1 Report
Inspection Report — Aug 27, 2024
Routine
Date: Aug 27, 2024
Visit Reason
Biennial state compliance review of the assisted living residence by the Massachusetts Executive Office of Aging & Independence (AGE) on August 27, 2024.
Findings
The state cited 6 findings, including 4 repeat findings, matching the state median of 6. The action taken was Plan of correction required.
Citations (6)
Emergency call response and Food and dietary services: During the last ten days of July 2024 there were 125 emergency call response times over the fifteen minutes required by Residence policy. Menus lacked the required nutrition-standards statement (repeat finding).
Resident screening and assessment and Resident care plans: Documentation of individualized enrichment activities was missing in four Special Care Residence records and assessments by a physical/occupational therapist every six months were missing for five residents.
Quality assurance program: Documentation of review dates and responsible persons for follow-up to findings was missing for 2023. Observations included staff not practicing hand hygiene, missing medication labels, expired medication, and a medication without a documented open date (repeat finding).
Emergency drills and Incident reporting: Documentation of fire drills and elopement drills was missing for 2023. The Residence filed 19 incident reports more than 24 hours late (repeat finding).
Resident records: Correspondence logs did not consistently document all significant information necessary to maintain continuity of care.
Staff training: Biannual skills evaluations were not consistently documented for all Personal Care staff (repeat finding).
Report Facts
Findings: 6
Repeat findings: 4
State median findings: 6
Emergency call responses over limit: 125
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