Inspection Reports for
Notre Dame du Lac
555 Plantation St, Worcester, MA 01605, United States, MA, 01605
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Inspection Report — Jul 23, 2024
Routine
Date: Jul 23, 2024
Visit Reason
Biennial state compliance review of the assisted living residence by the Massachusetts Executive Office of Aging & Independence (AGE) on July 23, 2024.
Findings
The state cited 4 findings, including 2 repeat findings, which is below the state median of 6. The action taken was Plan of correction required.
Citations (4)
Emergency call response/Food and dietary services: During the first ten days of December 2022, April 2023 and June 2024 there were 43 emergency call response times over the fifteen minutes required by Residence policy, and menus lacked the required nutrition-standards statement.
Memory care unit: Bi-annual Special Care Residence operations reviews were not completed as required, documentation was missing for parts of 2023 and 2024, and an environmental hazard was identified with windows that could allow residents to exit unsafely (repeat finding).
Resident screening and assessment/Resident care plans: Three resident records were missing reassessment reviews every six months, five records were missing service plan reviews every six months, and documentation of physical/occupational therapist assessments for bed rail use was missing for eleven residents.
Quality assurance program: The Residence filed 31 incident reports more than 24 hours after incidents, was missing documentation for multiple required audits and reviews from 2022 through 2024, observed medication management and safety deficiencies, and had not submitted a required certification renewal application (repeat finding).
Report Facts
Findings: 4
Repeat findings: 2
State median findings: 6
Emergency call responses over limit: 43
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