The Delaney at the Vale

Emergency Response

• AGE reviewed the Personalized Emergency Response procedures developed to provide timely assistance to a Resident in the event of an emergency.
• There were 136 e-call response times over the 15-minute limit in accordance with the Residences policy.

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

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

Service Plan Development and Requirements

• Three records were missing documentation of a service plan review required within 30 days after the commencement of residency.
• Six records were missing documentation of residents stated goal.
• Five records were missing documentation of signatures of the Resident or Legal Representative on Service Plan reviews.
• Documentation that the Residence shall provide for the presence of a 24hr per day, on site staff was missing in all Resident's service plan records.
• Documentation of enrichment activities for SCR residents was missing in all Residents service plan records.
• Documentation of SCR residents' access to cooking capacity was missing in all Residents service Plan records.

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 for date the audit was conducted, clear audit findings, identifying staff responsible for follow- up, action for a set target date and a clear outcome was missing for calendar 2025.

Resident Safety Assurances

• Documentation for date the audit was conducted, follow-up action for a set target date and staff responsible for follow-up was missing for calendar year 2025.

Medication Quality Plan

• AGE reviewed the Residence's quarterly medication documentation audits to ensure compliance with SAMM and LMA Residence policies.
• Documentation that the Residence identified a target date for follow-up action, staff responsible for follow-up and documented outcomes were missing for calendar years 2025 and first quarter of calendar year 2026.

Medication administration observation

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

SAMM

• Two Residents missing the required label on the family filled medication cassettes.

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 9 incident reports greater than 24 hours after the occurrence of the incident or accident.

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.
• Three 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.

F. 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 noted laundry room doors are not secured with locks, laundry room doors function on wheel pole sliders which are unsecured.

G. 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 and Special Care unit logs did not consistently document all significant or pertinent information necessary to maintain the continuity of care for all Residents.

H. 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 nine Residents noting that the Resident can independently navigate around a bed rail/ U-bar was missing

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 that Introductory Visits have been completed by a nurse with all Personal Care staff for all Residents

2. Documentation of current bedrail/u-bar evaluations for any missing evaluations

• 3. Documentation of an SCR operational safeguards review related to secure locked laundry doors and procedures to reduce the risk of potential hazards in the physical environment.
• 4. Documentation confirming that Introductory Visits have been completed by a nurse with all Personal Care staff for all Residents.

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 June 8, 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.