Massachusetts inspects every assisted living residence at least once every two years. At its most recent compliance review on October 3, 2024, the state cited 5 findings at Corcoran House. 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 repeatIncident reportingThe Residence filed 8 incident reports greater than 24 hours after the occurrence of the incident during the period reviewed.▼
Telling the state, on time, when something happens to a resident.
EOEA reviewed the Residences records and submitted incident reports from the last quarter of calendar year 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 during the period reviewed.
The Residence filed 8 incident reports greater than 24 hours after the occurrence of the incident during the period reviewed.
General Requirements for an ALR-Emergency Preparedness Plan and Reporting Requirements: Reporting Resident Specific Emergencies
651 CMR 12.04(11) (e)
Emergency call responseIn the months of September 2024 there were 76 e-call response times over the 7 minutes required by the Residence policy.▼
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 September 2024 there were 76 e-call response times over the 7 minutes required by the Residence policy.
The Residence was not able to provide documentation of demonstrating an effective means of monitoring and ensuring reasonable staff response times to Resident requests for assistance for the months of December 2022 and August 2023.
General Requirements for an ALR - Service and Service Coordination Requirements: Emergency Response
651 CMR 12.04(2)(b)(3.)(b.)(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 of 2023 and 2024.
Documentation of the follow up action for set target date and staff responsible for follow-up was missing for calendar years 2023 and 2024.
Resident Safety Assurances
Documentation of a target date for follow-up was missing in calendar years 2023 and 2024.
The Residence was missing the follow up action for set target date, staff responsible for follow-up and clearly documented outcome for calendar years 2023 and calendar 2024.
EOEA observed three CNA staff providing medication assistance to five Residents to ensure the Residence has developed and implemented systems that support and promote safe SAMM:
One Resident had two pharmacy filled medication bubble packs missing pharmacy labels on medication cassettes.
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)
Resident care plansBed rail assessments▼
The written plan describing the care each resident is assessed to need.
EOEA reviewed the records of five Residents to determine compliance with requirements for Screening and Assessment, Service Plan Development and Service Plan Requirements.
EOEA reviewed the Residence records of 13 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 confirming that the Resident can independently navigate around the bed rail/U-bar were missing for two Residents for the calendar year 2023 and 2024.
General Requirements for an ALR: Service Plan Requirements
651 CMR 12.04(8)(a) 651 CMR 12.08(1)(s)
Controlled medication handlingControlled Substances management and count not conducted in accordance with the Residence’s policy.▼
How tightly the residence tracks medications that are subject to abuse.
EOEA reviewed the Controlled Substances policies and procedures intended to prevent the theft or diversion of controlled substances prescribed to the Residents who participate in SAMM and LMA.
Upon review of the controlled substance practices of the Residence, it was discovered that the Residence was inconsistent in documenting a controlled substance count for all Residents prescribed a controlled substance(s) in accordance with the Residence policy for all years reviewed.
Corrective Actions.
General Requirements for an ALR: Controlled Substances
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 state also asked for specific proof, listed here as written.▼
Submit to EOEA the following:
Documentation that all applicable Residents have an up-to-date bed rail assessment that meets EOEA requirements.
Documentation that all care staff and nursing have been trained on Control Substance policy and procedures.