1 Report
Inspection Report — Sep 5, 2024
Routine
Date: Sep 5, 2024
Visit Reason
Biennial state compliance review of the assisted living residence by the Massachusetts Executive Office of Aging & Independence (AGE) on September 5, 2024.
Findings
The state cited 5 findings, including 2 repeat findings, below the state median of 6. The action taken was Plan of correction required.
Citations (5)
Emergency call response: In the months of December 2022, June 2023, and July 2024 there were respectively 25, 40, and five emergency call response times over the ten minutes required by the Residence policy.
Resident care plans · Bed rail safety: Six Resident Records were missing documentation of signatures on Service Plan Assessments, and documentation of a physical/occupational therapist assessment was missing for four Residents using bed rails (repeat finding not indicated).
Quality assurance program: Two Residents were missing a label with their name and unit number identification on two Family Filled Medication cassettes (repeat finding).
Incident reporting: The Residence filed 54 incident reports greater than 24 hours after the occurrence of the incident during the period reviewed (repeat finding).
Resident records: The Residence did not use the Correspondence Logs to communicate all significant or pertinent information necessary to maintain the continuity of care for all Residents.
Report Facts
Findings: 5
Repeat findings: 2
State median findings: 6
Emergency call responses over the ten-minute limit: 40
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