The Wellington at Springfield

Self-Administered Medication Management (SAMM)

• 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 four 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 June 2025, December 2025 and February 2026, there were 490 e-call response times over the 10-minute limit.

Documentation of the Residence monitoring late response times over the

• 10-minute limit was missing for February 2026.

B. 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.
• Age identified deficiencies with operational safeguards related to the risk of potential hazards in the physical environment:
• Main entrance door in the SCR did not alarm when triggered.
• A bench was pushed against the SCR courtyard fence.
• An electrical panel was obstructed in a maintenance closet.

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

• AGE reviewed the documentation of nine 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 of an assessment at move in.
• Nine records were missing documentation of an initial assessment being completed by a nurse.
• Nine records were missing documentation noting the name and scope of any Legal Representative.

Service Plan Development and Requirements

• Two records were missing documentation of a service plan at move in.
• Eight records were missing documentation of a service plan review required within 30 days after the commencement of residency.
• Nine records were missing documentation of Resident goals.
• Nine records were missing documentation of the manner in which the Residence shall provide for personal emergency response devices or procedures.
• Three records were missing documentation of individualized enrichment activities provided to the Residents in the SCR.

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.
• Three records were missing documentation of a current assessment noting that the Resident can independently navigate around a bed rail/ U-bar.

D. 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 target date and staff responsible for follow up and clear outcomes was missing for the 2025 calendar year reviewed.

Resident Safety Assurances

• Documentation of a Safety review target date and staff responsible for follow up and clear outcomes was missing for the 2025 calendar year reviewed.

Medication Quality Plan

• AGE reviewed the Residence's quarterly medication documentation audits to ensure compliance with SAMM, LMA and Residence policies.
• Documentation of a Medication Quality Plan review was missing for the second quarter of 2025.
• Documentation of a target date was missing for the third quarter of 2025 and the first quarter of 2026.
• Documentation of staff responsible for follow up to findings was missing for the third quarter of 2025.
• Documentation of clear outcomes was missing for the third quarter of 2025 and first quarter of 2026.

Medication administration observation

• AGE observed two Personal Care Aides (PCA) and one nurse providing medication assistance to nine Residents to ensure the Residence has developed and implemented systems that support and promote safe SAMM and LMA.

SAMM

• AGE observed a compromised medication blister in one Resident's Medication Storage Unit.
• AGE observed expired medication in one Resident's Medication Storage Unit.
• AGE observed a loose medication pill in one Resident's Medication Storage Unit.
• AGE observed one medication listed on the Resident's Medication Administration Record which was not present in the Medication Storage Unit.
• AGE observed a PCA document the administration of medication prior to the Resident taking the medication.

LMA

• AGE observed with no pharmacy label in one Resident's Medication Storage Unit.

E. Reporting Resident-Specific Emergencies-

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

F. Controlled Substances

• AGE reviewed the Controlled Substance (CS) policy and procedure for Residents who participate in SAMM and LMA.
• CS count procedure by staff was inconsistent with policy on the day of the compliance review.

G. 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 five Residents.

Record Requirements- Correspondence Log

• AGE reviewed all current Correspondence Logs required to communicate information necessary to maintain the continuity of care for all Residents.
• The Traditional and SCR logs did not consistently document all significant or pertinent information.

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 48 hours after the provision of service or with any change of condition for the Resident:
• Three 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 five Personal Care (PC) staff to determine compliance with SAMM skills and Personal Care evaluation requirements.
• Documentation confirming the completion of personal care skills evaluations every six months was missing from five records for the 2025 calendar year and current 2026.

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 issues 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.
• B. Specific Corrective Actions.

Submit to AGE the following:

• Documentation confirming a full Residence audit for Residents using bed rails or u-bars and that all Residents using such a device have a current evaluation by a Physical / Occupational Therapist.
• Documentation confirming a current Introductory Visit has been completed, between all care staff and a nurse, for all Residents.
• Documentation confirming current biannual personal care skills evaluations have been completed by a nurse for all Personal Care staff.

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 May 7, 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, email ALRHelp@mass.gov .