Whitney Place at Westborough

• 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.
• In the months of November 2022, June 2023, and April 2024, there were 159 e-call response times over the ten (10) minutes required by Residence policy.
• The Residence has chosen to manually document hourly safety checks of Residents living in the Special Care Residence (SCR) to comply with the regulation to provide timely assistance to a Resident in the event of an emergency needs situation.
• Documentation of hourly safety checks for the second floor SCR from March 2024 had multiple instances where staff failed to properly document the hourly safety checks during the hours of 7:00 p.m. and 7:00 a.m.

Dietary Reviews

• EOEA reviewed the Residence's dietary plan reviews from 2022 through the date of the Compliance Review to confirm consistency with the most recent edition of the Dietary Guidelines.
• Menus lacked the inclusion of the required language designating that the meal selections meet the minimum dietary standards of the 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.
• Service and Service Coordination- Special Care
• EOEA reviewed the SCR operations on the date of the Compliance Review to verify that the SCR is complying with all the required safeguards.
• EOEA identified issues with operational safeguards related to secure entry and exit doors as well as issues with the procedures to reduce the risk of potential hazards in the physical environment:
• SCR emergency exit door alarms were not operational when triggered.
• Cleaning chemicals were stored in unsecured kitchen cabinets.
• Three (3) third floor SCR Activity Room windows, with faulty window blockers, were not secured.
• General Requirements for an Assisted Living Residence (ALR)
• EOEA reviewed four (4) Resident Records reviewing documentation from July 7, 2022, through the date of the Compliance Review to determine compliance with the requirements for Screening and Assessment.

Screening and Assessment

• Four (4) records were missing documentation of an initial assessment required prior to the commencement of residency.
• Four (4) records were missing documentation of a Service Plan reassessment required within 30 days after the commencement of residency.
• Four (4) records were missing documentation of a reassessment being completed every six months.
• Two (2) records were without documentation to confirm that assessments noted the name and scope of any Legal Representative.

Service Plan Development and Requirements

• Two (2) records were missing documentation of signatures of the Resident or his or her Legal Representative on Service Plan reviews.
• Two (2) records were missing documentation of a reassessment and service plan review being completed every six months.

Bed Rail Assessments

• EOEA reviewed the Residence records of 18 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 was missing for five (5) Residents utilizing a bed rail/ U-bar for the calendar years reviewed.
• 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 7, 2022, through the date of the Compliance Review.

Service Planning

• Documentation of the date of the review and the staff person responsible for follow-up action was missing for the 2022 and 2023 calendar years reviewed.

Resident Safety Assurances

• Documentation of the staff person responsible for follow-up action was missing for the 2022 and 2023 calendar years reviewed.

Medication Quality Plan

• EOEA reviewed the Residence's quarterly medication documentation audits from July 7, 2022 through the date of the Compliance Review to ensure compliance with SAMM and Residence policies.
• Documentation of clear findings was missing in the third quarter of the 2022 calendar year reviewed.
• Documentation of a target date for follow-up, the staff person responsible for follow-up, and clear outcomes was missing in all quarters of the 2023 calendar year reviewed.

Medication administration observation

• EOEA observed two (2) Personal Care (PC) staff providing medication assistance to four (4) Residents to ensure the Residence has developed and implemented systems that support and promote safe SAMM.
• During medication administration observations, EOEA noted that when PC staff was questioned about SAMM policies and procedures, the PC staff was unfamiliar with those policies and did not know how to reference the SAMM policies for clarification.

SAMM

• EOEA observed one (1) PC staff assist with SAMM medications, but this individual did not follow appropriate hand hygiene.
• EOEA observed one (1) PC staff drop one (1) pill in the SAMM medication box while transferring the Resident's medication from the pharmacy-filled medication pack to the medication cup. EOEA observed the PC staff pick up the pill with bare hands and place the pill in the medication cup.
• EOEA observed that one (1) Resident's family-filled cassette was empty therefore no medication was available for this Resident on . EOEA also observed that this Resident had a separate family-filled medication cassette on the table. The PC staff stated that the Resident keeps extra medication in the unsecured cassette for times when the Resident may want to take medication independently. [...]
• EOEA observed one resident with a family-filled cassette labeled for filled with medications. There was no documentation that the Resident had refused the medication during that period, nor was there any report to EOEA of medication errors on those dates.
• EOEA observed one Resident's SAMM medication storage unit was unsecure. The family-filled medication cassette inside was unlabeled and blocked the unit's lock unless great force was used.
• 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 of reporting qualifying incidents to EOEA within-24 hours-after the occurrence of the incident or accident.
• The Residence filed 20 incident reports greater than 24 hours after the incident or accident.
• Resident Records- Progress notes
• EOEA reviewed four (4) Resident records to determine compliance with record requirements.
• There was inconsistent documentation of significant occurrences in the progress notes for two (2) Residents.
• Record Requirements- Correspondence Log
• EOEA reviewed the documentation maintained in three separate 90-day correspondence logs to communicate information necessary to maintain the continuity of care for Residents.
• Three (3) logs did not consistently document all significant or pertinent information necessary to maintain the continuity of care for all Residents.
• 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.
• The records for two (2) Residents were not available for review by EOEA. Residence staff were unable to present the documentation by the review deadline.
• Training Requirements - Ongoing In-service Education and Training
• EOEA reviewed the personnel records of four (4) PC staff members to determine compliance with annual in-service training requirements.
• Documentation to support one hour of training on SAMM for four (4) PC staff was m1ssmg.