Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Quabbin Valley Healthcare during CMS and state inspections, most recent first.
A resident admitted with a Stage II coccyx pressure injury and diagnoses including schizoaffective disorder and type 2 DM did not have required Enhanced Barrier Precautions (EBP) implemented per facility policy. The policy required EBP, including posted signage, a precaution cart with gowns and gloves, and use of gown and gloves during high-contact care such as wound care for any resident with a wound. During an observed dressing change, there was no EBP signage or cart at the room, and an RN wore only a mask and gloves, removed the old dressing, cleansed the open coccyx wound, applied Santyl, and redressed the wound without a gown. The RN stated she believed a gown was unnecessary because the resident did not have MRSA and there was no EBP sign, while the IP confirmed the resident should have been on EBP and a gown should have been used during wound care.
A resident with severe cognitive impairment and total dependence on staff for bed mobility was repositioned by a single CNA, despite a care plan and CNA Care Card specifying the need for two-person assistance. The CNA did not review the Care Card before providing care, leading to the resident sliding off the bed and falling. Staff interviews confirmed the care plan requirements were not followed.
A resident with severe cognitive and physical impairments, requiring two-person assistance for bed mobility and positioning, was cared for by only one CNA who did not consult the Care Card outlining this requirement. During care, the resident slid off the bed and fell to the floor, as the CNA was unable to prevent the fall alone. The incident occurred despite facility policies and accessible documentation specifying the need for two staff members for such care.
Two residents who required wheelchairs were unable to access the bathrooms in their rooms due to doorways that were narrower than their wheelchairs. One resident had to maneuver awkwardly to use the bathroom and often waited for a shared accessible bathroom, while another sustained a minor injury and was unable to use the toilet or sink, instead using a container to empty a urinary catheter. Staff confirmed that most wheelchairs could not fit through the bathroom doors on certain units.
Surveyors found that multiple rooms housing two residents each did not meet the required 80 square feet per resident, with at least one room measuring only 75 square feet per resident. The Administrator confirmed the deficiency and noted the rooms were in an older section of the facility.
A resident with a history of wandering and cognitive impairment fell and sustained a hip fracture due to inadequate supervision in a secure unit. The resident was ambulating in the hallway without staff supervision, as the supervising nurse was in a location without visibility of the hallway, and the CNAs were attending to another resident. The facility's policy required supervision during ambulation, which was not provided, resulting in the resident's fall and injury.
A resident with severe cognitive impairment was improperly restrained by a CNA using a sheet tied around their waist to prevent disrobing while the CNA attended to other residents. The restraint was discovered the next morning when another CNA attempted to transfer the resident. The facility's policy prohibits restraints for convenience, and the incident was confirmed as improper use of a physical restraint.
The facility failed to obtain physician's orders before administering COVID-19 rapid tests to three residents. Nursing progress notes indicated that the tests were conducted without documented orders in the residents' medical records. The Infection Preventionist confirmed the absence of orders and acknowledged that they should have been documented upon admission.
A resident with a history of Anxiety Disorder, COPD, and CHF was transferred to the hospital without the necessary documentation, including medical history and transfer reasons, as required by the facility's policy. The transfer form was initiated but not completed, and essential documents like Advanced Directives and provider information were not sent, putting the resident at risk for complications.
The facility failed to provide necessary respiratory care for two residents. One resident with COPD had an oxygen flow rate set higher than the physician's order, with frost on the equipment indicating improper maintenance. Another resident's nebulizer tubing was not changed weekly as ordered, and the treatment record inaccurately reflected changes. These issues demonstrate lapses in adhering to physician orders and maintaining equipment.
A facility failed to maintain accurate medical records for a resident with COPD, as the nebulizer tubing was not changed weekly as ordered. Despite documentation indicating changes on specific dates, the tubing was observed to be unchanged since a prior date. This discrepancy was confirmed by the Unit Manager, revealing a failure to adhere to professional standards.
