Inspection Reports for
All American Assisted Living at Wrentham

Emergency call response: During the months of June 2023, December 2024 and March 2025, there were 613 e-call response times over the 10-minute limit.

Memory care unit: Residence staff did not respond to door alarms when triggered, one Resident accessible [redacted] was operational without required safeguards, and aquarium chemicals and fish food were unsecured and accessible by Residents.

Resident screening and assessment · Resident care plans: Three records were missing documentation of an initial assessment being completed by a nurse, three records lacked documentation confirming assessments noted the name and scope of any Legal Representative, five SCR records lacked documentation that Residents have supervised access to a heating element, four records missed documentation of a service plan review within 30 days after residency commencement, individualized enrichment activities documentation was missing in two SCR records, six records missed documentation of a service plan review every six months or after condition change, four records missed signatures of a Residence Representative, and four records missed signatures of the Resident or Legal Representative (repeat finding).

Quality assurance program: Documentation of the date the audit was completed was missing for 2023, clear findings documentation was missing for 2023 and 2024, documentation of staff responsible for follow-up action was missing for 2023 and 2024, documentation of target date for follow-up action was missing for second and third quarters of 2023, documentation of staff responsible for follow-up action was missing for first quarters of 2023 and 2024, observed medication fulfillment error and compromised medication bubble pack, and nurse documented medication pass completion prior to administration for three Residents (repeat finding).

Incident reporting: The Residence filed 26 incident reports greater than 24 hours after the occurrence of the incident or accident (repeat finding).

Controlled medication handling: The controlled substance count did not follow the procedures stated in the Residence policy and reports of criminal offender record information (CORI) checks prior to hire were inconsistent for three records.

Resident records: Both Correspondence Logs did not consistently document all significant or pertinent information necessary to maintain the continuity of care for all Residents.

Staff health screening: Three personnel records were missing documentation to confirm seasonal influenza vaccinations or declination statements for the 2023/2024 flu season (repeat finding).

Staff training: Documentation of annual training needs assessments was missing for 2023 and 2024, six records lacked documentation supporting consistent Introductory Visits with all applicable staff, documentation confirming completion of SAMM and skills evaluations every six months was missing from two records for 2023 and four records for 2024, and required disclosures to prospective Residents were missing in two records each (repeat finding).

Information given to residents: Missing Disclosure of Rights and Disclosures.