Meadows of Central Massachusetts (the)

Inspectors wroteBased on interviews and records reviewed, the facility failed to ensure care and services were provided to one Resident (#29) out of a total sample of 17 residents, in accordance with professional standards of practice. Specifically, the facility failed to obtain laboratory services as ordered by the Physician, including Complete Blood Count (CBC), Liver Function Test (LFT), and Valproic Acid level, putting the resident at risk for adverse side effects related to the use of Depakote (anticonvulsant) medication.

Inspectors wroteBased on the record review and interview, the facility failed to to utilize the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, as required placing all residents at risk for not having their clinical needs met either directly by the RN or indirectly by the Licensed Practical Nurse (LPN) or Certified Nurses Aides (CNA) that the RN was responsible for overseeing with provision of resident care. Specifically, the facility failed to: 1. Provide the services of a RN for at least eight consecutive hours a day, seven days a week when no staffing waivers were in place for three days for the period of 4/1/24 to 6/30/24. 2. Designate a Registered Nurse to serve as the Director of Nursing (DON) on a full time basis when no staffing waivers were in place.

Inspectors wroteBased on observation, interview, record and policy review, the facility failed to ensure one Resident (#108) out of a total sample of 17 residents, was free of significant medication errors. Specifically, for Resident #108, the facility failed to ensure that: -pain medications were administered timely as ordered by the Physician, when the Resident experienced pain and scheduled pain medications were ordered, which increased the Resident's risk for prolonged pain. -intravenous (IV: administered directly into a vein) antibiotics (medications used to treat infection) were administered timely as ordered by the Physician, when the Resident required IV antibiotics to treat an active infection, which increased the Resident's risk for illness. [...]

Inspectors wroteBased on observation, interview, record and policy review, the facility failed to identify and notify the Physician/Nurse Practitioner (NP) timely of a change in urinary catheter (also known as a Foley catheter - a flexible tube inserted into the bladder to drain urine outside of the body) condition for one Resident (#210) out of a total sample of 17 residents. Specifically, Resident #210, the facility failed to monitor and assess bleeding from the urinary catheter and notify the Physician/NP timely for required interventions, resulting in hospitalization for gross hematuria (excessive blood in the urine).

Inspectors wroteBased on observation, interview, record and policy review, the facility failed to provide a homelike environment, relative to accessibility of the call bell, for one Resident (#108) out of a total sample of 17 residents. Specifically, for Resident #108, the facility failed to ensure ready access to his/her call device when the Resident was dependent on staff for his/her care needs and was able to use an alternate call pad device (altered device for a call light that is activated by being tapped rather than pressed by a finger or thumb), which increased the Resident's risk for not having his/her care needs met timely and appropriately.

Inspectors wroteBased on record and policy review, observation, and interview, the facility failed to develop a plan of care for appropriate treatment and services related to limited range of motion for one Resident (#42), out of a total sample of 17 Residents. Specifically, for Resident #42, the facility failed to develop a plan of care relative to positioning for the Resident after he/she was assessed and recommendations made by Rehabilitative Services for a specialty wheelchair and molded lateral supports (fitted equipment that help reinforce body support and reduce postural deformity).

Inspectors wroteBased on observation, interview, record and policy review, the facility failed to provide urinary catheter (also known as a Foley catheter - a flexible tube inserted into the bladder to drain urine outside of the body) care and services according to professional standards of practice for three Residents (#210, #44 and #42) out of a total sample of 17 residents, which increased the Residents' risk for urinary catheter complications. Specifically, the facility failed to: 1. For Resident #210, identify that the Resident was admitted to the facility with a urinary catheter, resulting in delayed monitoring and assessment of the Resident's urinary catheter and obtaining Physician orders to implement catheter care and management when hematuria (blood in urine) was identified. 2. For Resident #42, obtain a Physician's order for a specific type of external urinary catheter. 3. [...]

