1 Report
Inspection Report — Oct 21, 2025
Routine
Date: Oct 21, 2025
Visit Reason
Biennial state compliance review of the assisted living residence by the Massachusetts Executive Office of Aging & Independence (AGE) on October 21, 2025.
Findings
The state cited 6 findings, including 3 repeat findings, matching the state median of 6. The action taken was a plan of correction required.
Citations (6)
Emergency call response: During December 2023 and October 2025, there were 12 emergency call response times over the 15-minute limit, and documentation of monitoring late response times was missing for December 2023.
Memory care unit: Staff training deficiencies were identified in the Special Care Residence, with only one staff responding to triggered door alarms on Wing C.
Quality assurance program: Documentation of audit completion dates was missing for 2024 and 2025 calendar years, nurses were observed providing medication assistance, one nurse pre-signed LMA documentation, and one compromised medication blister pack was found (repeat finding).
Incident reporting: The Residence filed 58 incident reports more than 24 hours after the occurrence of an incident or accident (repeat finding).
Resident records: Two Special Care Residence logs did not consistently document all significant or pertinent information necessary for continuity of care (repeat finding).
Staff training: Documentation confirming completion of biannual skills evaluations was missing from three Personal Care staff records.
Report Facts
Findings: 6
Repeat findings: 3
State median findings: 6
Loading inspection reports...
