Federal inspectors found the facility violated its own infection control protocols when Resident #25 developed symptoms on June 3 but wasn't tested until June 7, when the resident asked staff for the test. The resident tested positive.
The outbreak on Resident #25's unit had already begun on June 1. The facility's own policy required immediate testing of any symptomatic resident during an outbreak.
"Resident #25 should have been tested immediately after showing possible signs and symptoms of COVID-19 on 6/3/24, and he/she was not tested until 6/7/24 when he/she requested to be tested," the infection preventionist told inspectors on June 17.
Nursing notes documented the resident's decline. On June 3, staff recorded productive cough, decreased appetite, nausea, vomiting and that the resident "was not feeling well." Two days later, notes showed the resident still had a productive cough and developed expiratory wheezing.
The facility's COVID-19 policy specifically states that during outbreaks, staff should "immediately test any symptomatic resident" and monitor all residents for respiratory changes like cough and shortness of breath, as well as gastrointestinal symptoms like diarrhea.
The infection preventionist confirmed that staff were supposed to monitor residents for these exact symptoms and test immediately when found. Instead, the resident had to ask for the test four days after symptoms began.
Catheter Equipment Left Exposed to Contamination
Inspectors also found infection control violations involving urinary catheter equipment storage that put another resident at risk.
Resident #111, who has moderate cognitive impairment and requires assistance with all care, had urinary drainage bags stored improperly in the bathroom. Instead of being placed in a basin and covered with a plastic bag as required by facility policy, the bags hung uncovered on a bathroom handrail next to the toilet.
On June 11, inspectors observed the drainage bag hanging on the handrail without any protective covering. The next day, they found the bag in the same location with the connection tip uncovered and touching the bathroom wall.
"Germs could get on the large urinary drainage bag if it was not kept clean in the plastic storage bag," said the certified nursing aide responsible for the resident's care. The aide acknowledged she had rinsed the bag with water and hung it on the handrail so staff would know where to find it, but admitted there was no plastic storage bag available in the room.
The facility's policy for indwelling urinary catheters states that "drainage bags should be placed in a basin, covered with a plastic bag and stored in the lower level of the nightstand when not in use."
Multiple staff members confirmed the improper storage violated policy. A unit manager said drainage bags should be placed in plastic bags in residents' bathrooms when not in use. The infection prevention nurse explained that uncovered storage "puts the resident at risk for urinary infection" because bacteria can contact the equipment.
Missing Physician Orders for COVID Tests
The same inspection revealed that three residents received COVID-19 rapid tests without proper physician orders. Residents #25, #103, and #112 all had the tests administered in early June, but none had documentation of physician orders authorizing the testing.
Nursing progress notes showed Resident #25 received a COVID test on June 7, Resident #103 on June 1, and Resident #112 on June 1. When inspectors reviewed the residents' physician orders for June 2024, they found no authorization for any of the COVID testing.
The infection preventionist acknowledged that all residents should have physician orders in place for COVID rapid testing, and that these orders should have been placed in the medical records when residents were admitted to the facility.
Falsified Treatment Records
Inspectors documented that staff falsified treatment records for a resident with chronic obstructive pulmonary disease who required weekly nebulizer equipment changes.
Resident #54's physician ordered that oxygen and nebulizer tubing be changed weekly on Sundays, starting February 5, 2023. The resident received nebulizer treatments four times daily for shortness of breath using a combination medication.
Treatment records showed the nebulizer tubing had been changed on June 2 and June 9. But when inspectors examined the actual equipment on June 11 and again on June 13, they found tubing dated May 27 — meaning it hadn't been changed for over two weeks.
A unit manager confirmed the tubing was dated May 27 and acknowledged that treatment records indicating changes on June 2 and June 9 were "inaccurate." The manager said the nebulizer tubing should be changed weekly but was not changed, and the documentation was false.
The facility's own policy requires dating equipment when changed or cleaned. The resident continued receiving daily nebulizer treatments through the contaminated tubing that should have been replaced weeks earlier.
Vaccination Gaps Leave Residents Vulnerable
Two residents didn't receive required pneumococcal vaccinations despite being eligible, leaving them at increased risk for serious infections.
Resident #16, who has chronic obstructive pulmonary disease, became eligible for an updated pneumococcal vaccine in September 2023 but never received it. The resident had received earlier pneumococcal vaccinations in 2009 and 2018, and the healthcare proxy had signed consent forms for vaccination.
The infection preventionist confirmed that a provider had recently reviewed the resident's record and determined eligibility for the next dose, but said "the Resident became eligible in September 2023 and should have been offered and administered the Pneumococcal Vaccination at that time."
Resident #23, who has emphysema and chronic kidney disease, became eligible for the PCV20 vaccine in November 2022 but also never received it. The resident's healthcare proxy had signed consent forms allowing vaccination per CDC guidelines.
The infection prevention nurse said the resident's physician had specifically directed staff to keep the resident current on all vaccinations when due, but acknowledged Resident #23 "had not been offered or administered the PCV20 as yet and so was at risk for Pneumococcal infections due to living in a high risk environment, age and comorbid diagnoses."
Room Size Violations Affect 15 Bedrooms
Fifteen resident bedrooms failed to meet minimum space requirements, measuring only 75 square feet per resident instead of the required 80 square feet for multi-bed rooms.
The undersized rooms — numbered 101 through 105, 107, and 118 through 128 — are located in the facility's 1958 construction. The administrator told inspectors that enlarging the rooms would be cost prohibitive and result in the loss of available beds.
The facility requested a waiver from the state Department of Public Health on May 30, 2024, but had not received a response by the time of the June inspection. Inspectors noted that the room sizes did not appear to compromise resident health and safety during their observations.
The violations occurred during a routine inspection that found problems spanning infection control, medication management, record keeping and facility standards at the 821 Daniel Shays Highway facility.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Quabbin Valley Healthcare from 2024-06-17 including all violations, facility responses, and corrective action plans.