Massachusetts inspects every assisted living residence at least once every two years. At its most recent compliance review on March 14, 2024, the state cited 9 findings at The Reserve at East Longmeadow. 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
9 findings · 3 repeatMedication assistance and care coordinationIn the months of April 2023, October 2023, and January 2024 there were 860 e-call response times over the expected ten minutes required by the Residence procedures.▼
How staff help residents with medication and coordinate their care.
Self- Administered Medication Management (SAMM) and Limited Medication administration (LMA).
EOEA reviewed the records of eight Residents to determine compliance with requirements with SAMM and LMA documentation.
Four records were intermittently missing staff initials/signatures or documentation which would indicate the observation of the Residents’ actions regarding the medication (e.g., whether the Resident took or refused the medication, the date and time).
EOEA reviewed response times and tests of the emergency response system from calendar year 2023 through the date of the Compliance Review to determine compliance with Service Coordination requirements.
In the months of April 2023, October 2023, and January 2024 there were 860 e-call response times over the expected ten minutes required by the Residence procedures.
A review of e-call response times during the months of April 2023, October 2023, and January 2024, suggest that the Residence did not demonstrate an effective means of ensuring reasonable staff response times to Resident requests for assistance.
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 December 2023 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 two 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.
General Requirements for an ALR: Service and Service Coordination Requirement
651 CMR12.04(2)(b)(2)(d)
Incident reportingThe Residence filed 3 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 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 3 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 responseMissing e-call response time not compliant with the ALR policy-E-Calls; lack of effective monitoring to the emergency response system. Missing documentation of hourly safety checks.Repeat finding▼
How quickly staff answer a resident's emergency call button.
This was also cited at the previous compliance review.
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. Insufficient evidence to determine safe Limited Medication Administration (LMA).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 calendar years 2022 and 2023.
Documentation that the Residence provided a target date for follow- up action and staff responsible for follow -up was missing for the calendar years 2022 and 2023.
Resident Safety Assurances
Documentation that the Residence provided the date audit conducted and staff responsible for follow-up, target date for follow-up and staff responsible for calendar years 2022 and 2023.
EOEA observed two Resident Assistance staff providing medication assistance to four Residents and one Nurse staff providing medication assistance to four Residents to ensure the Residence has developed and implemented systems that support and promote safe SAMM and LMA:
LMA:
One resident’s medication storage unit contained [redacted].
One resident was missing [redacted] not available in medication storage unit.
Two residents had a compromised pharmacy filled medication pack with a slice noted on the pharmacy filled medication pack.
One Nurse was observed pre-signing Medication Administration Record sheet prior to administering the medication to the residents.
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)(b)(c)
Resident recordsCorrespondence Log missing clear and legible information.Repeat finding▼
Records that keep a resident's care information complete and available to staff.
EOEA reviewed the current 90-day Correspondence Logs, for both the Traditional and Special Care Residence, required to communicate information necessary to maintain the continuity of care for all Residents.
The Residence did not use the Correspondence Logs to communicate clear and legible information necessary to maintain the continuity of care for all Residents.
Resident Rights and Required Disclosures
EOEA reviewed eight Resident records to determine compliance that the Residence shall deliver an EOEA consumer guide to the prospective Resident and the Residence shall maintain the Disclosure Statement in each Resident record.
Documentation confirming that the Resident had received the EOEA consumer guide at the first formal meeting with the Residence was missing in five Resident records.
The required Disclosure forms and notification of the right to bring a Representative prior to the first meeting, were not signed by the Resident, Resident Legal Representative and/or Residence in five records.
This was also cited at the previous compliance review.
Record Requirements- Correspondence Log
651 CMR 12.05(4)
Information given to residentsInconsistent documentation with all required disclosures. Inconsistent documentation of Resident Rights and Services disclosure.▼
What the residence must tell residents in writing about services, costs and rights.
Resident Rights and Required Disclosures: Resident Records
651 CMR 12.08 651 CMR 12.05(1)(g)
RecordkeepingMissing documentation required for Personnel Records▼
Records the residence is required to keep.
EOEA reviewed the personnel records of eight staff members to determine compliance with Personnel Record requirements.
Personnel records did not contain signed and dated job descriptions for three records.
Record Requirements: Personnel Record Requirements
651 CMR 12.05(3)(a)(c)
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 eight staff members to determine compliance with Health Screening requirements.
Four records were missing documentation to confirm receipt or declination of the seasonal influenza vaccine.
Four records were missing documentation of a completed tuberculosis screening.
Staffing Requirements: Health Screening Requirements
651 CMR 12.06(8)(b)(d)
Reports filed with the stateMissing documentation of required annual report of aggregate information. Missing documentation of required notification to EOEA with ten business days after Assisted Living Residence Manger leaves his or her position the Residence shall forward the contact information for any interim or new Residence Manager to EOEA, including telephone number(s) and email address▼
Paperwork the residence owes the state each year.
In accordance with the regulation the Residence is required to submit reports to EOEA by a specified date/time period each year.
As of the date of the compliance review March 14, 2024 , the ALR did not submit 2022 Aggregate Data Report.
The Residence did not submit the required notification for change in Assisted Living Residence Manager withing the required ten business days.
General Requirements for an ALR-Reports to EOEA -Annual Reports -Additional Reporting Requirements
651 CMR 12.04(13)(a)(2.) 651 CMR12.04(13)(b)2.
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:
Submission of the 2022 Aggregate Data Report to EOEA.
Documentation that all applicable staff have completed the required health screenings.
Documentation of Personnel records which did not contain signed and dated job descriptions for three records.