Quabbin Valley Healthcare
Inspection Findings
F-Tag F0656
F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
falls to determine accuracy of resident care plans, to determine whether the resident Care Cards were consistent with their care plans, and whether any falls were as a result of staff failing to implement residents' care plans. F) On 12/12/25, the Unit Managers initiated weekly audits to ensure residents who require two persons for bed mobility, positioning and transfers were provided the appropriate level of staff assistance to prevent falls. G) The incident was presented and discussed at the December 2025 Quality Assurance Performance Improvement (QAPI) committee meeting. Audit results were reported to the QAPI committee and will be continued to be reported to the committee and remain ongoing until 100% compliance is met.H) The Administrator and/or her designee are responsible for overall compliance.
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
12/23/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Quabbin Valley Healthcare
821 Daniel Shays Highway Athol, MA 01331
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-Tag F0689
F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
said she did not know Resident #1 required two caregivers because she did not consult his/her Care Card.During a telephone interview on 12/26/25 at 11:52 A.M., the Administrator said she learned in morning report on 12/05/25 that Resident #1 had experienced a fall and it was reported that he/she was lowered to the floor with no injuries.The Administrator said on 12/08/25, she interviewed all staff that were present during his/her fall, and said CNA #1 told her she was providing care to Resident #1 without assistance from another staff member when he/she fell, that she was unaware Resident #1 required two caregivers for positioning and bed mobility and had not checked his/her Care Card prior to providing care.
The Administrator said Resident #1's Care Card clearly identified he/she was a two person assist with positioning, and said if there were two caregivers present, he/she would not have fallen.On the day of the survey, the facility provided the surveyor with a plan of correction, with an effective date of 12/16/25, that addressed the area of concern as follows:A) Resident #1 was assessed after his/her fall on 12/05/25, and he/she showed no signs of an injury or change in behavior as a result of the fall.B) On 12/08/25, when Resident #1 exhibited signs of discomfort, he/she was reassessed by nursing and the Nurse Practitioner, imaging studies were ordered, results were inconclusive, and he/she continued to be monitored by staff. C)
On 12/08/25, the Administrator initiated an investigation into the circumstances surrounding Resident #1's fall and determined his/her fall was the result of Certified Nurse Aide (CNA) #1 providing care to him/her without the assistance of another caregiver present. CNA #1 was immediately re-educated on the importance of reviewing the Care Card and ensuring she provides care consistent with the Care Card. D)
On 12/08/25, the Staff Development Coordinator (SDC) and/or her designee, initiated education for all clinical staff titled, Dependent Assist, one or two Caregivers, with the goal for nursing staff / CNAs to recognize and understand how to read and implement individual residents' needs in accordance with their Care Card. E) On 12/08/25, the Director of Nurses (DON) initiated a whole house audit of resident falls to determine accuracy of resident care plans, to determine whether the resident Care Cards were consistent with their care plans, and whether any falls were as a result of staff failing to implement residents' care plans. F) On 12/12/25, the Unit Managers initiated weekly audits to ensure residents who require two persons for bed mobility, positioning and transfers were provided the appropriate level of staff assistance to prevent falls. G) The incident was presented and discussed at the December 2025 Quality Assurance Performance Improvement (QAPI) committee meeting. Audit results were reported to the QAPI committee and will be continued to be reported to the committee and remain ongoing until 100% compliance is met.H)
The Administrator and/or her designee are responsible for overall compliance.
Event ID:
Facility ID:
If continuation sheet
QUABBIN VALLEY HEALTHCARE in ATHOL, MA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in ATHOL, MA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from QUABBIN VALLEY HEALTHCARE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.