Quabbin Valley Healthcare
QUABBIN VALLEY HEALTHCARE in ATHOL, MA — inspection on December 23, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
12/23/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Quabbin Valley Healthcare
821 Daniel Shays Highway Athol, MA 01331
SUMMARY STATEMENT OF DEFICIENCIES
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.
Facility ID:
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.