1 Report
Inspection Report — Apr 15, 2025
Routine
Date: Apr 15, 2025
Visit Reason
Biennial state compliance review of the assisted living residence by the Massachusetts Executive Office of Aging & Independence (AGE) on April 15, 2025.
Findings
The state cited 4 findings, including 3 repeat findings, which is below the state median of 6. The action taken was a plan of correction required.
Citations (4)
Emergency call response: During the months of December 2023, June 2024 and March 2025, there were 51 e-call response times over the 10-minute limit, and hourly safety checks documentation was incomplete for nine SCR Residents during night hours (repeat finding).
Resident screening and assessment · Resident care plans: Three resident records were missing signatures of the Resident or Legal Representative.
Quality assurance program: Documentation of audit dates and responsible persons for follow up was missing for 2023 and 2024 calendar years; expired medications and unlabeled medications were found in residents' storage units; unclear medication administration documentation; and one staff member discussed matters outside the scope of SAMM (repeat finding).
Incident reporting: The Residence filed 22 incident reports more than 24 hours after the occurrence of the incident or accident (repeat finding).
Report Facts
Findings: 4
Repeat findings: 3
State median findings: 6
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