Inspectors wroteBased on observation, interview, record and policy review, the facility failed to provide care and services for assisted nutrition and hydration in accordance with the Physician order for one Resident (#46), who required Total Parenteral Nutrition (TPN: method of providing nutrition where a liquid formula is given into a vein through an intravenous catheter (IV) to provide most of the nutrients a resident needs, used when a resident cannot or should not eat or drink by mouth) of one resident who required TPN, out of a total sample of 17 residents. [...]

Inspectors wroteBased on observation, record and policy review, and interview, the facility failed to ensure that care and services for pain management consistent with professional standards of practice were provided in a timely manner for one Resident (#108) out of a total sample of 17 residents. Specifically, the facility failed to provide pain management interventions in a timely manner for Resident #108 when the Resident was experiencing severe pain and was dependent on staff to receive pharmacological (medication) and non-pharmaceutical interventions to treat pain.

Inspectors wroteBased on observation, record and policy review, and interview, the facility failed to ensure that one Resident (#6) out of a total sample of 17 resident was free of medication errors. Specifically, the facility failed to: -ensure that antibiotic medication (Clindamycin) ordered for Resident #6 was administered for seven days as ordered and not 12 days as indicated on the Medication Administration Record (MAR).

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure all medications used in the facility were stored and labeled in accordance with currently accepted professional principles of practice. Specifically, the facility failed to ensure staff properly labeled all medications stored in one of three medication carts reviewed.

Inspectors wroteBased on observation, interview, record and policy review, the facility failed to implement infection control measures to stop the spread of infection for two Residents (#6 and #46) out of 17 sampled residents, and on one Unit out of two units. Specifically, the facility failed to: 1. Ensure that Enhanced Barrier Precautions (EBP) and Infection control practice were maintained for Resident #6. 2. Ensure that infection control practices were adhered to during a PICC (peripherally inserted central catheter - a long flexible tube that is inserted into a vein in the arm and threaded into a large vein near the heart) line dressing change for Resident #46. 3. Ensure that a glucometer machine (glucose meter: a small, portable device that measure the amount of glucose (sugar) in the blood) was appropriately disinfected between Resident use.

Inspectors wroteBased on observation, record review and interview, the facility failed to obtain treatment orders for one Resident (#20), out of three applicable Residents, in a total sample of 15 Residents. Specifically, the facility failed to obtain treatment orders when skin breakdown was initially observed and resulted in the development of a Pressure Ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) for Resident #20.

Inspectors wroteBased on policy review, record review and interview, the facility failed to provide appropriate treatment and services to prevent a decline in bladder continence for one Resident (#43) out of a total sample of 15 Residents. Specifically, the facility failed to provide treatment and services for Resident #43, who was cognitively intact, aware of his/her toileting needs and had a desire to maintain urinary continence.

Inspectors wroteBased on observation, record review and interview, the facility failed to follow infection control guidelines relative to: 1. Placing one Resident (#16) on Contact Precautions (intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment) when diagnosed with a Multidrug-Resistant Organism (MDRO) and an infection. 2. Not placing Residents that met criteria on Enhanced Barrier Precautions (use of gowns and gloves for specific high contact resident care activities associated with MDRO transmission). 3. Completing an assessment and creating a plan to minimize the risk of Legionella (a serious type of lung infection that occurs when small droplets of water are breathed in or accidentally swallowing water containing the Legionella bacteria) outbreak.

Inspectors wroteBased on record review and interview, the facility failed to ensure yearly Licensed Staff Competencies included the care and services for residents receiving Dialysis (process of removing excess water and toxins from the blood in people whose kidneys no longer perform these functions naturally) treatment.

Inspectors wroteBased on observation, policy review and interview, the facility failed to serve and distribute food in accordance with professional standards for food service safety. Specifically, the facility failed to maintain appropriate cold food and beverage temperatures during meal service to minimize the risk of food-borne illness.

