Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Meadows Of Central Massachusetts (the) during CMS and state inspections, most recent first.
Failure to obtain ordered lab monitoring for a resident receiving Depakote. The resident had psychosis, Alzheimer's disease, and dementia with agitation, and the MD ordered a Valproic Acid level, CBC, and LFT while the MAR showed Depakote was given as prescribed. The record did not show the labs were completed or why the order was not followed, and the UM and DON could not provide evidence that the lab request had been completed.
The facility failed to have a Registered Nurse (RN) on duty for at least eight consecutive hours a day, seven days a week, and did not designate a full-time Director of Nursing (DON) who is a RN. The DON worked only 32 hours per week, and an LPN covered the remaining days. The facility had no staffing waivers in place.
A resident with multiple medical conditions did not receive timely administration of critical medications, including pain relief, IV antibiotics, anticoagulants, and anticonvulsants, as ordered by the physician. The resident was observed in severe pain, and interviews revealed a misunderstanding of the facility's medication administration policy, leading to significant delays in care.
A resident with a urinary catheter experienced gross hematuria, but the facility failed to notify the Physician or NP in a timely manner. Despite observations of bloody urine, the staff did not have specific orders for catheter care, and communication lapses led to a delay in intervention. The resident, with a history of urinary retention and on anticoagulant medication, was eventually hospitalized due to the lack of prompt action.
A resident with quadriplegia was unable to access their call device due to improper placement, despite being dependent on staff for care. The call pad, necessary for alerting staff, was found dangling below the bed, out of reach. Staff interviews confirmed the resident's inability to use the device, highlighting a failure to provide a homelike environment.
A resident with Traumatic Brain Injury and contractures did not have a care plan updated to include recommended positioning interventions. Despite recommendations for a specialty wheelchair with molded lateral supports, the resident was observed in a Geri chair without these supports. Staff interviews revealed a lack of communication and implementation of the recommended interventions, leading to ineffective positioning.
A facility failed to provide proper urinary catheter care for three residents, leading to increased risks of complications. One resident was admitted with a catheter but lacked physician orders for its care, resulting in unaddressed hematuria. Another resident had an external catheter without a physician's order, and a third resident received a catheter of the wrong size, contrary to medical instructions.
A resident requiring Total Parenteral Nutrition (TPN) did not receive Clinimix E and SMOFlipids as ordered, due to a failure by the nursing staff to administer the infusions correctly. The resident's infusions were not completed on schedule, and the staff did not take appropriate steps to address the issue, such as consulting with the pharmacy or obtaining new orders. The Assistant Director of Nursing, Dietitian, and Nurse Practitioner were not informed of the missed infusions, resulting in the resident not receiving the necessary nutrition and hydration.
A resident with severe pain did not receive scheduled pain medications on time, resulting in prolonged discomfort. The resident, dependent on staff for pain relief, was observed crying in bed with their call device out of reach. Medications due between 8:00 A.M. and 9:00 A.M. were not administered until after 11:00 A.M., despite the resident's report of severe pain. The ADON confirmed that the medications were time-critical and should have been administered within one hour of the scheduled time.
A resident with a Stage 4 Pressure Ulcer was prescribed Clindamycin for seven days, but the MAR indicated administration for 12 days. The medication was not delivered from the pharmacy, leading a nurse to borrow it from another resident, contrary to facility policy. Interviews revealed staff were unaware of the prohibition on borrowing medications.
The facility failed to properly label and store medications, as observed with an Albuterol inhaler lacking a pharmacy label on a medication cart. Nurse #5 was unaware of when the inhaler was opened and confirmed the absence of necessary labeling. The ADON acknowledged the labeling deficiency.
The facility failed to implement infection control measures for two residents and on one unit. A resident with a Stage 4 Pressure Ulcer did not receive care under Enhanced Barrier Precautions, and a PICC line dressing change was not performed according to policy. Additionally, a glucometer was not disinfected between uses, contrary to facility expectations.
