Grove Manor Estates

Service and Service Coordination Requirements - Emergency Response

• The Residence has chosen to manually document hourly safety checks of Residents living in the Special Care Residence to comply with the regulation to provide timely assistance to a Resident in the event of an emergency needs situation.
• Documentation of hourly safety checks for March 2023 through the date of compliance review had multiple instances where staff failed to document the hourly safety checks of the Residents during the hours of 7:00 p.m. and 7:00 a.m.

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

• AGE reviewed seven Resident Records reviewing documentation from March 2023 through the date of the Compliance Review to determine compliance with the requirements for Screenings, Assessments and Service Plan Development and Requirements.

Service Plan Development and Requirements

• Two records were missing documentation of a service plan review required within 30 days after the commencement of residency.
• Four records were missing documentation of a reassessment and service plan review being completed every six months.

Bed Rail Assessments

• AGE reviewed the Residence records of 22 Residents utilizing bed rails / U-bars or similar devices from calendar year 2023 through the date of the Compliance Review to determine compliance with the required assessment by a physical/occupational therapist every six months.
• Four of the 22 records were missing documentation of a current assessment noting that the Resident can independently navigate around a bed rail/ U-bar were missing.

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 from March 2023, through the date of the Compliance Review.

Service Planning

• Documentation of the target date and person responsible for follow up action were missing for the 2023 and 2024 calendar years.

Medication Quality Plan

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

Medication administration observation

• AGE observed three PC staff and one nurse providing medication assistance to eight Residents to ensure the Residence has developed and implemented systems that support and promote safe SAMM / LMA.

SAMM

• AGE observed two Resident's family filled medication cassettes without a label of the Resident's name and Unit number.
• AGE observed one Resident's family filled medication cassette not secured in the medication storage unit.

LMA

• AGE observed one Resident's medication storage unit that contained one medication from a prior day that had not been administered.

D. Reporting Resident-specific Emergencies- Incident Reports

• AGE reviewed the Residence records and incident reports from March 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 19 incident reports greater than 24 hours after the occurrence of the incident or accident.

E. Controlled Substances

• AGE reviewed the Controlled Substance policy and procedure to provide safeguards to prevent theft and dispose of controlled substances prescribed to Residents who participate in SAMM.
• The Residence policy does not include steps regarding the safeguards for storage and disposal of controlled substances.

F. Record Requirements- Personnel Record Requirements

• AGE reviewed the personnel records of seven staff members to determine compliance with personnel record requirements.
• Three records were missing documentation of a signed job description.
• Two Personal Care (PC) records were missing documentation of current licensure or certification.

G. Record Requirements - Correspondence Log

• AGE reviewed the current Correspondence Log, for both the Traditional and Special Care Residence, required to communicate information necessary to maintain the continuity of care for all Residents.
• The Residence did not use the Traditional Correspondence Log to communicate all significant or pertinent information necessary to maintain the continuity of care for all Residents.

H. Staffing Requirements- Health Screening Requirements

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

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 three records for the 2024 calendar year.

A specific plan of what will be or has been done to correct each of the cited in Section II above;

• Provide a description of what will be done to prevent the recurrence of each of the issue(s) identified in Section II to ensure the problem does not recur;

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.

Submit to AGE the following:

• Documentation of completion of bed rail assessments for all Residents using a bed rail/ U-bar.
• Documentation of completion of a revised Controlled Substance policy and procedure to provide safeguards for storage and disposal of controlled substances.
• Documentation of completion of all Personnel Record requirements for all personnel.
• Documentation to support that Introductory Visits were consistently conducted with all applicable staff.
• Documentation confirming the completion of SAMM and skills evaluations for all PCA staff.

V. NEXT STEPS:

• In accordance with 651 CMR 12.09(4)(g), you are required to respond in writing to AGE within 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 30, 2025.
• 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 10 days of your receipt of this letter.
• If you have any questions regarding this matter, please contact me at 617-222-7411 or by email at Christopher.mundy2@mass.gov