1 Report
Inspection Report — Jan 3, 2025
Routine
Date: Jan 3, 2025
Visit Reason
Biennial state compliance review of the assisted living residence by the Massachusetts Executive Office of Aging & Independence (AGE) on January 3, 2025.
Findings
The state cited 5 findings, including 3 repeat findings, which is below the state median of 6. The action taken was a plan of correction required.
Citations (5)
Emergency call response: In the month of April 2023 there were 320 e-call response times over the 15 minutes required by the Residence policy, and similar delays occurred in December 2023 and November 2024.
Resident screening and assessment · Resident care plans: Several resident records lacked documentation confirming the name and scope of any Legal Representative, assessment results for allergies and diagnosis, descriptions of services not affiliated with the residence, and required reassessments and service plan reviews (repeat finding).
Quality assurance program: The residence's quality assurance program was missing or incomplete components, including unlabeled medication cassettes and an undated opened medication container (repeat finding).
Incident reporting: The residence filed 12 incident reports more than 24 hours after the occurrence of the incidents during the period reviewed (repeat finding).
Resident records: The computerized resident records system did not consistently provide an auditable record of service plan entries, and correspondence logs did not communicate all significant information necessary for continuity of care.
Report Facts
Findings: 5
Repeat findings: 3
State median findings: 6
Emergency call responses over limit: 320
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