Charter Senior Living of Danvers

• Reporting Resident-specific Emergencies- Incident Reports
• EOEA reviewed the Residences records and submitted incident reports from the last quarter of calendar year 2022 through the day of the compliance review for evidence that all occurrences of an incident or accident that has or may have a Significant Negative Effect on a Resident's health, safety or welfare were reported to EOEA within 24 hours after the occurrence of the incident during the period [...]
• The Residence filed 16 incident reports greater than 24 hours after the occurrence of the incident during the period reviewed.
• Service and Service Coordination Requirements-E-calls
• EOEA reviewed the Personalized Emergency Response procedures developed to provide timely assistance to a Resident in the event of an emergency needs situation.
• In the months of December 2023 and July 2024 there were 466 e-call response times over the ten minutes required by the Residence policy.
• The Residence is not consistently monitoring the reasons for late e-call response times in order to meet the service needs of Residents.
• The Residence has chosen to manually document hourly safety checks of Residents living in the Special Care Residence (SCR) to comply with the regulations to provide timely assistance to a Resident in the event of an emergency needs situation.
• Documentation of hourly checks in the Specialized Care Residence neighborhood was not auditable. Provider was not able to provide documentation for safety checks at the time of the Compliance Review.
• The Residence is not demonstrating an effective means of monitoring hourly safety checks to ensure staff is available to provide "timely assistance to Residents and prompt response to urgent or emergency needs" during those times when they are not visible in the common areas of the community.

Dietary Requirements

• EOEA reviewed the Residence's dietary plan reviews from 2023 through the date of compliance review to confirm consistency with the most recent edition of Dietary Guidelines.
• The review lacked the inclusion of the required language that the proposed menus meet the minimum dietary standards of the daily recommend allowances of sodium, sugar and fat content as established by the Food and Nutrition Board of the of the
• National Research Council of the National Academy of Sciences.
• Quality Assurance and Performance Improvement
• EOEA reviewed documentation to ensure the Residence has established an effective, ongoing quality improvement and assurance program for Service Planning, Resident
• Safety Assurances and Medication Quality for the calendar year of 2022(last quarter) and 2023.

Medication Quality Plan

• The Residence was missing clear findings, for set target date and staff responsible for follow-up in calendar years 2023 and 2024.

Medication administration observation

• EOEA observed one Medication Technician staff and two Nurses providing medication assistance to eight Residents to ensure the Residence has developed and implemented systems that support and promote safe SAMM and LMA:

SAMM

• One Resident had one over the counter bottle medication located on a footrest table in the resident room.
• One Resident had a loose pill medication in the SAMM medication locked box.

LMA

• One Resident had a two over the counter bottle medications missing pharmacy labels in the LMA medication locked box.
• One Resident had three over the counter bottle medications located on the table in the resident room.
• General Requirements for an Assisted Living Residence (ALR)
• EOEA reviewed seven Resident Records to determine compliance with requirements for the Screening and Assessment, Service Plan Development and Service Plan Requirements.

Screening and Assessment

• Two records were missing documentation of the Legal Representative and the scope of authority.
• Seven records were without documentation to confirm the initial assessment was conducted by a nurse.

Service Plan Development and Requirements

• Three SCR service plan records were missing Documentation of individualized enrichment activities provided to the resident.
• Two records were without documentation to confirm the ability of the Resident to manage medication.

Service Plan Requirements- Bed Rail Assessments

• EOEA reviewed the Residence records of 27 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.
• Documentation of an assessment confirming that the Resident can independently navigate around the bed rail/U-bar were missing for 9 Residents for the calendar year 2023 and 2024.
• Record Requirements - Correspondence Log
• EOEA reviewed the current 90-day Correspondence Log required to communicate information necessary to maintain the continuity of care for all Residents.
• The Residence did not use the Correspondence Log to communicate all significant or pertinent information necessary to maintain the continuity of care for all

Residents

• The Residence did not consistently document for each 24-hour period in each Correspondence Log.
• Training Requirements Introductory Visit and Review
• EOEA reviewed the records of seven Residents to determine compliance with the requirements that a nurse review 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.
• One record was missing signature documentation to support that Introductory Visits have been conducted with all applicable staff prior to or within 48 hours after the provision of Personal Care services.
• One record was missing documentation to support that Introductory Visits was conducted with all applicable staff with any change of condition.

Supervision

• EOEA reviewed the records of five Personal Care (PC) staff to determine compliance with Personal Care and SAMM skills evaluation requirements in the calendar year 2023 through the date of the Compliance Review.
• Documentation confirming the completion of Personal Care (PC) skills evaluations and SAMM evaluations every six months was missing from three records.
• Service and Service Coordination Requirements
• Self- Administered Medication Management (SAMM) and Limited Medication administration (LMA).
• EOEA reviewed the records of seven Residents to determine compliance with requirements with SAMM and LMA documentation.
• Seven records were missing staff initials/signatures or documentation which would indicate the observation of the Residents' actions regarding the medication (e.g., whether the Resident took or refused the medication, the date and time).
• Health Screening Requirements
• EOEA reviewed the personnel records of seven staff members to determine compliance with Health Screening requirements.
• Two records were missing documentation to confirm receipt or declination of the seasonal influenza vaccine
• Reports to EOEA
• In accordance with the regulation the Residence is required to submit reports to EOEA by a specified date/time period each year.
• The Residence did not submit the required notification for change in Assisted Living Residence Manager withing the required ten business days.