Windrose at Weymouth

• Service and Service Coordination Requirements Dietary Reviews
• AGE reviewed Residence's dietary plan reviews from the last quarter of the calendar year 2023 through the date of the Compliance Review to confirm consistency with the most recent edition of the Dietary Guidelines.
• Dietary Reviews missing one six-month review in calendar year 2023. The second half of the 2024 calendar year 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 [...]
• Service and Service Coordination- Special Care
• AGE reviewed the Special Care Residence (SCR) operations review from the last quarter of calendar year 2023 through the date of the Compliance Review to verify that the SCR is being operated with all the required safeguards:
• Documentation to support the required operations review was conducted for the last quarter of calendar year 2023 and calendar year 2024 was missing.
• AGE observed the Special Care Unit:
• AGE noted chemicals not secured in the common kitchen area.
• The laundry room door was unlocked.
• AGE identified issues with operational safeguards related to secure entry and exit doors:
• Entry and exit door alarms were not responded to by staff on duty as required by Residence policy when triggered by AGE during door alarm testing.
• General Requirements for an Assisted Living Residence (ALR)
• AGE reviewed four Resident Records looking at documentation from the Resident's date of move-in through the date of the Compliance Review to determine compliance with the requirements for Screenings, Assessments and Service Plan Development and Requirements.

Service Plan Development and Requirements

• Two records were missing documentation of a reassessment and service plan review being completed every six months.
• 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 from the last quarter of calendar year 2023 through the date of the Compliance Review.

Service Planning

• Documentation that the Residence identified a target date for follow-up action, staff responsible for follow-up and documented clear outcomes were missing for calendar year 2024.

Resident Safety Assurances

• Documentation of an Evidenced Informed Falls Prevention Program review being included in the annual safety review process was missing for the 2023 and 2024 calendar years reviewed.
• Documentation for Resident Safety Assurances was missing for the 2023 and 2024 calendar years reviewed.

Medication Quality Plan

• AGE reviewed the Residence's quarterly medication documentation audits from the last quarter of calendar year 2023 through the date of the Compliance Review to ensure compliance with SAMM and LMA Residence policies.
• Documentation of a quarterly medication review summary was missing for the last quarter of the 2024 calendar year.
• Reporting Resident-specific Emergencies- Incident Reports
• AGE reviewed the Residence records and incident reports from the last quarter of calendar year 2023 through the date of the compliance review to determine whether the Residence complied with the requirement that reports are accurate, including all details associated with the incident and that the filing of qualifying incidents are received by AGE within 24 hours after the occurrence of the [...]
• AGE received a concern on Exemption C , from Exemption C
• Exemption C Exemption C shared information which involved multiple Residents of Windrose at Weymouth regarding quality-of-care concerns. After a review of all related information provided to AGE from Exemption C , AGE determined that the Residence did not report the incidents accurately.
• The Residence filed 14 incident reports greater than 24 hours after the occurrence of the incident or accident.
• Record Requirements- Correspondence Log Personnel Record Requirements
• AGE reviewed the personnel records of four staff members to determine compliance with Personnel Record requirements.
• Four personnel records did not contain signed and dated job descriptions.
• AGE reviewed the documentation maintained in the 90-day correspondence log to communicate information necessary to maintain the continuity of care for Residents.
• The log did not consistently document all significant or pertinent information necessary to maintain the continuity of care for all Residents.
• The correspondence log was missing for the month of November 2024.
• Staffing Requirements- Health Screening Requirements
• AGE reviewed the personnel records of four staff members to determine compliance with Health Screening requirements.
• Two records were missing documentation to confirm seasonal influenza vaccinations or declination statements for the 2024/2025 flu season.
• 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 calendar year 2024.
• Training Requirements - Training Needs Assessment
• AGE reviewed the Residence's documentation for evidence of compliance with the training needs assessment regulation.
• Documentation to support that the Residence has conducted a training needs assessment for calendar years 2023 and 2024 were missing.

Introductory Visit and Review

• AGE reviewed the records four 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 of the Resident:
• Three records were without documentation to support that Introductory Visits were consistently conducted with all applicable staff prior to or within 48 hours, or at the time of change in the Resident's condition.

LBGTQ Training

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

Supervision

• AGE reviewed the records of three Personal Care (PC) staff to determine compliance with Personal Care evaluation requirements in the calendar year 2024 through the date of the Compliance Review.
• Documentation confirming the completion of Personal Care evaluation requirements was missing for calendar year 2024.