Failure to Obtain Ordered Laboratory Monitoring for Depakote Therapy
Penalty
Summary
The facility failed to ensure that laboratory services ordered by the physician were obtained for one resident, identified in the report as Resident #29. The resident was admitted with diagnoses including Unspecified Psychosis, Alzheimer's Disease, and Dementia with Agitation, and the MDS described the resident as severely cognitively impaired, with short- and long-term memory problems, behaviors on four to six days out of seven, and use of antipsychotic, antidepressant, and anticonvulsant medications. The physician's orders included Depakote Sprinkles 125 mg, 375 mg twice daily, and an order to obtain a Valproic Acid level, CBC, and LFT. The resident's MAR showed Depakote was administered as ordered, and behavioral health notes documented recommendations for valproic acid level, CBC, and LFT monitoring related to Depakote therapy. Further review of the medical record did not show that the ordered Valproic Acid level, CBC, and LFT were completed, and there was no documentation explaining why the laboratory order was not followed. During interviews, the Unit Manager said she did not recall any Valproic Acid level or lab services for the resident and could not explain why the ordered labs were not completed. The DON also stated that she was unable to provide evidence that the lab request was completed and that the ordered laboratory services were not completed for the resident and should have been.
Failure to Maintain RN Coverage and Full-Time DON
Penalty
Summary
The facility failed to utilize the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, as required. This deficiency was identified through a review of the PBJ Staffing Data Report for Quarter 3 of 2024, which indicated that there were four or more days within the quarter with no RN hours. Specifically, the facility did not have an RN on duty for eight hours on 4/27/24, 5/12/24, and 6/21/24. During an interview, the Administrator confirmed that no RNs worked on these days and acknowledged that the facility did not have any staffing waivers in place. Additionally, the facility failed to designate a Registered Nurse to serve as the Director of Nursing (DON) on a full-time basis. The DON, who is a RN, worked only 32 hours per week, covering Monday through Thursday, while the Assistant Director of Nursing (ADON), who is not a RN, covered the remaining days. The Administrator confirmed that the facility did not have any waivers for staffing in place, and the ADON, a Licensed Practical Nurse (LPN), stated that staff would approach her with clinical problems or questions on the days the DON was not present.
Significant Medication Errors in Resident Care
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as observed during a survey. The resident, who was admitted with multiple diagnoses including chronic embolism, thrombosis, and unspecified convulsions, did not receive timely administration of several critical medications. These included pain medications, intravenous antibiotics, anticoagulants, and anticonvulsants, all of which were ordered by the physician to be administered at specific times to manage the resident's conditions effectively. On the day of the survey, the resident was observed in bed, crying and reporting severe pain, indicating that the scheduled pain medications had not been administered on time. The resident also reported that the intravenous antibiotic medication, crucial for treating an active infection, had not been administered as scheduled. The surveyor noted that the resident's call device was out of reach, and upon activation, the nurse confirmed the delay in medication administration. Interviews with the unit manager and assistant director of nursing revealed a misunderstanding of the medication administration policy, which requires medications to be given within one hour of the scheduled time. The unit manager admitted to administering the resident's medications late, including pain and IV antibiotic medications. The assistant director of nursing emphasized the critical nature of timely medication administration for the resident's conditions, highlighting the facility's failure to adhere to its own policies and the physician's orders.
Failure to Notify Physician of Resident's Catheter Bleeding
Penalty
Summary
The facility failed to timely notify the Physician or Nurse Practitioner of a change in the condition of a resident with a urinary catheter, leading to hospitalization for gross hematuria. The resident, who had a history of urinary retention and was on anticoagulant medication, was observed with bloody urine in the catheter tubing. Despite this observation, the facility did not have any specific orders for the care and maintenance of the Foley catheter, and the bleeding was not promptly reported to the Physician. The resident was admitted with a Foley catheter due to urinary retention and had a history of chronic kidney disease and Parkinson's disease. The catheter was observed to have bloody urine, but the facility staff failed to notify the Physician in a timely manner. Nurse #3 was informed by a CNA about the bloody urine but did not have time to notify the Physician and instead asked another nurse to do so. However, the nurse responsible for the resident's care was unaware of the catheter and the bleeding. The Unit Manager and the facility's NP were not aware of the resident's condition until later. The NP was informed of the hematuria but was not made aware of its severity, leading to a delay in appropriate intervention. The resident's condition was eventually reported, and orders were given to hold the anticoagulant medication and to transfer the resident to the hospital after a significant delay. This lack of timely communication and intervention resulted in the resident's hospitalization.
