Inspection Reports for
All American Assisted Living at Raynham

Emergency call response: During the months of December 2023, June 2024, and January 2025, there were 777 e-call response times over the ten-minute limit in accordance with the Resident’s policy (repeat finding).

Memory care unit: The documentation supporting the required Special Care Residence operations was incomplete for the 2023 and 2024 calendar years.

Resident care plans: Four records were missing documentation of a service plan review required within 30 days after the commencement of residency, and five records were missing documentation of Resident goals.

Quality assurance program: Documentation of the audit was missing for the 2023 calendar year. Documentation of the summary of findings, the target date and person responsible for follow up action, and the outcome of any action taken were missing for the 2023 and 2024 calendar years. Observations included medication handling and storage issues, including ungloved handling, missing pharmacy labels, incorrect room numbers, unsigned documentation, loose tablets, expired medication, and medication without noted open or beyond use dates (repeat finding).

Emergency drills · Incident reporting: Documentation of elopement drills for all shifts and a fire drill for the third shift was missing for the 2023 calendar year. The Residence filed 62 incident reports greater than 24 hours after the occurrence of the incident or accident (repeat finding).

Controlled medication handling: Documentation showing the Residence conducted required Controlled Substance count audits was missing for all reviewed years.

Resident records: The Residence did not use the Traditional and Special Care Correspondence Logs to communicate all significant or pertinent information necessary for the continuity of care.

Staff health screening: Four records were missing documentation to confirm seasonal influenza vaccinations or declination statements for the 2024/2025 flu season (repeat finding).

Staff training: Documentation of annual training needs assessments was missing for the 2023 and 2024 calendar years reviewed. Two records were without documentation to support that Introductory Visits were consistently conducted with all applicable staff.