A facility failed to follow infection control protocols for two residents. One resident, showing COVID-19 symptoms, was not tested immediately despite an outbreak, delaying testing by four days. Another resident's urinary drainage bag was improperly stored uncovered on a bathroom handrail, contrary to policy requiring it to be in a plastic bag. These deficiencies were confirmed by staff interviews and observations.
The facility failed to administer the Pneumococcal Vaccine to two residents, increasing their risk for infections. One resident with COPD was not offered the vaccine when eligible, despite previous vaccinations. Another resident with emphysema and chronic kidney disease was not given the PCV20 vaccine, despite being eligible and having consent from the Health Care Proxy. The Infection Preventionist and IP Nurse confirmed these oversights, leaving the residents at risk due to their high-risk environment and health conditions.
The facility failed to ensure that 15 resident rooms met the required 80 square feet per resident, with rooms measuring only 75 square feet. Despite this, the room sizes did not compromise resident health and safety. The Administrator requested a waiver from the Department of Public Health, citing cost prohibitions and potential loss of beds, but had not received a response.
The facility failed to protect two residents from abuse by staff members. One resident was forcefully transferred and pushed down onto their bed by a CNA, resulting in new bruises and fear. Another resident had their call light removed by a CNA, leaving them unable to request assistance. Both incidents were substantiated, and the CNAs involved were terminated.
A facility failed to ensure staff followed their Abuse Policy when a nurse aide witnessed a CNA place a resident's call light out of reach and did not report the incident until the end of their shift. The resident, who was dependent on staff for personal care and cognitively intact, confirmed the incident, which made them feel upset.
A facility failed to report an abuse allegation within the required two-hour timeframe. A resident's call light was deliberately removed by a CNA, and the incident was reported to the DON but not to the DPH until the following day, exceeding the mandated reporting window by more than 16 hours.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to implement its Enhanced Barrier Precautions (EBP) policy for a resident admitted with a Stage II pressure injury on the coccyx. The facility’s policy, effective 01/2023, required EBP for any resident with a wound, including chronic and surgical wounds, and specified that gowns and gloves must be worn for high-contact care activities such as wound care. The policy also required EBP signage to be posted outside the resident’s room and a precaution cart with gowns and gloves to be available, with precautions to remain in place for the duration of the resident’s stay or until the wound healed. Resident #2, admitted with diagnoses including schizoaffective disorder and type 2 diabetes mellitus, had a coccyx wound requiring daily dressing changes per physician order. On observation during a wound care dressing change, there was no EBP signage or precaution cart with gowns and gloves at the resident’s door, despite the resident meeting criteria for EBP under facility policy. The nurse performing the dressing change donned only a mask and gloves, did not wear a gown, and proceeded to remove the old dressing, cleanse the open, shallow coccyx wound with scant drainage and yellow tissue, apply Santyl, and place a new dressing. In interview, the nurse stated she did not think a gown was needed because the resident did not have MRSA and there was no EBP sign posted. The Infection Preventionist later confirmed that the resident should have been placed on EBP upon admission due to the presence of a wound and that the nurse should have worn a gown during wound care per facility policy.
Failure to Follow Two-Person Assist Care Plan Results in Resident Fall
Penalty
Summary
A deficiency occurred when a resident, who was severely cognitively impaired and dependent on staff for all activities of daily living, including bed mobility and positioning, was repositioned in bed by a single CNA without the required assistance of a second staff member. The resident's care plan and CNA Care Card both clearly indicated the need for two staff members to assist with bed mobility and positioning. Despite this, the CNA proceeded alone, resulting in the resident sliding off the bed and falling to the floor. The CNA involved stated that she was not familiar with the resident's care needs and did not check the Care Card prior to providing care. She had previously cared for the resident on a different unit but was unaware of the two-person assist requirement. Although another CNA was present in the room, she was attending to a different resident and did not assist or witness the fall. The facility's policy required all staff to be familiar with and follow the care plan, and the Care Cards were accessible at the nursing station for staff reference. Interviews with facility staff, including the unit manager and DON, confirmed that the resident was completely dependent on staff and that the Care Card accurately reflected the need for two-person assistance. The incident was witnessed and reported, and the CNA acknowledged not reviewing the Care Card before providing care, which directly led to the failure to implement the care plan as required.
