Brookmeadow at Cobb Corner Assisted Living Residence

• Service and Service Coordination Requirements-

Self-Administered Medication Management (SAMM)

• EOEA reviewed seven Resident Records to determine compliance with requirements for Self-administered Medication Management (SAMM).
• Documentation of actions regarding whether the Resident took or refused the medication on multiple dates and times was missing for three Residents.

Emergency Response

• AGE reviewed the Personalized Emergency Response procedures developed to provide timely assistance to a Resident in the event of an emergency.
• Documentation of e-call response times over the eight-minute limit was missing for the months of December 2023 and June 2024.
• During the four days reviewed for April 2025, there were 23 e-call response times over the eight-minute limit.
• The Residence has chosen to manually document hourly safety checks of Residents living in the Special Care Residence (SCR) to provide timely assistance in the event of an emergency needs situation during the hours of 7:00 p.m. and 7:00 a.m.
• Documentation of hourly safety checks from April 1, 2025 through the date of the compliance review for 24 Residents had multiple instances where staff failed to document the hourly safety checks of the Residents during the hours required.

Dietary Reviews

• EOEA reviewed the Residence's dietary plan reviews from June 2023 through the date of the Compliance Review to confirm consistency with the most recent edition of the Dietary Guidelines.
• A Dietary Review was missing for the second half of the 2024 calendar year.
• The June 2023 Dietary Review lacked the inclusion of the required language designation that the meal selections meet the minimum dietary standards of the daily recommended allowances of sodium, sugar and fat content as established by the Food and Nutrition Board of the National Research Council of the National Academy of Sciences.
• General Requirements for an Assisted Living Residence (ALR)-
• AGE reviewed the documentation of five Resident Records from June 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

• Two records were without documentation to confirm that assessments noted the name and scope of any Legal Representative.

Bed Rail Assessments

• AGE reviewed the Residence records of three Residents utilizing bed rails / U-bars or similar devices for the period of 2023 through the date of the Compliance Review to determine compliance with the required assessment by a physical/occupational therapist every six months.
• Six records were missing documentation of a current assessment noting that the Resident can independently navigate around a bed rail/ U-bar.

Service Plan Development and Requirements

• Three records were missing documentation of a service plan review required within 30 days after the commencement of residency.
• Documentation of a service plan review required every six months or after a change in Resident condition, was missing for five records.
• 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 June 14, 2023, through the date of the Compliance Review.

Service Planning

• Documentation that an audit was completed for the 2023 calendar year was missing.
• Documentation of the date and person responsible for follow up action was missing for the 2024 calendar year reviewed.

Resident Safety Assurances

• Documentation of the date the audit was completed was missing for the 2023 and 2024 calendar years reviewed.
• Documentation of the target date, person responsible for follow up action and clear outcomes was missing for the 2024 calendar year reviewed.

Medication Quality Plan

• AGE reviewed the Residence's quarterly medication documentation audits from June 14, 2023, through the date of the Compliance Review to ensure compliance with SAMM and Residence policies.
• Documentation that an audit was completed for the last three quarters of the 2023 calendar year was missing.
• Documentation of the target date for follow up action was missing for the 2024 calendar year reviewed.
• Documentation of the person responsible for follow up action was missing for the 2024 calendar year reviewed and the first quarter of 2025.

Medication administration observation

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

SAMM

• AGE observed two Residents with over-the-counter medications unsecured in their units.
• AGE observed one Resident with a compromised medication blister pack.
• Reporting Resident-specific Emergencies- Incident Reports
• AGE reviewed the Residence records and incident reports from June 14, 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 18 incident reports greater than 24 hours after the occurrence of the incident or accident.
• Record Requirements-

Personnel Record Requirements

• AGE reviewed the personnel records of seven staff members to determine compliance with personnel record requirements.
• Five personnel records were missing documentation of a signed job description.
• Two records were missing documentation of reports of criminal offender record information prior to their hire date.

Correspondence Log

• AGE reviewed all current Correspondence Logs required to communicate information necessary to maintain the continuity of care for all Residents.
• The logs did not contain documentation on each for each 24-hour period during the 90-day period previous to the compliance review as required.
• The Traditional log did not consistently document all significant or pertinent information necessary to maintain the continuity of care for all Residents.
• Staffing Requirements-

Staffing Levels

• AGE reviewed the Residence records to determine compliance with Staffing Level requirements.
• Documentation to confirm the Residence conducted quarterly staffing level assessment was missing for the first and second quarter of 2024.

Health Screening Requirements

• AGE reviewed the personnel records of seven staff members to determine compliance with Health Screening requirements.
• Seven records were missing documentation to confirm seasonal influenza vaccinations or declination statements for the 2024/2025 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 the 2023 calendar year reviewed.

Introductory Visit and Review

• AGE reviewed the records of seven 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:
• Two records were without documentation to support that Introductory Visits were consistently conducted with all applicable staff.

Supervision

• AGE reviewed the records of five 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 five records for the 2024 calendar year reviewed.