1 Report
Inspection Report — May 7, 2025
Routine
Date: May 7, 2025
Visit Reason
Biennial state compliance review of the assisted living residence by the Massachusetts Executive Office of Aging & Independence (AGE) on May 7, 2025.
Findings
The state cited 6 findings, 5 of which were repeats from the previous review. The action taken was a plan of correction required.
Citations (6)
Emergency call response: In the months of December 2023, June 2024, and February 2025 there were 1,047 e-call response times over the 10 minutes required by Residence policy, and documentation of monitoring and testing was inconsistent or missing (repeat finding).
Resident care plans: Three SCR records were missing documentation of 24-hour onsite awake staff, and seven records lacked current assessment of residents' ability to navigate bed rails or similar devices (repeat finding).
Quality assurance program: Documentation of review dates and staff responsible for follow-up was missing for 2023 and 2024, evidence-informed falls prevention documentation was missing for 2023, medication review summaries were missing for late 2023, and medication storage units contained unlabeled or improperly paired medications (repeat finding).
Controlled medication handling: Documentation to support controlled substance count audits was missing for all years reviewed.
Incident reporting: The Residence filed 30 incident reports more than 24 hours after the occurrence of the incident or accident (repeat finding).
Staff training: Seven records lacked nurses’ signatures verifying Introductory Visits, and three staff lacked documented personal care and SAMM skills evaluations every six months in 2024 and 2025 (repeat finding).
Report Facts
Findings: 6
Repeat findings: 5
State median findings: 6
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