Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 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.
Medication Pass Error Rate Exceeded: Two residents were involved in medication pass errors that resulted in an observed error rate above 5%. One resident received Symbicort inhalation without the nurse ensuring the resident rinsed and spit after use, despite the order and inhaler instructions. Another resident’s Keppra tablet was dropped on the medication cart surface and then picked up and placed with the resident’s other meds for administration, even though the cart had not been cleaned or disinfected.
Failure to protect resident privacy and dignity: one resident was exposed during wound care without adequate curtain coverage, allowing visibility from the doorway, and another resident was observed in the day room wearing a hospital gown instead of clothing. Staff acknowledged the privacy lapse and that the resident in common areas should have been dressed in clothing.
The facility failed to follow its abuse policies when an LPN did not report and the facility did not investigate an alleged resident-to-resident incident involving two cognitively impaired residents. One resident had a history of aggression and behavioral symptoms, and nursing notes documented agitation, hitting, yelling, and pushing other residents. The LPN stated the resident pushed another resident’s wheelchair and swore at the resident, but did not notify supervision because there was no physical contact with the resident.
Two medication administration errors were observed during med passes. An RN gave a resident Symbicort but did not ensure the resident rinsed and spit afterward as ordered, and another RN dropped a Keppra tablet on the med cart, picked it up, and administered it with other meds from a souffle cup. Both nurses stated their actions did not meet professional standards.
A resident with two Stage 4 pressure ulcers on the buttocks did not receive wound care as ordered. During observed dressing changes, an RN used collagen matrix and regular Calcium Alginate instead of the ordered collagen powder and Calcium Alginate AG, then covered the wounds with foam dressings. The RN stated the wrong products were used and that the incorrect dressing could result in the wound worsening.
A resident with metabolic encephalopathy and a BIMS score of 14/15 used an indwelling urinary catheter, but the chart lacked a physician order for the catheter, including the catheter size, balloon size, and change frequency. During observation, the catheter tubing was secured to the resident's leg and the drainage bag was secured below the level of the bladder; the UM confirmed the required order was missing.
BiPAP equipment was not maintained according to policy for a resident with COPD, respiratory failure, and OSA. The mask was observed lying directly on the bedside table instead of being stored in a bag, and the humidifier chamber had debris and floating particles in the water. The resident said nursing helped with the BiPAP, but staff could not confirm when the equipment had last been cleaned, and there were no physician orders for BiPAP cleaning and maintenance.
A resident with ESRD on HD and a 1500 cc fluid restriction repeatedly exceeded the ordered limit, with TAR entries showing multiple days of intake above the prescribed amount. Nursing notes did not document physician notification, and the DON confirmed there was no evidence the MD was informed. Staff also reported the resident sometimes had soda at the bedside and that fluids were added to meal trays, while the resident’s physician notes documented bilateral LE edema during the same period.
A resident with overactive bladder, HTN, and low back pain had two OTC products left on the bedside table during a med pass: Biotene Dry Mouth Moisturizing Spray and Simple Saline Nasal Spray. The resident said the items were brought from home and used as needed, but the RN stated there were no MD orders and no self-administration assessment had been completed; the UM also confirmed the medications should have been assessed, ordered, and secured.
Infection control practices were not followed during wound care for a resident with stage 4 pressure ulcers and EBP orders, as a nurse repeatedly changed gloves without performing hand hygiene and a CNA provided care without the required gown. Staff also failed to disinfect a glucometer between resident finger stick blood sugar checks, using hand wipes instead of the facility’s approved disinfectant wipes, including between checks on a resident on EBP.
Failure to document education on pneumococcal vaccination occurred when a resident with dementia and an invoked HCP refused the vaccine after being approached by nursing staff. Although the HCP had signed consent for pneumococcal vaccination and staff stated education should be provided to the resident and HCP when a vaccine is refused, the record did not show that benefits and risks were explained when the resident declined PCV20.
Missing Discharge MDS Assessments for three residents discharged to the community. Record review showed that three residents were discharged from the facility, but their charts did not contain the required discharge MDS assessments. During interview, the MDS Coordinator confirmed that the RAI manual requires a Discharge MDS when a resident discharges to the community and acknowledged that the assessments should have been completed.