Failure to Provide Required Two-Person Assistance During Bed Mobility Results in Resident Fall
Penalty
Summary
A deficiency occurred when a resident, who was severely cognitively impaired and dependent on two staff members for bed mobility and positioning, was provided care by only one CNA. The resident's care plan and CNA Care Card both indicated the need for assistance from two staff members for bed mobility and positioning due to significant physical and cognitive impairments, including unspecified dementia with agitation and adjustment disorder. Despite these documented requirements, the CNA did not consult the Care Card prior to providing care and was unaware of the resident's need for two-person assistance. During morning care, the CNA attempted to reposition the resident alone. While the CNA was preparing to provide incontinent care, the resident began to slide off the bed. The CNA tried to reposition the resident but was unable to prevent the resident from sliding off the bed and falling to the floor. Another CNA was present in the room but was attending to a different resident and did not assist with the care of the resident in question. The incident was witnessed, and the resident was assessed to have no injuries immediately following the fall. Interviews with staff confirmed that the CNA responsible for the resident's care did not check the Care Card and was not familiar with the resident's specific care needs. The facility's policy required all caregivers to be aware of and follow care plan interventions, and the Care Cards were accessible at the nursing station. The failure to consult the Care Card and provide the required level of assistance directly led to the resident's fall from bed during care.
Inaccessible Bathroom Facilities for Wheelchair Users
Penalty
Summary
The facility failed to ensure that residents who required the use of a wheelchair for mobility had access to a bathroom in or near their rooms that could be quickly and safely accessed. For two residents, the bathroom doorways in their rooms were narrower than the width of their wheelchairs, preventing direct entry. One resident, who was cognitively intact and required moderate assistance for transfers, had to position their wheelchair at an angle in the doorway and pull themselves up using a grab bar inside the bathroom, while staff stood outside the bathroom and out of reach. This resident reported difficulty accessing the bathroom and often had to wait to use a more accessible bathroom in the hallway, which was frequently occupied. Another resident, who had moderate cognitive impairment, neuropathic bladder, a colostomy, and chronic kidney disease, was unable to fit their wheelchair through the bathroom door and sustained a minor injury when attempting to enter. This resident was provided with a container to empty their urinary catheter bag because they could not access the toilet or sink in the bathroom. Staff interviews confirmed that the bathroom doors on certain units were too small for most wheelchairs, and the facility attempted to place only ambulatory residents in those rooms due to the limited doorway size.
Resident Rooms Below Required Square Footage
Penalty
Summary
The facility failed to ensure that 14 resident rooms, each housing two residents, met the required minimum of 80 square feet per resident in multi-bed rooms. On observation, one such room was measured at only 75 square feet per resident. This deficiency was identified through direct observation, interviews, and record review by surveyors. The affected rooms were located in a section of the facility built in 1958, and the Administrator acknowledged that these rooms did not meet the current size requirements. Despite the deficiency, surveyors noted that the room sizes did not compromise the health and safety of the residents at the time of the survey.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision to a resident with a history of wandering and cognitive impairment, resulting in a fall and injury. The resident, who resided on a secure unit, was known to wander during the evening shift and required staff supervision while ambulating. On the evening of the incident, the resident was ambulating in the hallway without supervision and fell, sustaining a hip fracture that required surgical intervention. The facility's policy required staff to supervise residents during ambulation, as indicated in the resident's care plan. However, on the night of the incident, the supervising nurse was in the Day Room, which did not allow visibility of the hallway where the resident was ambulating. The two CNAs on duty were attending to another resident, leaving the hallway unsupervised. This lack of supervision was a contributing factor to the resident's fall. Interviews with staff revealed that the resident was known to be up frequently and had a history of falls, including one in the previous month. Despite this, the staff did not maintain the required level of supervision. The unit manager and DON acknowledged that the resident should have been supervised during ambulation, but the staff failed to do so, leading to the resident's fall and subsequent injury.
