1 Report
Inspection Report — Feb 11, 2025
Routine
Date: Feb 11, 2025
Visit Reason
Biennial state compliance review of the assisted living residence by the Massachusetts Executive Office of Aging & Independence (AGE) on February 11, 2025.
Findings
The state cited 5 findings, including 3 repeat findings, which is below the state median of 6. The action taken was Plan of correction required.
Citations (5)
Emergency call response: In the month of December 2023 there were 497 e-call response times over the 12 minutes required by the Residence policy, and similar delays occurred in May and December 2024 (repeat finding).
Resident screening and assessment · Resident care plans: Multiple resident records were missing documentation for legal representative assessments, allergies, diagnoses, service descriptions, supervised heating element access, resident behaviors, initial service plans, and service plan reassessments.
Quality assurance program: Documentation of target date for follow up concerning findings was missing for the 2023 calendar year reviewed (repeat finding).
Incident reporting: The Residence filed 55 incident reports greater than 24 hours after the occurrence of the incident during the period reviewed (repeat finding).
Staff training: Documentation of the nurse signature for PCA skills evaluations every six months of calendar year 2024 were missing for four PCA records reviewed.
Report Facts
Findings: 5
Repeat findings: 3
State median findings: 6
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