Failure to Post Daily Nurse Staffing Hours: The facility posted a staffing form in the lobby that listed census and staff counts by job type, but it did not include the actual hours worked or hours in a shift for RNs, LPNs/LVNs, and CNAs. The form remained dated with an earlier date on multiple days, and the Administrator stated it should have been updated daily but had not been, and that she was unaware of the requirement to post actual hours worked.
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.
Medication Pass Error Rate Exceeded
Penalty
Summary
The facility failed to maintain a medication pass error rate of less than 5% during observation, interview, and record review, with 2 residents involved in 2 medication pass errors out of 34 opportunities for an observed error rate of 5.88%. Resident #75, admitted in May 2025 with diagnoses including chronic respiratory failure with hypoxia, chronic combined systolic and diastolic congestive heart failure, major depressive disorder, and bipolar disorder, had an order for Symbicort inhalation aerosol 80/4.5 mcg, 2 puffs twice daily with instructions to rinse the mouth after use. During the medication pass, Nurse #1 administered the inhaler, the resident closed his/her mouth for five seconds, and when asked about water, declined; the nurse then left the room and returned the inhaler to the cart without requesting that the resident rinse and spit. Resident #54, admitted in December 2021 with diagnoses including pure hyperglyceridemia, alcohol induced disorder, unspecified intercranial injury, bipolar disorder, and alcohol dependence with alcohol-induced persisting dementia, had an order for Keppra 750 mg by mouth three times daily for epilepsy. During the medication pass, Nurse #2 dropped the Keppra tablet onto the surface of the medication cart, then donned gloves, used a spoon to pick up the dropped medication, and placed it into the souffle cup with the other medications for administration. Nurse #2 stated the medication cart had not been cleaned and/or disinfected before the medication pass and said she was unsure when it was last cleaned; she also stated she should have discarded the dropped medication and obtained a new tablet.
Failure to Protect Resident Privacy and Dignity
Penalty
Summary
The facility failed to provide a dignified existence for Resident #2 during a wound care procedure. Resident #2 was admitted in February 2025 with a diagnosis including metabolic encephalopathy and had a BIMS score of 14, indicating cognitive intactness. During an observed wound care treatment, Nurse #7 positioned the resident on the right side facing the wall and exposed the resident’s buttocks while the privacy curtain was not pulled far enough to prevent visibility from the open bedroom doorway. The surveyor intervened because the resident could be seen from the doorway, and the nurse then pulled the curtain farther to block the view. Nurse #7 stated privacy should have been provided before exposing the resident, and the DON stated staff were expected to provide privacy before exposing a resident to maintain dignity. The facility also failed to ensure Resident #64 was dressed in clothing rather than a hospital gown while in common areas with other residents. Resident #64 was admitted in February 2025 with a diagnosis including traumatic subdural hemorrhage and had severe cognitive impairment with a BIMS score of 0. The resident’s care plan did not indicate a preference for wearing a hospital gown. The surveyor observed the resident seated in a Broda chair in the day room wearing a hospital gown, first with no blanket or sheet present and later with a blanket covering the lower torso and feet. Nurse #6 stated the resident typically wore clothing and should have been dressed in clothing when brought out for breakfast. The Administrator also acknowledged concern for dignity when the resident was observed in a hospital gown in the day room and noted the resident frequently moved around and pushed blankets off.
Failure to Report and Investigate Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to implement its abuse prevention, identification, and investigation policies for two residents involved in an alleged resident-to-resident incident. The facility’s policies required staff to proactively identify potential abuse, immediately report alleged violations, and notify the nursing supervisor when abuse was alleged or suspected. The report states that Nurse #9 did not report the incident involving Resident #16 and Resident #66, and no investigation was initiated at the time of the event. Resident #16 was admitted with diagnoses including dementia with mood disturbance, major depressive disorder, and generalized anxiety. The resident was severely cognitively impaired with a BIMS score of 3 and required a wheelchair for mobility and substantial to maximal assistance to wheel 50 feet. Resident #66 was admitted with dementia with behavioral disturbance, was also severely cognitively impaired with a BIMS score of 6, wandered during the observation period, and had documented verbal behavioral symptoms including threatening, screaming, and cursing at others. Resident #66’s behavioral history also included aggression toward other residents and prior altercations. On the evening shift of 6/1/25, nursing documentation described Resident #66 as increasingly agitated, hitting, yelling at residents, and later hitting and pushing other residents. During interview, Nurse #9 stated that Resident #66 was agitated, attempted to enter the Dayroom, pushed Resident #16’s wheelchair while Resident #16 was seated in it, and swore at Resident #16. Nurse #9 said she did not alert a nursing supervisor or administration because Resident #66 did not make physical contact with Resident #16. The Administrator and UM #2 stated they were not notified of the incident, and the Administrator said no investigation had been conducted because staff did not report the event.
