Massachusetts inspects every assisted living residence at least once every two years. At its most recent compliance review on June 11, 2024, the state cited 5 findings at Brightview Canton. 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. Where the state withheld private details, such as a resident's medication or the date of an incident, the text reads [redacted].
Facility details
What the state found
5 findings · 3 repeatEmergency call responseIn the month of April 2024 there were 140 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 2022 to 2024 to determine compliance with Service Coordination requirements.
In the month of April 2024 there were 140 e-call response times over the ten minutes required by the Residence policy.
In the month of June 2023 there were 62 e-call response times over the ten minutes required by the Residence policy.
In the month of December 2022 there were 42 e-call response times over the ten minutes required by the Residence policy.
This was also cited at the previous compliance review.
General Requirements for an ALR: Emergency Response
651 CMR 12.04(2)(b)(3)(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 to 2024.
Documentation that a target date for follow up action and staff member responsible for follow up action was missing for calendar year 2023.
Resident Safety Review
Documentation for the Resident Safety Review of a specific target date for follow-up and staff responsible for follow-up actions were missing for all calendar years reviewed.
Documentation of a specific target date for follow-up and staff responsible for follow-up actions were missing for the fourth quarter of 2022 and all four quarters of calendar year 2023.
EOEA observed two PCA staff providing medication assistance to four 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 Resident had one medication storage area that was not labeled with the Resident’s name and room number.
One nurse did not document [redacted] on the medication administration record for one Resident.
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 reportingResident specific incident reports not submitted and submitted late to EOEA.Repeat finding▼
Telling the state, on time, when something happens to a resident.
EOEA reviewed the Residence records and submitted incident reports from August 2, 2022 through June 11, 2024 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.
Through a review of progress notes, EOEA identified one incident meeting the criteria set forth at 651 CMR 12.04(11)(d) and 12.02 which was not reported.
The Residence filed nine incident reports greater than 24 hours after the occurrence of the incident during the period 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
651 CMR 12.04(11)(e)
Resident recordsInconsistent documentation of information necessary for the continuity of care.▼
Records that keep a resident's care information complete and available to staff.
EOEA reviewed the current 90-day Correspondence Logs for the Traditional and SCR Units required to communicate information necessary to maintain the continuity of care for all Residents.
The Residence did not use the Correspondence Logs to communicate all significant or pertinent information necessary to maintain the continuity of care for all Residents.
Record Requirements: Correspondence Log
651 CMR 12.05(4)
Staff trainingInconsistent documentation of Introductory Visits.▼
Training and skills checks the residence must give and document for its staff.
EOEA reviewed the records of six 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 for the Resident.
Six records were missing signature documentation to support that Introductory Visits have been conducted with all applicable staff prior to or within 48 hours after the provision of Personal Care services.
Corrective Actions.
Training Requirements: Introductory Visit and Review
651 CMR 12.07(7)
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 state also asked for specific proof, listed here as written.▼
Submit to EOEA the following:
Confirm the completion of an Introductory Visit for all current care staff with all Residents.
Confirmation that all critical incidents identified with EOEA during the Compliance Review not previously reported are submitted via the EOEA (Dynamics) on-line incident reporting system.