Inspection Reports for
Brightview Danvers

Emergency call response: In June 2023 there were 224 emergency call response times over the ten minutes required by the Residence policy, and documentation of required six-month assessments by a physical/occupational therapist was missing for 10 Residents utilizing bed rails or similar devices (repeat finding).

Resident screening and assessment: Missing Bedrail assessments.

Quality assurance program: Documentation of all findings was missing for the fourth quarter of 2023 and second quarter of 2024, and one Resident had a compromised blister pack in the medication storage area (repeat finding).

Incident reporting: The Residence filed 20 incident reports more than 24 hours after the occurrence during the period reviewed (repeat finding).

Resident records: The Residence did not use the Correspondence Log to communicate all significant information necessary for continuity of care and did not consistently document for each 24-hour period (repeat finding).

Staffing: Three personnel records were missing documentation to confirm receipt or declination of the seasonal influenza vaccine.

Staff training: Four records were missing signature documentation to support that Introductory Visits were conducted with all applicable staff prior to or within 48 hours after the provision of Personal Care services (repeat finding).

Records given to the state: Records to determine compliance with emergency response times for December 2022 were not available for review.