Monastery Heights Senior Living and Memory Care

• Service and Service Coordination Requirements-

Self-Administered Medication Management (SAMM and LMA)

• EOEA reviewed nine 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 two Residents.

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 December 2023, June 2024 and March 2025, there were 367 e-call response times over the seven 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 Residence is complying with all the required safeguards.
• Documentation of the required review was incomplete for the second review of 2023 and both reviews of the 2024 calendar year reviewed.
• Age identified deficiencies with operational safeguards related to the risk of potential hazards in the physical environment:
• Cleaning chemicals and hair care products were unsecured in the kitchenette and accessible by Residents.
• The laundry door was unsecured, and cleaning chemicals were accessible by Residents.
• General Requirements for an Assisted Living Residence (ALR)-
• AGE reviewed the documentation of eight Resident Records from April 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- Bed Rail Assessments

• AGE reviewed the Residence records of 22 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 conducted by a physical/occupational therapist every six months for 15 Residents noting that the Resident can independently navigate around a bed rail/ U-bar was missing.

Service Plan Development and Requirements

• Three SCR records were missing documentation that Residents have supervised access to a heating element.
• Seven records were missing a physician evaluation required prior to move in.
• Two records were missing documentation of Resident goals.
• Two records were missing documentation of a service plan review required within 30 days after the commencement of residency.
• Three records were missing details of the Residence providing 24-hour per day, on site staff.
• Three records were missing how the Residence shall provide personal emergency response for Residents.
• Documentation of a service plan review required every six months or after a change in Resident condition, was missing for three 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 April 25, 2023, through the date of the Compliance Review.

Service Planning

• Documentation that each service plan is identified by number or code and identifying specific findings was missing for the 2023 and 2024 calendar years reviewed.

Resident Safety Assurances

• Documentation of the target date and the staff person responsible for follow-up action to the review ? findings were missing for the 2024 calendar year reviewed.

Medication Quality Plan

• AGE reviewed the Residence's quarterly medication documentation audits from April 25, 2023, through the date of the Compliance Review to ensure compliance with SAMM, LMA and Residence policies.
• Documentation of specific findings was missing for the 2023, 2024 and current 2025 calendar years reviewed.

Medication administration observation

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

SAMM

• AGE observed one Resident's documentation indicating that the morning medication had been provided outside the required administration timeframe.
• AGE observed medication unsecured outside one Resident's medication storage unit.
• AGE observed one Resident's pharmacy filled medication pack was missing a label indicating the name of the Resident and any medication information.
• Age observed one Resident's family filled medication cassette without any medication prescribed to be administered on the day of the compliance review.
• Reporting Resident-specific Emergencies- Incident Reports
• AGE reviewed the Residence records and incident reports from April 25, 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 70 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.
• AGE observed one Resident's controlled substance medication storage unit was unsecured as required by Residence policy.
• AGE observed one Resident's controlled substance medication blister packs were compromised.
• Resident Records- Progress Notes
• AGE reviewed nine Residents' records to determine compliance with record requirements.
• Documentation of significant occurrences in the Progress Notes was missing for two Residents.
• Record Requirements-

Personnel Record Requirements

• AGE reviewed the personnel records of nine staff members to determine compliance with personnel record requirements.
• Two personnel records were missing documentation of a signed job description.
• Four 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 Special Care 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 third quarter of 2023.
• Training Requirements

Introductory Visit and Review

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

Supervision

• AGE reviewed the records of four 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 reviewed.
• Reports to AGE - Additional Reporting Requirements
• AGE requires the Residence to report all information required by 651 CMR 12.03(2) within 30 days prior to the effective date of an alteration of the Residence operating plan and certification application.
• On December 6, 2024, AGE was made aware that the Residence had completed a name change. The Residence was provided with an updated Certificate reflecting the name change. During the April 24, 2025, compliance review site visit, AGE observed the Residence had not changed the signage in front of the Residence to reflect the name change as required.