Massachusetts inspects every assisted living residence at least once every two years. At its most recent compliance review on June 4, 2024, the state cited 8 findings at Brightview Danvers. 5 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
8 findings · 5 repeatEmergency call responseIn the month of June 2023 there were 224 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 to 2024 to determine compliance with Service Coordination requirements.
In the month of June 2023 there were 224 e-call response times over the ten minutes required by the Residence policy.
In the month of April 2024 there were 133 e-call response times over the ten minutes required by the Residence policy.
EOEA reviewed the Residence records of 10 Residents utilizing bed rails / U-bars or similar devices for the period of 2023 through the date of the Compliance Review to determine compliance with the required assessment by a physical/occupational therapist every six months.
Documentation of an assessment conducted by a physical/occupational therapist every six months was missing for 10 Residents utilizing a bed rail/ U-bar for the calendar years reviewed.
This was also cited at the previous compliance review.
General Requirements for an ALR: Emergency Response
651 CMR 12.04(2)(b)(3)(b)
Resident screening and assessmentMissing Bedrail assessments.▼
Checking, before and during residency, that the residence can meet a resident's needs.
General Requirements for an ALR: Screening and Assessment
651 CMR 12.04(6) 651 CMR 12.04(8)(a)(3)(c)
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 of all findings were missing for the fourth quarter of calendar year 2023 and the second quarter of calendar year 2024.
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 compromised blister pack in the medication storage area.
This was also cited at the previous compliance review.
General Requirements for an ALR: Quality Assurance and Performance Improvement
651 CMR 12.04(10)(c)
Incident reportingThe Residence filed 20 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 records and submitted incident reports from July 19, 2022 through June 4, 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.
The Residence filed 20 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.Repeat finding▼
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 the Correspondence Log.
This was also cited at the previous compliance review.
Record Requirements: Correspondence Log
651 CMR 12.05(4)
StaffingMissing documentation of employee Vaccination Requirements.▼
Who the residence employs and what it must document about them.
EOEA reviewed seven personnel records, to determine compliance.
Three records were missing documentation to confirm receipt or declination of the seasonal influenza vaccine.
Staffing Requirements: Contagious Disease and Vaccination Requirements
651 CMR 12.06(8)(e)
Staff trainingInconsistent documentation of Introductory Visits.Repeat finding▼
Training and skills checks the residence must give and document for its staff.
EOEA reviewed the records of seven 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.
Four 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.
This was also cited at the previous compliance review.
Training Requirements: Introductory Visit and Review
651 CMR 12.07(7)
Records given to the stateRecords of e-call response time were missing.▼
Providing the inspector the records the review requires.
EOEA reviewed the Residence’s records including all documents that should be maintained in relation to the operations of the Residence.
The Residence’s records to determine compliance with response times and tests of the emergency response system for the month of December 2022 as part of Service Coordination requirements was not available for review.
Corrective Actions.
Compliance Reviews of Assisted Living Residences: Record Review
651CMR 12.09(3)(c)
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 that all applicable Residents have a current bed-rail assessment.
Confirm the completion of an Introductory Visit for all current care staff with all Residents.