Inspectors wroteBased on document review, policy review and interview, the facility failed to conduct inspection of all bed frames, mattresses, and bed rails, if any, as part of a regular maintenance program to identify areas of possible entrapment. Specifically, beds with air mattresses were not inspected to identify areas of possible entrapment.

Inspectors wroteBased on record review and interview, the facility failed to ensure that staff completed a Significant Change in Status Assessment (SCSA) for one Resident (#43), out of total sample of 15 Residents. Specifically, the facility failed to ensure that its staff completed the SCSA following a decline in Resident #43's functional status after a fall that resulted in a hip fracture.

Inspectors wroteBased on observation, policy review, record review and interview, the facility failed to follow the care plan for one Resident (#23) and failed to develop a care plan for one Resident (#43), out of a sample of 15 residents. Specifically, the facility failed to ensure that its staff: 1. Followed the care plan related to the hourly rate an enteral feeding (liquid nutrients delivered via a tube that is inserted into the stomach) was to be administered for Resident #23. 2. Developed a care plan related to urinary incontinence (lack of voluntary control over urination or defecation) for Resident #43.

Inspectors wroteBased on observation, record review and interview, the facility failed to review and revise the comprehensive care plan relative to a positioning device, for one Resident (#22) out of a total sample of 15 Residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide care for a Peripherally Inserted Central Catheter (PICC- a long catheter inserted through a peripheral vein then into the central vascular system to administer intravenous (IV) treatments over a long period of time) for one applicable Resident (#16), in a total sample of 15 Residents. Specifically, the facility failed to ensure PICC line flushes, dressing changes and tubing changes were completed and documented for Resident #16. Findings Include: Resident #16 was admitted to the facility in November 2022 with diagnoses including Respiratory Failure with Hypoxia (when the respiratory system cannot adequately provide oxygen to the body) and Venous Ulcer (wound caused by abnormal or damaged veins) of left calf and Varicose (enlarged) Veins of bilateral legs. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to provide care and services consistent with professional standards for one Resident (#37), out of two applicable residents, in a total sample of 15 Residents. Specifically, the facility failed to: a. Consistently evaluate and document the status of an Arteriovenous (A/V) fistula (a surgical connection of an artery to a vein to provide blood flow for dialysis). b. Coordinate delivery of medications with the Resident's dialysis treatment schedule to ensure the Resident received all medications, as ordered by the Physician.

Inspectors wroteBased on observation, record review and interview, the facility failed to notify the Physician when there was a change in the status of skin integrity for one Resident (#20), out of a total sample of 15 Residents.

Inspectors wroteBased on policy review, record review and interview, the facility failed to provide Behavioral Healthcare Services for one Resident (#38) out of a sample of 15 residents, when such services were indicated by a Psychiatric Clinician.

Inspectors wroteBased on observation, record review and interview, the facility failed to obtain a routine medication for one Resident (#16), out of a total sample of 15 Residents, resulting in negative symptoms that required further medical management.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide an ordered medication, causing the Resident to experience negative symptoms which required further intervention for one Resident (#16), out of a total sample of 15 residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide recommended dental services for one Resident (#38) out of a total sample of 15 residents. Specifically, the facility failed to ensure that its staff: 1. Implemented a recommendation for an antibiotic (to treat tooth infection) in a timely manner. 2. Provided follow-up dental services for tooth extractions due to a tooth infection.

Inspectors wroteBased on policy review, record review and interview, the facility failed to offer Pneumococcal Vaccination to one Resident (#35) of five applicable Residents, out a total sample of 15 Residents, unless the immunization was medically contraindicated or the resident had already been immunized. Specifically, the facility staff failed to offer, educate the Resident/Resident Representative on the benefits and risks, and administer the Center for Disease Control and Prevention (CDC)'s recommended Pneumococcal Conjugate Vaccine (PCV) 15 or 20, when the member had previously received the Pneumococcal Polysaccharide Vaccine (PPSV) 23 vaccine at the age sixty-five.