Massachusetts inspects every assisted living residence at least once every two years. At its most recent compliance review on August 6, 2024, the state cited 7 findings at Atria Woodbriar Park. 3 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
What the state found
7 findings · 3 repeatEmergency call responseIn the months of June 2024 and December 2023 there were 70 e-call response times over the ten minutes required by the Residence policy.Repeat finding▼
How quickly staff answer a resident's emergency call button.
EOEA reviewed response times and tests of the emergency response system from the calendar years 2023 and 2024 to determine compliance with Service Coordination requirements.
In the months of June 2024 and December 2023 there were 70 e-call response times over the ten minutes required by the Residence policy.
The Residence is not consistently monitoring the reasons for late e-call response times in order to meet the service needs of Residents.
This was also cited at the previous compliance review.
General Requirements for an ALR - Service and Service Coordination Requirements: Emergency Response
651 CMR 12.04(2)(b)(3.)(b.)(c.)
Memory care unitMissing or incomplete components of the Bi-annual Special Care Residence (SCR) operations review requirements.▼
Extra requirements that apply to units caring for residents with dementia.
EOEA reviewed the Special Care Residence (SCR) operations review from calendar year 2022 through the date of the Compliance Review to verify that the SCR is being administered with all the required safeguards.
Documentation to support the required SCR operations review was conducted for the second half of calendar year 2022 and all of calendar year 2023 was missing.
General Requirements for an ALR: Special Care
651 CMR 12.04(4)(d)
Resident screening and assessmentInconsistent with documenting all requirements of Assessments and Service Plans.▼
Checking, before and during residency, that the residence can meet a resident's needs.
EOEA reviewed six Resident Records to determine compliance with requirements for the Screening and Assessment, Service Plan Development and Service Plan Requirements.
Four records were missing documentation of the Legal Representative and the scope of authority.
General Requirements for an ALR: Screening and Assessment
651 CMR 12.04(6)(b)
Quality assurance programMissing or incomplete components of the Quality Assurance and Performance Improvement requirements.Repeat finding▼
The residence's own program for auditing and improving the care it gives.
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, 2023 and 2024.
Documentation of a set target date for follow-up action and person responsible for follow up action was missing for calendar year 2023.
Resident Safety Assurances
Documentation of a Resident Safety Assurances audit was missing in all calendar years.
Documentation of Evidence Informed Falls Prevention Program was missing for calendar years 2022 and 2023.
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.
Documentation of a Medication Quality audit was missing for the third quarter of the calendar year 2023.
EOEA observed two PCA staff providing medication assistance to two Residents and one nurse providing medication administration to three Residents to ensure the Residence has developed and implemented systems that support and promote safe SAMM and LMA:
One PCA staff documented on the medication observation record for one Resident prior to the completion of the medication observation.
One nurse documented on the medication administration record for one Resident prior to the completion of the medication administration.
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)
Incident reportingThe Residence filed 52 incident reports greater than 24 hours after the occurrence of the incident during the period reviewed.Repeat finding▼
Telling the state, on time, when something happens to a resident.
EOEA reviewed the Residence’s Records and submitted Incident Reports from October 10, 2022 through the day of the compliance review for evidence that all occurrences of an incident or accident that has or may have a Significant Negative Effect on a Resident’s health, safety or welfare were reported to EOEA within 24 hours after the occurrence of the incident or accident.
The Residence filed 52 incident reports greater than 24 hours after the occurrence of the incident during the period reviewed.
EOEA reviewed the Residence’s Emergency Plan to ensure compliance that the Residence can address potential disasters and emergencies.
Documentation of a missing person drill conducted by the Residence for second and third shifts were missing for the 2023 calendar year reviewed.
This was also cited at the previous compliance review.
General Requirements for an ALR - Emergency Preparedness Plan and Reporting Requirements: -Reporting Resident Specific Emergencies -Missing Person Drills
651 CMR 12.04(11)(a)(4),(e)
Staff trainingInconsistent documentation of Training Needs Assessments.▼
Training and skills checks the residence must give and document for its staff.
EOEA reviewed the Residence’s documentation for evidence of compliance with training needs assessment regulations.
Documentation to support that the Residence has conducted a training needs assessment in the 2022 calendar year was missing.
Training Requirements: Training Needs Assessment
651 CMR 12.07(5)
Resident recordsInconsistent documentation of information necessary for the continuity of care. Missing days in the Correspondence Logs.▼
Records that keep a resident's care information complete and available to staff.
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.
The Residence did not consistently document for each 24-hour period in each Correspondence Log.
Corrective Actions.
Record Requirements: Correspondence Log
651 CMR 12.05(4)
Glossary
Abbreviations the state uses without explaining themWhat 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.