice during food distribution in the main kitchen and standards of practice for food storage in three out of three unit nourishment kitchens. Specifically, the facility failed to ensure: 1) dietary staff wore hair restraints to fully cover their hair and beard during meal service, 2) labeled and dated all resident food items, that outdated food items were not accessible for resident consumption and the nourishment kitchens were clean and free of dried food and debris on three out of three units.

Inspectors wroteBased on record review and interview, the facility failed to ensure its staff completed a Minimum Data Set (MDS) Assessment to accurately reflect the status of one Resident (#88), out of a total sample of 26 residents. Specifically, facility staff failed to accurately code Resident #88's risk for pressure ulcers (PUs-localized damage to the skin and/or underlying soft tissue, usually over a bony prominence or related to a medical or other device) and the presence of a Stage Three (full-thickness skin loss) PU on one MDS Assessment.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure its staff implemented the plan of care for two Residents (#88 and #232), out of a total sample of 26 total residents. Specifically, the facility failed to ensure its staff: 1) provided Resident #88 with appropriate air mattress settings and positioning in bed, according to the Resident's care plan, Wound Physician recommendations, and Physician orders, increasing the Resident's risk for development of, and worsening of a Stage Three pressure ulcer (PU), and 2) obtained weekly weights, according to the Dietitian's recommendation and the Physician's order for Resident #232 after identified weight loss.

Inspectors wroteBased on observation, record review, policy review and interview, the facility failed to ensure its staff provided necessary treatments related to the care of pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure on the skin) for one Resident (#131) out of three closed records, and one Resident (#107) out of three applicable residents, in a total sample of 26 residents. Specifically, the facility failed to: 1) for Resident #131, implement a Physician ordered treatment to a pressure ulcer, and 2) for Resident #107, obtain a Physician ordered treatment to a pressure ulcer following the removal of a wound vacuum (method of decreasing air pressure around a wound to assist with wound healing).

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure its staff provided appropriate care and services of an indwelling urinary catheter as required (a tube placed through the urethra into the bladder to drain urine), for one Resident (#120) out of a total sample of 26 residents. Specifically, the facility staff failed to ensure that Resident #120's indwelling catheter tubing was securely placed to prevent possible dislodgment and trauma.

Inspectors wroteBased on record review and interview, the facility failed to provide care and services consistent with professional standards for one Resident (#40), who required renal dialysis (a procedure to remove waste products and excess fluid from the body when the kidneys stop working), out of one applicable sampled resident, in a total sample of 26 residents. Specifically, the facility failed to ensure complete and accurate communication with the dialysis facility for the Resident's dialysis appointments.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure its staff provided two Residents (#46 and #65), with Dementia diagnoses with appropriate treatment to maintain their highest practicable level of mental and psychosocial well-being, out of 26 total sampled residents. Specifically, the facility staff failed to: 1) For Resident #46, provide appropriate interventions to assist with de-escalation when the Resident was disoriented, exit seeking, wandering, and disrobing during the overnight (11:00 P.M. through 7:00 A.M.) hours, and 2) For Resident #65, interact with the Resident who was awake and seated in a common resident area with five other residents, during an activity where staff interacted with all other residents in the area.

Inspectors wroteBased on record review and interview, the facility failed to ensure its staff maintained an infection prevention and control program to prevent the transmission of a communicable disease when the facility was experiencing an outbreak of COVID -19 infections. Specifically, the facility staff failed to assess two Residents (#114 and #115), out of five applicable residents, in a total sample of 26 residents, every shift for signs and symptoms of COVID-19, on a nursing unit where outbreak testing was being conducted.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure 15 resident bedrooms measured the required square footage of 80 square feet per resident in a multi-bedroom.