Quabbin Valley Healthcare

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.

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