Inspection Reports for
Duxbury House Memory Care Residence

Resident screening and assessment: Five resident records lacked documentation confirming the initial assessment was conducted by a nurse, and documentation of individualized enrichment activities was missing in five Special Care Residence records. Documentation of a physical/occupational therapist assessment every six months was missing for four residents (repeat finding not indicated).

Incident reporting: The residence filed eleven incident reports more than 24 hours after the occurrence of the incident or accident (repeat finding).

Resident records: The second-floor correspondence log did not consistently document all significant or pertinent information necessary to maintain the continuity of care for all residents.

Staff health screening: Two personnel records were missing documentation to confirm seasonal influenza vaccinations or declination statements for the 2023/2024 flu season.

Staff training: Three records lacked documentation supporting that Introductory Visits were consistently conducted with all applicable staff prior to or within 48 hours, at move-in or change of condition (repeat finding).

Information given to residents: Documentation was missing for providing a Disclosure of Rights and Services and informing residents of the right to be accompanied by a Legal Representative for three residents.