All American Assisted Living at Wrentham

• Service and Service Coordination Requirements- Emergency Response
• AGE reviewed the Personalized Emergency Response procedures developed to provide timely assistance to a Resident in the event of an emergency.
• During the months of June 2023, December 2024 and March 2025, there were 613 e-call response times over the 10-minute limit.
• Service and Service Coordination- Special Care
• AGE reviewed the Special Care Residence (SCR) operations on the date of the Compliance Review to verify that the SCR is complying with all the required safeguards.
• Age identified deficiencies with operational safeguards related to the risk of potential hazards in the physical environment:
• Residence staff did not respond to door alarms when triggered.
• One Resident accessible Exemption C was operational without required safeguards to only allow supervised access.
• Aquarium chemicals and fish food were unsecured and accessible by Residents.
• General Requirements for an Assisted Living Residence (ALR)-
• AGE reviewed the documentation of eight Resident Records from January 2023 through the date of the Compliance Review to determine compliance with the requirements for Screenings, Assessments and Service Plan Development and Requirements.

Screening and Assessment

• Three records were missing documentation of an initial assessment being completed by a nurse.
• Three records were without documentation to confirm that assessments noted the name and scope of any Legal Representative.

Service Plan Development and Requirements

• Five SCR records were missing documentation that Residents have supervised access to a heating element.
• Four records were missing documentation of a service plan review required within 30 days after the commencement of residency.
• Documentation of individualized enrichment activities provided to the residents was missing in two Special Care Residence (SCR) records.
• Documentation of a service plan review required every six months or after a change in Resident condition, was missing for six records.
• Four records were missing signatures of a Residence Representative.
• Four records were missing signatures of the Resident or Legal Representative.
• Quality Assurance and Performance Improvement
• AGE reviewed documentation to ensure the Residence has established an effective, ongoing quality improvement and assurance program for Service Planning, Safety Assurances, and Medication Quality from January 12, 2023, through the date of the Compliance Review.

Service Planning

• Documentation of the date the audit was completed was missing for the 2023 calendar year reviewed.
• Documentation of the clear findings was missing for the 2023 and 2024 calendar years reviewed.

Resident Safety Assurances

• Documentation of the staff members responsible for follow-up action was missing for the 2023 and 2024 calendar years reviewed.

Medication Quality Plan

• AGE reviewed the Residence's quarterly medication documentation audits from January 12, 2023, through the date of the Compliance Review to ensure compliance with SAMM, LMA and Residence policies.
• Documentation of the target date for follow-up action was missing for the second and third quarters of the 2023 calendar year reviewed.
• Documentation of the staff person responsible for follow-up action was missing for the first quarters of the 2023 and 2024 calendar years reviewed.

Medication administration observation

• AGE observed one Personal Care (PC) staff and one nurse providing medication assistance to six Residents to ensure the Residence has developed and implemented systems that support and promote safe SAMM and LMA.

LMA

• AGE observed a pharmacy provided medication present in one Resident's medication storage unit, with a similar name to the Resident's prescribed medication, that was identified by AGE to be a fulfillment error by the pharmacy.
• AGE observed a compromised medication bubble pack stored in one Resident's medication storage unit.
• AGE observed the nurse documenting the completion of the medication pass prior to administering the medication for three Residents.
• Reporting Resident-specific Emergencies- Incident Reports
• AGE reviewed the Residence records and incident reports from January 12, 2023, through the date of the Compliance Review to determine whether the Residence complied with the requirement to report qualifying incidents to AGE within 24 hours after the occurrence of the incident or accident.
• The Residence filed 26 incident reports greater than 24 hours after the occurrence of the incident or accident.
• Controlled Substances
• AGE reviewed the Controlled Substance (CS) policy and procedure for Residents who participate in SAMM / LMA.
• Upon reviewing the controlled substance practices of the Residence; AGE observed the controlled substance count did not follow the procedures stated in the Residence policy.
• Record Requirements-

Personnel Record Requirements

• AGE reviewed the personnel records of eight staff members to determine compliance with Personnel Record requirements.
• Reports of criminal offender record information (CORI) checks prior to hire was inconsistent for three records.

Correspondence Log

• AGE reviewed the current Correspondence Logs, for both the Traditional and Special Care Residence, required to communicate information necessary to maintain the continuity of care for all Residents.
• Both logs did not consistently document all significant or pertinent information necessary to maintain the continuity of care for all Residents.
• Staffing Requirements- Health Screening Requirements
• AGE reviewed the personnel records of eight staff members to determine compliance with Health Screening requirements.
• Three records were missing documentation to confirm seasonal influenza vaccinations or declination statements for the 2023/2024 flu season.
• Training Requirements

Training Needs Assessment

• AGE reviewed the Residence records to determine compliance with annual training needs assessment requirements.
• Documentation of annual training needs assessments was missing for 2023 and 2024

Introductory Visit and Review

• AGE reviewed the records of eight Residents to determine compliance with the requirements that a nurse reviews the Resident's service plan with all relevant personal care workers within the 48 hours after the provision of service or with any change of condition for the Resident:
• Six records were without documentation to support that Introductory Visits were consistently conducted with all applicable staff.

Supervision

• AGE reviewed the records of four (4) Personal Care (PC) staff to determine compliance with SAMM skills and Personal Care evaluation requirements in the calendar year 2023 through the date of the Compliance Review.
• Documentation confirming the completion of SAMM and skills evaluations every six months was missing from two records for 2023 and from four records for the 2024 calendar year reviewed.
• Resident Rights and Disclosures- Resident Disclosures
• AGE reviewed eight Resident records to confirm compliance with the Disclosure of Rights and Services requirements.
• The required disclosure of the Residences' delivery of a consumer guide to the prospective Resident at the first meeting was missing in two records.
• The required disclosure of the AGE informational cover sheet was missing in two records.