Failure to Ensure Accessible Call Device for Resident
Penalty
Summary
The facility failed to provide a homelike environment by not ensuring ready access to a call device for a resident who was dependent on staff for care needs. The resident, who had quadriplegia due to a spinal injury, was cognitively intact and required substantial assistance for daily activities. The resident's care plan indicated the need for an alternative call pad device, which could be activated by tapping, to alert staff for assistance. However, the call pad device was not positioned within the resident's reach, as observed by the surveyor, leading to the resident's inability to call for help when needed. During observations, the call pad device was found dangling below the bed, out of the resident's reach, and not positioned on the mattress near the resident's left hand as required. Interviews with the resident and staff confirmed that the resident was unable to locate or use the call pad device due to its improper placement. The Assistant Director of Nursing acknowledged that the resident was dependent on staff to position the call pad device correctly, which was necessary for the resident to alert staff for assistance.
Failure to Implement Recommended Positioning for Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with limited range of motion, specifically regarding positioning after recommendations were made by Rehabilitative Services. The resident, who was admitted with diagnoses including Traumatic Brain Injury and multiple contractures, was assessed by Rehabilitative Services, which recommended a specialty wheelchair with molded lateral supports. However, these recommendations were not incorporated into the resident's care plan. Observations revealed that the resident was seated in a Geri chair with various supports, but not in the recommended tilt-in-space chair with molded lateral supports. Interviews with staff, including the Rehabilitation Director and nursing personnel, indicated a lack of communication and implementation of the recommended interventions. The Rehabilitation Director noted that the resident's current positioning was ineffective, and the recommended interventions were not in place. Further interviews with nursing staff and the Unit Manager highlighted a breakdown in the process of updating the care plan and educating staff on new positioning needs. The Unit Manager and Nurse #6 were unaware of any specialty positioning devices for the resident, and there was confusion about whether a tilt-in-space chair had been ordered. This lack of coordination and follow-through resulted in the resident not receiving the appropriate care as recommended by Rehabilitative Services.
Deficiencies in Urinary Catheter Care and Management
Penalty
Summary
The facility failed to provide appropriate urinary catheter care and services according to professional standards for three residents, leading to increased risks of complications. Resident #210 was admitted with a urinary catheter, but the facility did not identify this upon admission, resulting in delayed monitoring and assessment. There were no physician orders for the care and maintenance of the Foley catheter, and the resident exhibited hematuria, which went unaddressed due to a lack of communication among the nursing staff. Resident #42 had an external urinary catheter but lacked a physician's order for its use. This oversight indicates a failure to ensure that all necessary medical orders were in place for the resident's care. The absence of a physician's order for the external catheter suggests a lapse in the facility's protocol for managing urinary catheters, which could potentially lead to inappropriate or inadequate care. Resident #44 had a suprapubic catheter inserted, but the size did not match the physician's order. The facility staff inserted a 20 French catheter instead of the ordered 16 French, indicating a failure to adhere to specific medical instructions. This discrepancy highlights a lack of attention to detail in following physician orders, which is critical for ensuring the safety and well-being of residents requiring catheterization.
Failure to Administer TPN as Ordered
Penalty
Summary
The facility failed to provide care and services for assisted nutrition and hydration in accordance with the Physician's order for a resident who required Total Parenteral Nutrition (TPN). The resident, admitted with diagnoses including Unspecified Intestinal Obstruction and Gastro-Esophageal Reflux Disease, required TPN indefinitely due to a high risk for re-obstruction. The Physician's order specified the administration of Clinimix E and SMOFlipids, which were not provided as ordered, increasing the resident's risk for malnutrition. On the evening of October 9th, the resident was supposed to receive 2000 mL of Clinimix E and 50 grams of SMOFlipids, but the infusions were not completed as scheduled. The Clinimix E infusion was still running at a reduced rate the following afternoon, and the SMOFlipids were not reconnected after being stopped for a lab draw. Nurse #7, who was responsible for the infusions, failed to reconnect the SMOFlipids and did not know why they should not be reconnected. The nurse also did not take appropriate steps to address the leftover infusions, such as consulting with the pharmacy or obtaining new orders from a physician. The Assistant Director of Nursing (ADON) and the Dietitian were not informed of the missed infusions, and the Nurse Practitioner (NP) was not contacted to adjust the orders. The facility staff did not alert the Dietitian about the resident's low protein levels or the need for a consult, and the NP was unaware of the issue due to a lack of communication from the staff. This lack of communication and failure to follow the Physician's orders resulted in the resident not receiving the necessary nutrition and hydration as prescribed.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to provide timely pain management interventions for a resident experiencing severe pain. The resident, who was admitted with conditions including unspecified cord compression, muscle spasms, and cutaneous abscesses, was dependent on staff for both pharmacological and non-pharmacological pain relief. The facility's policy on pain management emphasized the importance of individualized assessment and timely intervention, yet the resident did not receive scheduled pain medications on time. On the day of the incident, the resident was observed in bed, crying, with their call device out of reach. The resident reported to the surveyor that they had not received their scheduled pain medications, which were due between 8:00 A.M. and 9:00 A.M. The medications were not administered until after 11:00 A.M., despite the resident's report of severe pain. The Unit Manager, responsible for administering the medications, acknowledged the delay and confirmed that the resident reported a pain level of eight out of ten prior to receiving the medications. Interviews with the Assistant Director of Nursing (ADON) revealed that the resident frequently experienced pain and that their medications were considered time-critical. The ADON stated that the medications should have been administered within one hour of the scheduled time to effectively manage the resident's pain. The delay in administering medications resulted in the resident experiencing prolonged severe pain until the medications were finally given.
