4
Findings
below the state median of 6
1
Repeat findings
cited at the previous review too
July 16, 2024
Last state review

Massachusetts inspects every assisted living residence at least once every two years. At its most recent compliance review on July 16, 2024, the state cited 4 findings at Atria Marland Place. 1 of them had already been cited at the previous review. Across the 145 Massachusetts residences with a published report, the median is 6.

This page covers one review, not a history, and it is not a score or a ranking. A finding means the state identified something the residence has to correct; it does not on its own mean a resident was harmed. The state does not publish what happened after this review, so a finding listed here may since have been fixed.

Facility details

Owner
WG Marland Place, SH, LLC
Action taken
Plan of correction required
Initial certification
8/9/1996
Current certification
Certified through 8/9/2024
Previous compliance review
11/10/2022

What the state found

4 findings · 1 repeat
Emergency call responseIn the month of June 2024 there were 65 e-call response times over the ten minutes required by the Residence policy.▼

How quickly staff answer a resident's emergency call button.

What the inspector found

EOEA reviewed response times and tests of the emergency response system from the calendar years 2022 to 2024 to determine compliance with Service Coordination requirements.

In the month of December 2022 there were 25 e-call response times over the ten minutes required by the Residence policy.

In the month of June 2023 there were 37 e-call response times over the ten minutes required by the Residence policy.

In the month of June 2024 there were 65 e-call response times over the ten minutes required by the Residence policy.

General Requirements for an ALR - Service and Service Coordination Requirements: Emergency Response
651 CMR 12.04(2)(b)(3.)(b.)(c.)

Quality assurance programEOEA observed five PCA staff providing medication assistance to 12 Residents to ensure the Residence has developed and implemented systems that support and promote safe SAMM:
Repeat finding
▼

The residence's own program for auditing and improving the care it gives.

What the inspector found

EOEA reviewed documentation to ensure the Residence has established an effective, ongoing quality improvement and assurance program for Service Planning, Resident Safety Assurances and Medication Quality for the calendar years 2022 and 2023.

Documentation of a date the audit was completed on was missing for calendar year 2022.

Resident Safety Assurances

Documentation of a Resident Safety Assurances audit was missing in all calendar years.

Documentation of a set target date for follow-up action and person responsible for follow up action was missing in last quarter of calendar year 2022.

EOEA observed five PCA staff providing medication assistance to 12 Residents to ensure the Residence has developed and implemented systems that support and promote safe SAMM:

EOEA observed one compromised medication blister stored in one Resident’s medication storage unit.

One Resident’s family filled cassette had one medication from a prior day that was not administered without explanation on the medication observation sheet.

This was also cited at the previous compliance review.

General Requirements for an ALR: Quality Assurance and Performance Improvement
651 CMR 12.04(10)(a)-(c)

Resident recordsResident Record computerized safety checks were not auditable by EOEA. Inconsistent documentation of information necessary for the continuity of care.▼

Records that keep a resident's care information complete and available to staff.

What the inspector found

EOEA reviewed the Residence’s development and maintenance of all documents that should be maintained in relation to the Resident records.

The Residence’s computerized records to document providing timely assistance to a Resident in the event of an emergency needs situation by hourly safety checks between the hours of 7PM and 7AM for six Special Care Residence Residents were made available for review but were not auditable.

EOEA reviewed the current 90-day Correspondence Log required to communicate information necessary to maintain the continuity of care for all Residents.

The Residence did not use the Correspondence Log to communicate all significant or pertinent information necessary to maintain the continuity of care for all Residents.

Record Requirements: -Resident Records -Correspondence Log
651 CMR 12.05(1) 651 CMR 12.05(4)

StaffingMissing documentation of employee Vaccination Requirements.▼

Who the residence employs and what it must document about them.

What the inspector found

EOEA reviewed 12 personnel records, to determine compliance.

Two records were missing documentation to confirm receipt or declination of the seasonal influenza vaccine.

Corrective Actions.

Staffing Requirements: Contagious Disease and Vaccination Requirements
651 CMR 12.06(8)(e)

Glossary

Abbreviations the state uses without explaining them
EOEAExecutive Office of Elder Affairs — the former name of AGE, used in older reports.
SAMMSelf-administered medication management — the resident manages their own medication with oversight.
e-callThe emergency call system a resident uses to summon staff.
What the residence must doThe residence must send the state a plan to correct each finding, what it will do to keep it from happening again, who is responsible and by when.▼

The residence must send the state a plan to correct each finding, what it will do to keep it from happening again, who is responsible and by when.