Improper Use of Physical Restraint on a Resident
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, which were imposed for the convenience of staff rather than for medical treatment. The incident involved a resident with a neurocognitive disorder with Lewy body, dementia with behavioral disturbance, and delusional disorder, who was severely cognitively impaired. The resident frequently demonstrated behaviors such as disrobing and unsafe rising from a chair, particularly during the evening and overnight shifts. On the night of the incident, a Certified Nurse Aide (CNA) placed a sheet across the resident's waist and tied it behind the reclining chair to prevent the resident from disrobing while the CNA attended to other residents. The CNA did not seek assistance from other staff members, as they were busy, and forgot to untie the sheet before leaving at the end of the shift. The restraint was discovered the following morning when another CNA attempted to transfer the resident and found them unable to stand due to being tied to the chair. The facility's policy on physical restraints clearly states that residents have the right to be free from restraints used for discipline or convenience. The Director of Nurses confirmed that the use of the sheet as a restraint was inappropriate and not in line with the facility's restraint-free policy. The incident was substantiated as improper use of a physical restraint, leading to the termination of the CNA involved.
Failure to Obtain Physician's Orders for COVID-19 Testing
Penalty
Summary
The facility failed to obtain physician's orders prior to administering COVID-19 rapid tests for three residents. Specifically, the facility administered COVID-19 rapid tests to Residents #25, #103, and #112 without having documented physician's orders for these tests in their medical records. This oversight was identified through a review of nursing progress notes and physician's orders for each resident, which showed no documentation of orders for the COVID-19 rapid tests. During an interview, the Infection Preventionist confirmed that all residents should have a physician's order in place for COVID-19 rapid testing. Upon reviewing the medical records with the surveyor, the Infection Preventionist acknowledged that the orders were missing for the three residents in question. The Infection Preventionist noted that these orders should have been documented in the residents' medical records at the time of their admission to the facility.
Failure to Complete Required Transfer Documentation
Penalty
Summary
The facility failed to ensure that the required transfer documentation was completed and communicated appropriately when transferring a resident to the emergency room. Specifically, Resident #16, who had a medical history including Anxiety Disorder, COPD, and CHF, was transferred to the hospital without a form that included important information about the resident's medical history and the reason for the transfer. This lack of documentation put the resident at risk for complications and adverse events upon transfer to the hospital. The facility's policy on transfer and discharge procedures was not followed, as evidenced by the absence of discharge paperwork that should have included the resident's Advanced Directives, specific instructions or precautions for ongoing care, and provider information. During an interview, Unit Manager #2 confirmed that the necessary documentation, such as a transfer form, change in condition, and a Nurse's note, was expected to be completed but was not. The transfer form for Resident #16 was initiated but not completed, and the appropriate documentation was not sent with the resident to the hospital as required.
Deficiencies in Respiratory Care for Two Residents
Penalty
Summary
The facility failed to provide necessary respiratory care and services for two residents, leading to deficiencies in their care. Resident #12, who was admitted with acute respiratory failure and chronic obstructive pulmonary disease (COPD), was observed with a nasal cannula attached to a portable oxygen tank that had a buildup of frost. The oxygen flow rate was set at 6 liters per minute (LPM), exceeding the physician's order of 0-4 LPM. The frost on the tank and tubing indicated improper maintenance, and the nurse confirmed that the equipment should not have frost and the flow rate was set too high. Resident #54, also diagnosed with COPD, had a nebulizer device with tubing dated 5/27/24, which was not stored in a plastic bag as required. The physician's orders specified that the nebulizer tubing should be changed weekly on Sundays. However, the treatment administration record inaccurately indicated that the tubing had been changed on 6/2/24 and 6/9/24, while the actual tubing had not been changed since 5/27/24. The unit manager confirmed the discrepancy and acknowledged that the tubing was not changed or stored properly. These deficiencies highlight the facility's failure to adhere to physician orders and maintain respiratory equipment according to professional standards. The incorrect oxygen flow rate and improper maintenance of equipment for Resident #12, along with the failure to change and store nebulizer tubing for Resident #54, demonstrate lapses in the facility's respiratory care practices.
