Inspection Reports for
The Residence at Boylston Place

Medication assistance: Documentation of actions regarding whether the Resident took or refused the medication on multiple dates and times was missing for two Residents.

Resident screening and assessment · Resident care plans: Four records were missing documentation of a service plan reassessment required within 30 days after the commencement of residency, signatures of the Resident or Legal Representative, and documentation of a reassessment review being completed every six months; documentation of individualized enrichment activities was missing in two Special Care Residence records.

Quality assurance program: Documentation of the date the audit was conducted, the target date for follow up to findings and clear outcomes was missing for the 2023 calendar years reviewed. Documentation of the staff person responsible for follow-up action was missing for the 2023 and 2024 calendar years reviewed. Documentation of a quarterly medication review was missing for the fourth quarter of the 2022 calendar year. Unsecured medications were observed in two SAMM Resident apartments, expired medications in one Resident’s medication storage container, and medications without a pharmacy label stored in one Resident’s medication storage container (repeat finding).

Incident reporting: The Residence filed 58 incident reports greater than 24 hours after the occurrence of the incident or accident (repeat finding).

Controlled medication handling: One Resident’s Controlled Substance Log Book does not list the name of the controlled medications being monitored to prevent theft.

Resident records: The Traditional log did not consistently document all significant or pertinent information necessary to maintain the continuity of care for all Residents.

Staffing: Documentation to confirm the Residence conducted quarterly staffing level assessments was missing for all quarters of 2023, and the first two quarters of 2024.

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

Staff training: Documentation of General Orientation for two staff records were missing. Documentation of annual training needs assessments was missing for the 2022 and 2023 calendar years reviewed. Five records were without documentation to support that Introductory Visits were consistently conducted with all applicable staff prior to or within 48 hours, at the time of move-in or at the time of change in the Resident’s condition. A Disclosure of Rights and Services was missing in four records. The required notification of the right to bring a Representative prior to the first meeting were missing in four records.

Information given to residents: Missing Full Disclosure of Rights and Services.

Compliance review process: EOEA was not provided timely access to the requested Residence records including SCR Resident Safety Checks for August and September 2024, monthly documentation of SCR Safety Checks for four SCR Residents, and E-call response times for December 2022, June 2023 and September 2024.