1 Report
Inspection Report — Feb 25, 2025
Routine
Date: Feb 25, 2025
Visit Reason
Biennial state compliance review of the assisted living residence by the Massachusetts Executive Office of Aging & Independence (AGE) on February 25, 2025.
Findings
The state cited 6 findings, including 4 repeat findings, matching the state median of 6. The action taken was a plan of correction required.
Citations (6)
Emergency call response: During the months of October 2024 and January 2025, there were 138 e-call response times over the seven (7) minute limit.
Resident screening and assessment: Missing Bed Rail Assessments (repeat finding).
Quality assurance program: Documentation of the review identifying a staff person for follow-up action was missing for 2024, and medication administration record documentation was missing from one Resident’s medication storage container (repeat finding).
Incident reporting: The Residence filed 19 incident reports greater than 24 hours after the occurrence of the incident or accident.
Resident records: Two personnel records were missing documentation of a signed job description, and communication logs did not consistently document all necessary information (repeat finding).
Staff training: Documentation of general orientation and annual training needs assessments was missing for some staff, and biannual SAMM evaluations were not consistently documented (repeat finding).
Report Facts
Findings: 6
Repeat findings: 4
State median findings: 6
Emergency call responses over limit: 138
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