Inaccurate Medical Record Keeping for Nebulizer Tubing Change
Penalty
Summary
The facility failed to maintain accurate medical records for a resident with Chronic Obstructive Pulmonary Disease (COPD). The resident was admitted in January 2023 and had a physician's order to change all oxygen and nebulizer tubing weekly on Sundays, starting from February 2023. However, during an observation on June 11, 2024, the surveyor noted that the nebulizer tubing in the resident's room was dated May 27, 2024, indicating it had not been changed as per the weekly schedule. The Treatment Administration Record (TAR) inaccurately documented that the nebulizer tubing was changed on June 2 and June 9, 2024. Upon review, the Unit Manager confirmed that the tubing had not been changed since May 27, 2024, despite the TAR indicating otherwise. This discrepancy between the actual condition of the equipment and the documentation highlights a failure to adhere to the facility's policy and professional standards for maintaining accurate medical records.
Infection Control Deficiencies in COVID-19 Protocol and Urinary Catheter Storage
Penalty
Summary
The facility failed to implement COVID-19 protocols for a resident who was on Transmission Based Precautions. The resident began showing symptoms indicative of COVID-19, such as a productive cough, decreased appetite, nausea, and vomiting, on June 3, 2024. Despite the facility's policy requiring immediate testing of symptomatic individuals during an outbreak, the resident was not tested until June 7, 2024, after personally requesting a test. This delay occurred even though the COVID-19 outbreak on the unit was identified on June 1, 2024, and the resident's symptoms were documented in nursing progress notes. Another deficiency was identified concerning the storage of a urinary drainage bag for a resident with an indwelling urinary catheter. The facility's policy required that drainage bags be stored in a basin, covered with a plastic bag, and placed in the lower level of the nightstand when not in use. However, observations on June 11 and June 12, 2024, revealed that the urinary drainage bag was hanging uncovered on a bathroom handrail next to the toilet, with the connection tip touching the bathroom wall. This improper storage was confirmed by interviews with CNAs and the Unit Manager, who acknowledged that the bag should have been stored in a plastic bag to prevent contamination. The Infection Preventionist and other staff members confirmed that the facility's policies were not followed in both cases. The failure to adhere to the COVID-19 testing protocol and the improper storage of the urinary drainage bag were identified as deficiencies during the survey. These actions and inactions placed the residents at risk for infection and demonstrated a lack of compliance with established infection control measures.
Failure to Administer Pneumococcal Vaccines
Penalty
Summary
The facility failed to ensure the administration of the Pneumococcal Vaccine to two residents, increasing their risk for facility-acquired Pneumococcal infections. Resident #16, who was admitted in August 2018 with COPD, had received previous Pneumococcal vaccinations but was not offered the next appropriate dose when eligible in September 2023. The Infection Preventionist (IP) confirmed that the resident's record was reviewed, and the resident was deemed eligible for the vaccine, but it was not administered as required. Resident #23, admitted in September 2021 with emphysema and chronic kidney disease, was also not administered the PCV20 vaccine despite being eligible since November 2022. The resident's medical record indicated severe cognitive impairment, and the Health Care Proxy had consented to vaccinations per CDC guidelines. The IP Nurse acknowledged that the resident was not brought current with vaccinations, as directed by the physician, leaving the resident at risk for infections due to their high-risk environment, age, and comorbid conditions.
Deficiency in Resident Room Size
Penalty
Summary
The facility failed to ensure that 15 resident bedrooms met the required square footage of 80 square feet per resident in multi-bed rooms. Specifically, Rooms 101 - 105, 107, 118 - 122, 124 - 126, and 128 were found to measure only 75 square feet per resident. This deficiency was identified through observations made by the surveyor during the survey period. Despite the size discrepancy, it was noted that the room sizes did not compromise the health and safety of the residents residing in these rooms. The Administrator had previously sent a letter to the Department of Public Health on 5/30/24 requesting a waiver for the affected rooms, citing that the rooms were part of the facility's 1958 construction and that enlarging them would be cost prohibitive and could result in the loss of available resident beds. The Administrator had not yet received a response from the Department of Public Health regarding the waiver request.
