1 Report
Inspection Report — Jul 25, 2024
Routine
Date: Jul 25, 2024
Visit Reason
Biennial state compliance review of the assisted living residence by the Massachusetts Executive Office of Aging & Independence (AGE) on July 25, 2024.
Findings
The state cited 8 findings, including 3 repeat findings, which is above the state median of 6. The action taken was a plan of correction required.
Citations (8)
Emergency call response: During April 2023 and June 2024 there were 57 emergency call response times over the ten minutes required by Residence policy (repeat finding).
Memory care unit: An environmental hazard was identified with an oven in the Special Care Residence common area being operational without staff assistance.
Resident screening and assessment · Resident care plans: Six resident records were missing documentation of a service plan reassessment within 30 days of residency commencement, and multiple other required reassessments and documentation were missing (repeat finding).
Quality assurance program: Documentation was missing for Safety Reviews in 2022, 2023, and 2024, medication audits lacked target dates and responsible staff, and unsecured or refused medications were improperly stored (repeat finding).
Incident reporting: The Residence filed 29 incident reports more than 24 hours after the occurrence of the incident or accident.
Resident records: Correspondence logs did not consistently document all significant information necessary to maintain continuity of care.
Staff training: Documentation was inconsistent for Introductory Visits and biannual skills evaluations were missing for some personal care staff.
Records given to the state: Records for emergency call responses for December 2022 were not available for review by EOEA.
Report Facts
Findings: 8
Repeat findings: 3
State median: 6
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