Massachusetts inspects every assisted living residence at least once every two years. At its most recent compliance review on September 13, 2024, the state cited 5 findings at The Atrium at Faxon Woods. 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
What the state found
5 findings · 1 repeatEmergency call response · Food and dietary servicesDelayed e-call response time not compliant with ALR policy. Insufficient dietary menus.▼
Emergency call response: How quickly staff answer a resident's emergency call button.
Food and dietary services: Meals, dietary review and how the kitchen is run.
The state cited these together under one finding.
EOEA reviewed the Personalized Emergency Response procedures developed to provide timely assistance to a Resident in the event of an emergency needs situation.
During the month of June 2023 there were 8 e-call response times over the twelve (12) minutes required by Residence policy and for the month of August 2024 there were three (3) e-call response times over the 15 minutes required by Residence policy.
EOEA reviewed the Residence’s dietary plan reviews from the 2022 calendar year 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.
General Requirements for an ALR: Emergency Response Dietary Reviews
651 CMR 12.04(2)(b) (3)(b),(4)
Incident reportingThe Residence filed 37 incident reports greater than 24 hours after the occurrence of the incident or accident.Repeat finding▼
Telling the state, on time, when something happens to a resident.
EOEA reviewed the Residence records and incident reports from October 2022 through the date of the Compliance Review to determine whether the Residence complied with the requirement to qualifying incidents to EOEA within 24 hours after the occurrence of the incident or accident.
The Residence filed 37 incident reports greater than 24 hours after the occurrence of the incident or accident.
This was also cited at the previous compliance review.
Emergency Preparedness Plan and Reporting Requirements: Reporting Resident Specific Emergencies
651 CMR 12.04(11)(e)
Resident progress notesInconsistent documentation of significant events.▼
The running notes staff keep on how each resident is doing day to day.
EOEA reviewed five (5) Residents’ records to determine compliance with record requirements.
Inconsistent documentation of significant occurrences in the Progress Notes for two (2) Residents.
Resident Record: Progress Notes
651 CMR 12.05(1)(c)
Resident recordsMissing information necessary for the continuity of care.▼
Records that keep a resident's care information complete and available to staff.
EOEA reviewed the documentation maintained in two 90-day correspondence logs to communicate information necessary to maintain the continuity of care for Residents.
Both logs did not consistently document all significant or pertinent information necessary to maintain the continuity of care for all Residents.
Record Requirements: Correspondence Log
651 CMR 12.05(4)
StaffingMissing documentation of Staffing Level Reviews.▼
Who the residence employs and what it must document about them.
EOEA reviewed the Residence records to determine compliance with Staffing Level requirements.
Documentation to confirm the Residence conducted quarterly staffing level assessments was missing for the first and second quarter of 2024. Staffing levels from those quarters were reviewed September 9, 2024.
Corrective Actions
Staffing Requirements: Staffing Levels
651 CMR 12.06(4)(a)
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.