Failure to Protect Residents from Abuse by Staff
Penalty
Summary
The facility failed to protect two residents from abuse by staff members. In the first incident, a Certified Nurse Aide (CNA) was witnessed by a visitor and a nurse forcefully transferring a severely cognitively impaired resident to their bed. The CNA was seen pushing the resident down onto the bed when they tried to get up, causing the resident to become visibly upset and fearful. A subsequent skin assessment revealed new bruises and reddened areas on the resident that were not present before the incident. The facility's internal investigation substantiated the physical abuse allegation, leading to the termination of the CNA involved. In the second incident, another CNA was reported by a nurse aide in training for removing the call light from a cognitively intact resident's reach and telling the resident they were in a time-out for using the call light too much. This left the resident without a means to request assistance. The resident confirmed that the CNA had taken their call light away on multiple occasions, making them feel upset and helpless. The facility's internal investigation substantiated the abuse allegation, and the CNA was terminated. Both incidents highlight the facility's failure to maintain an environment free from abuse, as required by their policy. The residents involved had specific medical conditions that made them particularly vulnerable, and the actions of the CNAs directly contradicted the facility's commitment to ensuring the safety and well-being of its residents.
Failure to Immediately Report Abuse Allegation
Penalty
Summary
The facility failed to ensure staff implemented and followed their Abuse Policy related to the immediate reporting of abuse allegations. On 04/03/24, during morning care, a nurse aide in training witnessed a CNA place a resident's call light out of reach and tell the resident they were in a time-out. The nurse aide did not report this incident to the Director of Nurses (DON) until the end of their shift, approximately eight hours later. The facility's policy mandates that any knowledge of abuse must be reported to the administration immediately, which was not adhered to in this case. The resident involved was admitted to the facility in May 2023 and had diagnoses including cerebral infarction and adjustment disorder with depressed mood. The resident was dependent on staff for all aspects of personal care and was cognitively intact, as indicated by a BIMS score of 13 out of 15. The resident confirmed that the CNA took their call light away, stating it made them feel upset. The DON confirmed that the nurse aide should have reported the incident immediately rather than waiting until the end of the shift.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse within the required two-hour timeframe as mandated by Federal Regulations and Facility Policy. On 04/03/24, the Director of Nurses (DON) became aware of an incident where a Certified Nurse Aide (CNA) deliberately removed a resident's call light, stating the resident was in a 'time-out.' This incident was reported to the DON at approximately 4:30 P.M., but the facility did not report the incident to the Department of Public Health (DPH) until the following day at 8:16 A.M., exceeding the mandated reporting window by more than 16 hours. The facility's policy clearly states that any suspected or confirmed abuse must be reported within two hours via the DPH portal, which was not adhered to in this case. The resident involved, admitted in May 2023, had diagnoses including cerebral infarction (stroke) and adjustment disorder with depressed mood. The DON conducted an interview with the resident on the same day of the incident, where the resident confirmed that the CNA had previously taken away the call light, citing 'time-out' as the reason. Despite substantiating the abuse allegation on the same day, the DON delayed reporting the incident to the DPH until the next morning. This delay in reporting constitutes a failure to comply with the facility's abuse policy and federal regulations, thereby compromising the resident's safety and well-being.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Athol
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alliance Health At Baldwinville | 10.8 mi | — | 10 | 0 |
| Applewood Center | 14.5 mi | — | 0 | 0 |
| Gardner Rehabilitation And Nursing Center | 14.7 mi | — | 13 | 0 |
| Wachusett Manor | 14.9 mi | — | 8 | 0 |
| Poet's Seat Healthcare Center | 16.1 mi | — | 0 | 0 |
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