Medication administration errors during observed passes
Penalty
Summary
The facility failed to provide medication services that met professional standards of quality for two residents during observed medication administration passes. One resident, admitted with chronic respiratory failure with hypoxia, chronic combined systolic and diastolic CHF, major depressive disorder, and bipolar disorder, had an order for Symbicort inhalation aerosol with instructions to rinse the mouth after use. During observation, the nurse administered two puffs of the inhaler, asked if the resident wanted water, and then left the room and returned the inhaler to the medication cart without having the resident rinse and spit as required. In interview, the nurse stated she should have encouraged the resident to rinse the mouth after use to avoid oral thrush, but did not, and said this did not meet professional standards of care. A second resident, admitted with diagnoses including pure hyperglyceridemia, alcohol induced disorder, unspecified intracranial injury, bipolar disorder, and alcohol dependence with alcohol-induced persisting dementia, had an order for Keppra 750 mg three times daily for epilepsy. During the medication pass, the nurse dropped the Keppra tablet on top of the medication cart, then donned gloves, picked it up with a spoon, placed it into a souffle cup with other medications, and administered it to the resident. The nurse stated the medication cart had not been cleaned or disinfected before the pass and she was unsure when it was last cleaned. She also stated she should have discarded the dropped Keppra and administered a new tablet, but did not, and said this did not meet professional standards and/or quality of care.
Incorrect Wound Dressing Care for Stage 4 Pressure Ulcers
Penalty
Summary
The facility failed to provide pressure ulcer care consistent with physician orders for one resident with two Stage 4 pressure ulcers on the left and right buttocks that were present on admission. The resident was cognitively intact with a BIMS score of 14 and had diagnoses including metabolic encephalopathy. Physician orders in August 2025 directed staff to cleanse both buttock wounds with normal saline, pat dry, apply collagen powder to the wound base, cover with Calcium Alginate AG, and then cover with a foam border dressing every day and evening shift. During observed wound care on 8/7/25, Nurse #7 removed the dressings, cleansed the wounds with normal saline, patted them dry, and then applied a collagen matrix dressing material instead of the ordered collagen powder. The nurse also used regular Calcium Alginate instead of the ordered Calcium Alginate AG before covering both wounds with bordered foam dressings. In interview, Nurse #7 stated that the collagen matrix and regular Calcium Alginate were used instead of the ordered products and said the dressing should have been changed back when the facility supply changed; she also stated that using the incorrect dressing could result in the wound worsening.
Missing Physician Order for Indwelling Urinary Catheter
Penalty
Summary
The facility failed to provide care consistent with professional standards for an indwelling urinary catheter for one resident. The resident was admitted in February 2025 with diagnoses including metabolic encephalopathy, and the MDS assessment indicated the resident was cognitively intact with a BIMS score of 14 out of 15 and used an indwelling urinary catheter. Review of the facility policy titled Indwelling Urinary Catheter, revised 9/1/24, stated that a physician's order must be obtained for insertion of an indwelling catheter and that the order must include catheter size, balloon size, and frequency of change. Review of the resident's August 2025 physician orders failed to show an order for use of an indwelling urinary catheter. During wound care observation, the surveyor observed the catheter tubing secured to the resident's right leg and the urinary collection bag secured to the bed below the level of the bladder. During interview, the Unit Manager reviewed the physician orders and stated there should be an order for the catheter size, balloon size, and frequency of catheter changes, but there was not.
