Ruggles Assisted Living

• Service and Service Coordination Requirements 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, August 2024 and October 2025, there were 509 e-call response times over the 5-minute limit.
• Documentation of the Residence monitoring late response times was missing for December 2023, August 2024 and October 2025.
• Documentation of the Residence testing the system to ensure functionality was missing for the 2023, 2024 calendar years reviewed, and 2025 through the date of the compliance review.

Dietary Reviews

• AGE reviewed the Residence's dietary plan reviews 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 2024 and current 2025 Dietary Reviews did not include the full required statement affirming that the meal selections meet the minimum dietary standards for 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 to determine compliance with the requirements for Screenings, Assessments, and Service Plan Development and Requirements.

Screening and Assessment

• Two records were missing documentation noting the name and scope of any Legal Representative.

Service Plan Development and Requirements

• One record was missing documentation of a service plan at the time of move in.
• Five records were missing documentation of a physician evaluation prior to move in. Physician evaluations reviewed by AGE qualified residents for Exemption C Exemption C .
• Two records were missing documentation of Resident goals.
• Four 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 four records.

Bed Rail Assessments

• AGE reviewed the Residence records of all Residents utilizing bed rails / U-bars or similar devices to determine compliance with the required assessment by a physical/occupational therapist every six months.
• AGE observed one Resident's bed with Exemption C after Residence management stated that no current Residents were utilizing Exemption C . Documentation of a current assessment noting that the Resident can independently navigate around Exemption C was missing.
• 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 of a Service Plan review was missing for the 2023, 2024 calendar years reviewed, and 2025 through the date of the compliance review.

Resident Safety Assurances

• Documentation that an audit was completed was missing for the 2023, 2024 calendar years reviewed, and 2025 through the date of the compliance review.
• Documentation of the Residence monitoring the Evidence Informed Falls Prevention Program was missing for the 2023, 2024 calendar years reviewed, and 2025 through the date of the compliance review.

AGE reviewed the Residence's quarterly medication documentation audits to

• ensure compliance with SAMM and Residence policies.
• Documentation of a Medication Quality Plan review being completed was missing for the fourth quarter of 2023, all quarters of 2024 and 2025 through the date of the compliance review.

Medication administration observation

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

SAMM

• AGE observed a loose unidentified pill in one Resident's medication storage unit.

AGE observed a compromised medication blister pack in one Resident's

• medication storage unit.
• Reporting Resident-Specific Emergencies

Evacuation Drills and Rehearsals

• AGE reviewed the Residence's Emergency Plan to ensure that the Residence can address potential disasters and emergencies.
• Documentation of fire drills was missing for the first and third shifts of 2023 and the second and third shifts of 2024. Fire drill documentation reviewed by AGE did not include lists of attendees.
• Documentation of a missing persons / elopement drill was missing for all shifts during the 2023, 2024 calendar years reviewed and 2025 through the date of the compliance review.

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 31 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.
• The Residence's Controlled Substance policy was incomplete and failed to include required procedures for reporting medication discrepancies.
• CS count procedure by staff was inconsistent with policy on the day of the compliance review.
• Three Residents' CS medications were not secured as required by Residence policy.
• Resident Records- Progress Notes
• AGE reviewed five Residents' records to determine compliance with record requirements.
• Documentation of significant occurrences in the progress notes was missing for two 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 assessments was missing for the fourth quarter of 2023, all quarters of 2024 and 2025 through the date of the compliance review.

Health Screening Requirements

• AGE reviewed the personnel records of five staff members to determine compliance with health screening requirements.
• Three 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 an annual training needs assessment was missing for the 2023 and 2024 calendar years reviewed.

Introductory Visit and Review

• AGE reviewed the records of five Residents to determine compliance with the requirements that a nurse reviews the Resident's service plan with all relevant personal care workers within 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 by a nurse with all applicable staff.

Supervision

• AGE reviewed the records of two Personal Care (PC) staff to determine compliance with SAMM skills and Personal Care evaluation requirements.
• Documentation confirming the completion of SAMM and personal care skills evaluations every six months was missing from two records for the 2024 and 2025 calendar years reviewed.

LGBTQ Training

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

I. Compliance Reviews of Assisted Living Residences - Compliance Review Requirements

• AGE reviewed Resident records as required by 651 CMR 12.09.
• By the completion of the compliance review the following requested Residence documentation and / or records were not auditable or provided in a timely manner:
• Residency Agreement and disclosure of rights and services records were not provided to AGE in an auditable format prior to the completion of the compliance review. Although some documents were observed in the clinical record, the required information was not presented appropriately, and the completed Resident business record auditing tools were not returned to AGE by the end of the review.
• The Residence provided limited staff information required for the compliance review concerning staff licensure & certification, general orientation & training, and job descriptions. Residence management stated that the actual records are stored off-site and were not presented to AGE before the completion of the compliance review.
• Three Residents were each missing multiple months of Medication Administration Records (MARs) in their clinical record. Management stated that those records had been scanned and stored on a computer system and were not presented to AGE before the completion of the compliance review.