The Arbors at Stoneham

• Service and Service Coordination Requirements- Emergency Response
• EOEA reviewed the Personalized Emergency Response procedures developed to provide timely assistance to a Resident in the event of an emergency needs situation.
• During the months of April 2023 and June 2024 there were 57 e-call response times over the ten (10) minutes required by Residence policy.
• Documentation of Residence management monitoring response times over the ten
• (10) minute limit was missing for April 2023.
• Service and Service Coordination- Special Care
• EOEA reviewed the Special Care Residence (SCR) operations review from calendar year 2022 through the date of the Compliance Review to verify that the SCR is being administered with all the required safeguards.
• On the day of the Compliance Review, EOEA identified an environmental hazard of an oven in the SCR common area which was operational without staff assistance.
• General Requirements for an Assisted Living Residence (ALR)-
• EOEA reviewed six (6) Resident Records reviewing documentation from September 2022 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

• Six (6) records were missing documentation of a service plan reassessment required within 30 days after the commencement of residency.
• Five (5) records were missing documentation of a reassessment being completed every six months.

Service Plan Development and Requirements

• Three (3) records were missing documentation of specified staff having key or access codes to the Resident's unit.
• Six (6) records were missing documentation of a service plan review required within 30 days after the commencement of residency.
• Three (3) records were missing documentation of how the Residence provides 24-hours per day, onsite staff.
• Documentation of individualized enrichment activities provided to the resident was missing in two (2) Special Care Residence (SCR) records.
• Five (5) records were missing documentation of a service plan review being completed every six months.

Bed Rail Assessments

• EOEA reviewed the Residence records of twelve (12) Residents utilizing bed rails / U-bars or similar devices for the period of 2022 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 six (6) Residents noting that the Resident can independently navigate around a bed rail/ U-bar for the calendar years reviewed was missing.
• 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, Safety Assurances, and Medication Quality from July 14, 2022, through the date of the Compliance Review.

Resident Safety Assurances

• Documentation of the date of the Safety Review was missing for the 2022, 2023 and 2024 calendar years reviewed.

Medication Quality Plan

• EOEA reviewed the Residence's quarterly medication documentation audits from July 14, 2022 through the date of the Compliance Review to ensure compliance with SAMM and Residence policies.
• Documentation of a target date for follow-up and clear outcomes was missing in the last two quarters of 2022.
• Documentation of the staff person responsible for follow up was missing in the third quarter of 2022 the last quarter of 2023 and the second quarter of 2024.
• Documentation of a Quarterly Medication Reviews being completed during the first quarter of 2023 was missing.
• Documentation of clear findings, a target date and person for follow up and clear outcomes for the first two quarters of 2024 was missing.

Medication administration observation

• EOEA observed five (5) Personal Care (PC) staff and one (1) nurse providing medication assistance to nine (9) Residents to ensure the Residence has developed and implemented systems that support and promote safe SAMM and LMA.

SAMM

• EOEA observed one (1) Resident's medication storage unit containing medication not listed on the pharmacy medication list.
• EOEA observed one (1) Resident's medication storage unit containing unsecured medication which had been refused but had not been removed and destroyed per Residence policy.
• Reporting Resident-specific Emergencies- Incident Reports
• EOEA reviewed the Residence records and incident reports from July 2022 through the date of the Compliance Review to determine whether the Residence complied with the requirement to qualifying incidents to EOEA within 24 hours after the occurrence of the incident or accident.
• The Residence filed 29 incident reports greater than 24 hours after the occurrence of the incident or accident.
• Record Requirements- Correspondence Log
• EOEA reviewed the documentation maintained in two 90-day correspondence logs to communicate information necessary to maintain the continuity of care for Residents.
• Both the Traditional and SCR logs did not consistently document all significant or pertinent information necessary to maintain the continuity of care for all Residents.
• Training Requirements-

Introductory Visit and Review

• EOEA reviewed the records of six (6) 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:
• Six (6) records were without documentation to support that Introductory Visits were consistently conducted with all applicable staff prior to or within 48 hours, at the time of move-in or at the time of change in the Resident's condition.

Supervision

• EOEA reviewed the records of four (4) Personal Care (PC) staff to determine compliance with Personal Care evaluation requirements in the calendar year 2022 through the date of the Compliance Review.
• Documentation confirming the completion of Personal Care (PC) skills and SAMM evaluations every six months was missing from four (4) records.
• Compliance Reviews of ALRs – Record Review
• EOEA reviewed the Residence's records including all documents that should be maintained in relation to the operations of the Residence.
• Records for e-call responses for the month of December 2022 were not available for review by EOEA.