Medication Administration Error with Clindamycin
Penalty
Summary
The facility failed to ensure that a resident was free of medication errors, specifically regarding the administration of the antibiotic Clindamycin. The resident, who was admitted with a diagnosis of a Stage 4 Pressure Ulcer, was prescribed Clindamycin to be administered four times a day for seven days. However, the Medication Administration Record (MAR) indicated that the medication was administered for 12 days, contrary to the physician's order. The error was compounded by the fact that the Clindamycin was not delivered from the pharmacy as expected. As a result, a nurse borrowed the medication from another resident's supply, unaware that this practice was not permitted. Interviews with nursing staff revealed a lack of awareness and adherence to the facility's medication management policy, which prohibits borrowing medications from other residents and requires medications to be dispensed by the pharmacy.
Improper Medication Labeling and Storage
Penalty
Summary
The facility failed to ensure that all medications were stored and labeled according to accepted professional principles. During a review of the medication cart on the First Floor, a surveyor and Nurse #5 found an Albuterol Sulfate inhalation aerosol unit stored in a ziplock bag without a pharmacy label. The label should have included the prescribed dose, strength, expiration date, route of administration, and instructions and precautions. Instead, the bag and the side of the inhaler had a resident's name and room number handwritten in black marker. Nurse #5 admitted to not knowing when the inhaler was opened and acknowledged the absence of a label or date on the bag or inhaler. Although she knew which resident the inhaler was for, she confirmed that there should have been a pharmacy label with instructions. She also mentioned that she had not administered the inhaler and intended to dispose of it. The Assistant Director of Nursing (ADON) later confirmed that the inhaler should have been labeled with the required information and should not have been on the medication cart.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to implement proper infection control measures for two residents and on one unit. Resident #6, who was admitted with a Stage 4 Pressure Ulcer, did not receive care under Enhanced Barrier Precautions (EBP) as required. During a wound dressing change, Nurse #4 did not wear a gown, failed to sanitize hands before donning gloves, and used scissors from her pocket without proper hand hygiene. Nurse #4 was unaware of the EBP requirement due to the absence of signage indicating the necessary precautions. Resident #46, admitted with an Unspecified Intestinal Obstruction, was due for a PICC line dressing change. During the procedure, Unit Manager #1 did not follow the facility's infection control policy. She initially forgot to wear a mask, did not sanitize her hands between glove changes, and failed to don a new gown after leaving and re-entering the resident's room. These lapses occurred despite the resident's reminder and the facility's policy requirements. Additionally, the facility did not ensure proper disinfection of a glucometer between resident uses. Nurse #7 performed a blood glucose check and placed the glucometer back on the medication cart without disinfecting it. He intended to clean it after completing medication administration for all residents, contrary to the expectation of disinfecting the device after each use. This oversight was acknowledged by both Nurse #7 and Unit Manager #1, who confirmed the facility's policy on glucometer disinfection.
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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 Rochdale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Life Care Center Of Auburn | 2 mi | ★★★★★ | 1 | 0 |
| Parsons Hill Rehabilitation & Health Care Center | 3.8 mi | ★★★★★ | 1 | 0 |
| Hermitage Healthcare (the) | 4.9 mi | ★★★★★ | 18 | 0 |
| Overlook Masonic Health Center | 5.7 mi | ★★★★★ | 0 | 0 |
| St Mary Health Care Center | 5.9 mi | ★★★★★ | 10 | 0 |
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