East Village Place

Emergency Response

• AGE reviewed the Personalized Emergency Response procedures developed to provide timely assistance to a Resident in the event of an emergency.
• The e-call response times were not made available at the date of site review.
• 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.
• 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.

B. General Requirements for an Assisted Living Residence (ALR)

• AGE reviewed the documentation of seven Resident records to determine compliance with the requirements for Screenings, Assessments, and Service Plan Development and Requirements.

Screening and Assessment

• Two records were missing documentation to confirm the Initial assessment was completed by a Nurse.

Service Plan Development and Requirements

• Four records were missing documentation of a service plan review required within 30 days after the commencement of residency.
• Three records were missing documentation of residents stated goal.

C. 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.

Service Planning

• Documentation that the Residence Identified by a number or code on the annual Service Planning conducted was missing for calendar year 2025.
• Documentation of follow- up action for a set target date for was missing for calendar 2025.

Resident Safety Assurances

• Documentation of follow -up action for a set target date was missing for calendar year 2024 and calendar year 2025.
• Documentation of monitoring the effectiveness of the Evidence Informed Falls Prevention Program as part of the Resident annual safety review process was missing for all years reviewed.

Medication administration observation

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

SAMM

• Three Residents missing the required label on the family filled medication cassettes.
• Three Residents had loose medication pills on the bottom of the SAMM medication box.
• One Resident dropped medication pill and the care staff failed to follow the dropped medication policy and handed residents the dropped medication.
• One resident in a shared unit was missing the required label on medication box.

D. Incident Reports

• AGE reviewed the Residence records and incident reports 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 20 incident reports greater than 24 hours after the occurrence of the incident or accident.

E. Controlled Substances

• AGE reviewed the Controlled Substance (CS) policy and procedure for Residents who participate in SAMM.
• Multiple residents with narcotic medication packaged in a multipack pharmacy filled SAMM bubble pack. This prevents the staff ability to Identify and perform an accurate narcotic count
• Upon review of the Control Substance policy, AGE noted the Residence Is missing addressing safe disposal.
• One Resident In a shared unit did not have a clear label separation of narcotic med box.

Introductory Visit and Review

• AGE 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 48 hours after the provision of personal care services or with any change of condition of the Resident.
• Five records were missing signature documentation to support that Introductory Visits had been conducted with all applicable staff prior to or within 48 hours after the provision of Personal Care services, at the time of move-in, or at the time of change in the Resident's condition.

LGBTQ Training

• AGE reviewed seven personnel records to determine compliance with training requirements.
• Six records were missing documentation to confirm completion of required LGBTQ training.

General Orientation

• AGE reviewed the personnel records of seven staff members to determine compliance with orientation requirements.
• Documentation of General Orientation for three staff records was incomplete.

G. Special Care

• AGE reviewed the Special Care Residence (SCR) operations review for the period reviewed to verify that the SCR is operating with all the required safeguards.

AGE observed the Special Care Residence:

• AGE identified window tilt feature not secured.

H. Record Requirements- Correspondence Log

• AGE reviewed the documentation maintained in the 90-day correspondence logs for the Traditional and Special Care units to communicate information necessary to maintain the continuity of care for Residents.
• The documentation for Traditional log did not consistently document all significant or pertinent information necessary to maintain the continuity of care for all Residents.

I. General Requirements for an Assisted Living Residence - Bed Rail Assessments

• AGE reviewed the Residence records of 15 Residents utilizing bed rails / U-bars or similar devices to determine compliance with the required assessment by a physical/occupational therapist every six months.
• Documentation of an assessment conducted by a physical/occupational therapist every six months for four Residents noting that the Resident can independently navigate around a bed rail/ U-bar was missing.

J. Resident Rights and Disclosures- Resident Disclosures

• AGE reviewed seven Resident records to determine compliance with providing consumer guides to prospective Residents.
• The required disclosure forms of the Residence's delivery of a consumer guide to the prospective Resident at the first meeting were missing in five records.

Identify the designation of the individual(s) who will be responsible for monitoring the correction; and,

• The date by which each correction will be achieved.
• B. Specific Corrective Actions.

Submit to AGE the following:

• 1.Documentation confirming an Annual Safety Review including an Evidenced Informed Falls Prevention review to monitor the effectiveness of the program by the Fall Risk Committee has been completed.
• 2.Documentation confirming the training regarding Controlled Substance policies / procedures for all nursing and applicable Personal Care staff has been completed.
• 3.Documentation confirming that Introductory Visits have been completed by a nurse with all Personal Care staff for all Residents.
• 4. Documentation confirming current biannual personal care skills evaluations have been completed by a nurse for all Personal Care staff.
• 5.Documentation of current training for all staff regarding procedures on SCR Units door alarm response times.

V. NEXT STEPS:

• In accordance with 651 CMR 12.09(4)(g), you are required to respond in writing to AGE within ten (10) days after receiving this notice indicating your agreement or disagreement with the findings. If you agree with the findings, please submit in writing to AGE all required information/corrections by May 4, 2026
• If you disagree with the findings, you may request an informal review pursuant to 651 CMR 12.10(1) by submitting your request using certified mail, return receipt requested, together with a detailed written rebuttal of the findings within ten (10) days of your receipt of this letter.
• If you have any questions regarding this matter, please email ALRHelp@mass.gov.