Massachusetts inspects every assisted living residence at least once every two years. At its most recent compliance review on May 21, 2024, the state cited 9 findings at Sunrise of Plymouth Beach. 4 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
9 findings · 4 repeatEmergency call responseIn the months of November 2022, August 2023 and April 2024 there were over 476 e-call response times over the ten (10) minutes required by Residence policy.Repeat finding▼
How quickly staff answer a resident's emergency call button.
EOEA reviewed the Personalized Emergency Response procedures developed to provide timely assistance to a Resident in the event of an emergency needs situation.
In the months of November 2022, August 2023 and April 2024 there were over 476 e-call response times over the ten (10) minutes required by Residence policy.
The Residence is not demonstrating a effective means of monitoring and ensuring reasonable staff response times to Resident requests for assistance during November 2022 and August 2023.
The Residence has chosen to manually document hourly safety checks of Residents living in the Special Care Residence (SCR) to comply with the regulation to provide timely assistance to a Resident in the event of an emergency needs situation.
Documentation of hourly safety checks for April 2024 through the date of compliance review had multiple instances where staff failed to document the hourly safety checks of the SCR Residents during the hours of 7:00 p.m. and 7:00 a.m.
Documentation of hourly safety checks for three (3) SCR Residents reviewed by EOEA from the date of move-in through the date of compliance review had multiple instances where staff failed to document the hourly safety checks of the SCR Residents during the hours of 7:00 p.m. and 7:00 a.m.
This was also cited at the previous compliance review.
General Requirements for an ALR: Emergency Response
651 CMR 12.04(3)(b)(c)
Memory care unitSafety issues identified in the Special Care Residence (SCR).Repeat finding▼
Extra requirements that apply to units caring for residents with dementia.
EOEA reviewed the Special Care Residence (SCR) operations on the date of the Compliance Review to verify that the SCR is being administered with all the required safeguards.
EOEA identified secured SCR entry and exit doors, with a 15-second delayed opening, not releasing when triggered.
EOEA reviewed the Residence records of three (3) Residents utilizing bed rails / U-bars or similar devices for the period of 2022 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 for one (1) Resident noting that the Resident can independently navigate around a bed rail/ U-bar for the calendar years reviewed.
This was also cited at the previous compliance review.
General Requirements for an ALR: Special Care
651 CMR 12.04(4)(a)(1)
Resident screening and assessment · Resident care plansBedrail assessment beyond regulatory scope.Repeat finding▼
Resident screening and assessment: Checking, before and during residency, that the residence can meet a resident's needs.
Resident care plans: The written plan describing the care each resident is assessed to need.
The state cited these together under one finding.
This was also cited at the previous compliance review.
General Requirements for an ALR: Screening and Assessment Service Plan Development and Requirements
651 CMR 12.04(8)(a)(3)(c) 651 CMR 12.08(1)(s)
Quality assurance programMissing or incomplete components of the Quality Assurance and Performance Improvement requirements.▼
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, Safety Assurances, and Medication Quality from August 30, 2022, through the date of the Compliance Review.
Documentation of the target date and the staff person responsible for follow-up action and clear outcomes was missing for the 2023 calendar year reviewed.
Resident Safety Assurances
Documentation of the staff person conducting the audit, the target date and the staff person responsible for follow-up action and clear outcomes was missing for the 2022 calendar year reviewed.
EOEA reviewed the Residence’s quarterly medication documentation audits from August 30, 2022 through the date of the Compliance Review to ensure compliance with SAMM, LMA and Residence policies.
Documentation of a target date for follow-up, the staff person responsible for follow-up, and clear outcomes was missing in last quarter of the 2022 calendar year reviewed.
Medication Quality Plan reviews were insufficient in documenting and addressing three (3) reported medication errors in the first quarter of 2023, one (1) reported medication error in the third quarter of 2023 and four (4) reported medication errors in the first quarter of 2024.
General Requirements for an ALR-Service and Service Coordination: Quality Assurance and Performance Improvement
651 CMR 12.04(10)(a)(b)(c)(2),(d)(e)
Incident reportingThe Residence filed 58 incident reports greater than 24 hours after the occurrence of the incident or accident.▼
Telling the state, on time, when something happens to a resident.
EOEA reviewed the Residence records and incident reports from August 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 58 incident reports greater than 24 hours after the occurrence of the incident or accident.
Emergency Preparedness Plan and Reporting Requirements: Reporting Resident Specific Emergencies
651 CMR 12.04(11)(e)
Resident recordsInconsistent documentation of each 24-hour period over 90-days. Inconsistent 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 documentation maintained in a 90-day correspondence log to communicate information necessary to maintain the continuity of care for Residents in the Residence.
The log did not consistently document for each 24-hour period in the Correspondence Log.
The log did not consistently document all significant or pertinent information necessary to maintain the continuity of care for all Residents.
This was also cited at the previous compliance review.
Record Requirements: Correspondence Log
651 CMR 12.05(4)
StaffingMissing documentation of timely 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 timely quarterly staffing level assessments was missing for all four quarters of 2023 and the first quarter of 2024.
Staffing Requirements: Staffing Levels
651 CMR 12.06(4)(a)
Staff health screeningMissing documentation of employee Health Screening Requirements.▼
Health checks the residence must document for the people it employs.
EOEA reviewed the personnel records of five (5) staff members to determine compliance with Health Screening requirements.
Five (5) records were missing documentation to confirm seasonal influenza vaccinations or declination statements.
Staffing Requirements: Health Screening Requirements
651 CMR 12.06(8)(e)(1)
Staff trainingMissing documentation of General Orientation Missing Training Needs Assessments Missing Personal Care Services Provider Training Requirements. Biannual skills evaluations were not consistently documented for all PC staff.▼
Training and skills checks the residence must give and document for its staff.
EOEA reviewed the personnel records of five (5) staff members to determine compliance with orientation requirements.
Documentation for five (5) employees having received a general orientation, consisting of all required topics and time requirements, was missing.
EOEA reviewed the Residence records to determine compliance with annual training needs assessment requirements.
Documentation of annual training needs assessments for the 2022 and 2023 calendar years reviewed missing.
EOEA reviewed the personnel records of three (3) personal care staff members to determine compliance with training requirements and exemptions.
Documentation for two (2) employees having received 54- hours of training prior to providing services unless exempt as set forth by 651 CMR 12.07(9), was missing.
EOEA reviewed the records of three Personal Care (PC) staff to determine compliance with Personal Care evaluation requirements in the calendar year 2022 through the date of the Compliance Review.
Documentation confirming the completion of Personal Care (PC) skills evaluations every six months was missing from three (3) records.
Corrective Actions
Training Requirements: General Orientation Training Needs Assessment Personal Care Services Provider Training Requirements Supervision
651 CMR 12.07(1),(2),(3), (5),(6),(8)
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.▼
Specific Corrective Actions.
Submit to EOEA the following:
Documentation confirming a review and necessary repair of SCR secure doors.
Documentation confirming a newly completed SAMM in-service training with post-training evaluation by a nurse for all medication PC staff.
Documentation confirming the completion of a current quarterly staffing level review for both Traditional and Special Care Residences.
Documentation confirming a newly completed training needs assessment for orientation requirements and annual in-service requirements.
Documentation confirming that all care staff have the required 54- hours of training on required topics or record of a Massachusetts CNA or HHA certificate.
Documentation confirming a newly completed PC skills evaluation by a nurse for all PC staff.