BiPAP Equipment Not Cleaned or Stored Properly
Penalty
Summary
The facility failed to ensure respiratory equipment for one resident was maintained in accordance with professional standards of practice related to cleaning, storage, and infection control. The resident had diagnoses including COPD, acute and chronic respiratory failure with hypoxia or hypercapnia, morbid obesity, quadriplegia, and OSA, and was dependent for upper body care and personal hygiene. The resident also used noninvasive mechanical ventilation and was cognitively intact with a BIMS score of 15 out of 15. During observation, the resident’s BiPAP mask was seen lying directly on the bedside table and not stored in a bag, and the humidifier chamber was observed dry with debris on the bottom. On a later observation, debris was seen floating in the water in the humidifier chamber, and the mask was again observed in direct contact with the bedside table. The resident stated nursing assisted with putting on the BiPAP and filling the humidifier chamber, and said the mask, tubing, and humidifier chamber had not been cleaned in a way the resident could remember. Review of the facility policy indicated the humidifier chamber should be emptied and wiped clean daily and washed weekly, and masks and cannulas should be stored in labeled plastic bags when not in use. The resident’s physician orders included oxygen tubing changes and BiPAP settings, but there were no orders for cleaning and maintenance of the BiPAP machine and equipment. Staff interviews showed differing understanding of responsibility for cleaning, with the UM stating the RT handled weekly cleaning, while the RT stated routine cleaning should be done by nursing staff. The DON stated there should be physician orders for BiPAP cleaning and that nursing would sign off on completion, but could not be sure when the equipment had last been cleaned.
Failure to Monitor and Report Excess Fluid Intake for Dialysis Resident
Penalty
Summary
The facility failed to provide safe, appropriate dialysis-related care for a resident with ESRD and dependence on renal dialysis by not accurately monitoring and managing ordered fluid intake. The resident was cognitively intact, on dialysis, and on a therapeutic diet with a 1500 cc fluid restriction, including 840 ml provided by the kitchen and intake/output monitoring every shift. Facility policies required daily intake and output documentation, totaling of fluid intake each shift, and physician notification when the resident’s condition or treatment plan changed or when ordered limits were exceeded. Review of the resident’s TAR for April through August 2025 showed multiple days when total fluid intake exceeded the 1500 cc restriction, including several readings above 1600 ml and some above 2500 ml. Nursing progress notes did not show that the physician was notified when the resident exceeded the fluid restriction. The resident’s physician progress notes also documented bilateral lower extremity edema on multiple occasions during the same period. During interviews, the UM stated that the resident sometimes had soda at the bedside and that nursing staff added fluids to meal trays before serving them. The UM and DON both stated that the physician should be notified when the resident exceeded the fluid restriction, and the DON confirmed there was no documentation that the physician had been notified. The DON stated the resident could be at risk for fluid overload and renal failure when the fluid restriction was exceeded. The Administrator and RD stated the concern should have been brought forward for review with the dialysis center and nephrologist, and the RD said she had not been informed that the resident was exceeding the fluid restriction.
Unsecured OTC Medications Left at Resident Bedside Without Orders or Self-Administration Assessment
Penalty
Summary
The facility failed to ensure that medications were stored in a safe and secure manner for one resident. Resident #123, who was admitted in July 2025 with diagnoses including overactive bladder, hypertension, and vertebrogenic low back pain, had a MDS assessment dated 7/30/25 showing cognitive intactness with a BIMS score of 13 out of 15. During a medication pass observation on 8/6/25 at 8:02 A.M., surveyors observed two over-the-counter medications on the resident’s bedside table: Biotene Dry Mouth Moisturizing Spray and Simple Saline Nasal Spray Instant Relief. The Biotene spray was labeled with the resident’s name and both products were identified by the resident as medications brought from home on admission and used whenever desired for dry mouth and nasal stuffiness. During interview, Nurse #1 stated the resident did not have physician orders for either the Biotene or the saline nasal spray and had not been assessed for safe self-administration of medications. Nurse #1 also stated the medications should not have been left at the resident’s bedside and should have been locked up. Unit Manager #3 stated the resident should have been assessed for indication for use, assessed for self-administration, and a physician’s order should have been obtained, but none of these had been done.
