1 Report
Inspection Report — Jul 16, 2024
Routine
Date: Jul 16, 2024
Visit Reason
Biennial state compliance review of the assisted living residence by the Massachusetts Executive Office of Aging & Independence (AGE) on July 16, 2024.
Findings
The state cited 4 findings, including 1 repeat finding, below the state median of 6. The action taken was Plan of correction required.
Citations (4)
Emergency call response: In the month of June 2024 there were 65 e-call response times over the ten minutes required by the Residence policy.
Quality assurance program: Documentation of a date the audit was completed on was missing for calendar year 2022, documentation of a Resident Safety Assurances audit was missing in all calendar years, and documentation of a set target date for follow-up action and person responsible for follow up action was missing in last quarter of calendar year 2022 (repeat finding).
Resident records: The Residence’s computerized records to document timely assistance by hourly safety checks were not auditable and the Correspondence Log was not used to communicate all significant information necessary to maintain continuity of care for all Residents.
Staffing: Two personnel records were missing documentation to confirm receipt or declination of the seasonal influenza vaccine.
Report Facts
Findings: 4
Repeat findings: 1
State median findings: 6
Emergency call responses over ten minutes: 65
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