The Falls at Cordingly Dam

AGE reviewed the Personalized Emergency Response procedures developed to provide timely assistance to a Resident in the event of an emergency.

During the months of December 2023, June 2024 and February 2025, there were 863 e-call response times over the 15-minute limit.

AGE reviewed the Special Care Residence (SCR) operations on the date of the Compliance Review to verify that the SCR is complying with all the required safeguards.

Age identified deficiencies with operational safeguards related to the risk of potential hazards in the physical environment:

Three (3) Resident accessible heating elements were operational without required safeguards to only allow supervised access.

AGE reviewed the documentation of nine (9) Resident Records from February 2023 through the date of the Compliance Review to determine compliance with the requirements for Screenings, Assessments and Service Plan Development and Requirements.

Documentation of a service plan assessment required at the commencement of residency and within 30 days after move in was not auditable for three (3) records. After July 2023, the Residence’s electronic medical record system does not clearly document assessments and service plans in a manner that clearly delineates the required periods of review.

Documentation of a service plan assessment required every six (6) months or after a Resident’s change of condition was not auditable for five (5) records. After July 2023, the Residence’s electronic medical record system does not clearly document assessments and service plans in a manner that clearly delineates the required periods of review.

AGE reviewed the Residence records of 34 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 for three (3) Residents noting that the Resident can independently navigate around the bed rail/ U-bar was missing for 17 Residents.

AGE 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 February 23, 2023, through the date of the Compliance Review.

AGE reviewed the Residence’s quarterly medication documentation audits from February 23, 2023, through the date of the Compliance Review to ensure compliance with SAMM, LMA and Residence policies.

Documentation of the staff member responsible for follow up action was missing for the second and third quarters of the 2023 calendar year reviewed.

AGE observed one (1) Personal Care (PC) staff and two (2) nurses providing medication assistance to 14 Residents to ensure the Residence has developed and implemented systems that support and promote safe SAMM / LMA.

One (1) PC staff carried a Resident’s medication blister pack outside of the Resident’s unit. This Resident also

AGE observed a family filled medication cassette unsecured in one Resident’s unit. The medications were identified to belong to [redacted].

AGE observed four (4) over the counter medications stored within one (1) Resident’s secured controlled substance medication storage unit. These medications were not listed on the Resident’s physician prescribed medication list. The Resident’s SAMM medication storage unit also contained two (2) unidentified loose pills.

AGE observed unsecured over the counter medications in one (1) Resident’s unit.

One (1) Resident’s controlled substance medication storage unit contained two (2) expired medications.

AGE reviewed the Residence records and incident reports from February 23, 2023, through the date of the Compliance Review to determine whether the Residence complied with the requirement to report qualifying incidents to AGE within 24 hours after the occurrence of the incident or accident.

The Residence filed 39 incident reports greater than 24 hours after the occurrence of the incident or accident.

AGE reviewed Resident records as required by 651 CMR 12.09.

By the completion of the compliance review the following requested Residence documentation and / or records were not auditable:

After July 2023, the Residence’s electronic medical record system does not clearly document assessments and service plans in a manner that clearly delineates the required periods of review.