Infection Control Failures During Wound Care, EBP Care, and Glucometer Disinfection
Penalty
Summary
Infection prevention and control practices were not followed during wound care for a resident with two stage 4 pressure ulcers present on admission and an active order for Enhanced Barrier Precautions. The resident was cognitively intact with a BIMS score of 14. During observed wound care, the nurse performed hand hygiene and donned a gown and gloves, but then repeatedly removed gloves and put on new gloves without performing hand hygiene between glove changes. The nurse also set up dressing supplies and continued wound cleansing and dressing application without hand hygiene at multiple points during the procedure. The resident was also observed on Enhanced Barrier Precautions while receiving care from a CNA who was handling bed sheets with gloved hands but was not observed to don a gown. An EBP sign and PPE bin were located outside the room, and another nurse later stated the resident was on EBP for multiple reasons, including infections, wounds, and a urinary catheter, and that the CNA should have had on a gown but did not. The facility also failed to disinfect a glucometer between resident finger stick blood sugar checks. A nurse used Sani Hand Wipes to clean the glucometer after checking one resident and then used the same cleaning method between checks on four additional residents, including one resident on EBP. Facility policy required use of Super Sani-Cloth Germicidal disposable wipes or another approved disinfectant for cleaning and disinfection of the meter, and the unit manager confirmed staff were expected to use those disinfectant wipes. The nurse stated she had always used the Sani Hand Wipes to clean the glucometer after each finger stick blood glucose check.
Failure to Document Vaccine Education After Pneumococcal Refusal
Penalty
Summary
The facility failed to provide documented education on the benefits and risks of the pneumococcal vaccine for one resident reviewed for vaccination. Resident #15 was admitted in December 2024 with diagnoses including dementia and dysphagia, had a BIMS score of 9 out of 15, and had an invoked HCP. The resident was over age 65 and had declined the pneumonia vaccine. The record showed a vaccine consent form signed by the HCP on 12/3/24 indicating consent for pneumococcal vaccination, and the immunization record showed PPSV23 received on 7/30/14 and PCV20 refused on 2/4/25. Progress notes dated 2/4/25 showed the resident was approached twice by nursing staff and refused the pneumococcal vaccine twice. During interviews, the Infection Preventionist and Nurse #8 stated that when a resident refuses a vaccine, staff should educate the resident and the HCP on the risks and benefits, provide vaccine information sheets, and document the refusal and education. However, further review of the medical record did not show that Resident #15 or the HCP were provided education on the benefits and risks of the pneumococcal vaccination when the resident refused.
Missing Discharge MDS Assessments for Three Residents
Penalty
Summary
The facility failed to ensure that discharge tracking MDS assessments were completed for three residents who were discharged to the community. Record review showed that Resident #25, admitted in February 2025, was discharged on 3/10/25, but the clinical record did not indicate that a Discharge MDS was completed. Resident #27, also admitted in February 2025, was discharged to the community on 3/10/25, and the record likewise did not show a completed Discharge MDS assessment. Resident #82 was admitted in March 2025 and discharged to the community on 4/25/25, but the clinical record did not indicate that a Discharge MDS was completed. During interview on 8/8/2025 at 12:59 PM, the MDS Coordinator stated that the RAI manual requires a Discharge MDS when residents discharge to the community. The surveyor and MDS Coordinator reviewed the records for Residents #25, #27, and #82, and the MDS Coordinator acknowledged that the required Discharge MDS assessments should have been completed and were not.
Failure to Post Daily Nurse Staffing Hours
Penalty
Summary
The facility failed to post required nurse staffing information daily that included the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift, including RNs, LPNs/LVNs, and CNAs. On 8/6/25, the surveyor observed a staff posting form in the lobby that listed the census and the number of staff by job type per shift, but it did not show the actual hours worked or hours in a shift for licensed and unlicensed staff. On 8/7/25, the lobby posting was still dated 8/6/25 and again did not include the actual hours worked or hours in a shift. On 8/8/25, the posting remained dated 8/6/25 and still failed to show the actual hours worked or hours in a shift for licensed and unlicensed staff. During interview, the Administrator reviewed the posting form and stated it should be updated every day but had not been updated, and said she was unaware of the requirement to post the actual hours worked for staff.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 104 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.