Massachusetts inspects every assisted living residence at least once every two years. At its most recent compliance review on September 10, 2024, the state cited 6 findings at Linda Manor Assisted Living. 2 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
6 findings · 2 repeatEmergency call responseEvidence of ALR management testing system to ensure functionality not compliant with ALR policy.▼
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 2022 to 2024 to determine compliance with Service Coordination requirements.
Documentation of the ALR management testing the system to ensure functionality as required by the Residence policy was missing for the calendar years reviewed.
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.▼
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, 2023 and 2024.
EOEA observed three PCA staff providing medication assistance to four Residents and one nurse providing medication administration to four Residents to ensure the Residence has developed and implemented systems that support and promote safe SAMM and LMA:
One nurse documented on the medication administration record for two Residents prior to the completion of the medication administration.
General Requirements for an ALR: Quality Assurance and Performance Improvement
651 CMR 12.04(10)(c)
Incident reportingThe Residence filed 26 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 November 17, 2022 through September 10, 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 26 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)
Controlled medication handlingControlled Substance policy is not being followed.▼
How tightly the residence tracks medications that are subject to abuse.
EOEA reviewed the Controlled Substance (CS) policy and procedure to prevent the theft or diversion of controlled substances prescribed to Residents who participate in SAMM / 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 one Resident prescribed a controlled substance in accordance with the Residence policy.
General Requirements for an ALR: Controlled Substances
651 CMR 12.04(14)(a)
Resident recordsInconsistent documentation of information necessary for the continuity of care.▼
Records that keep a resident's care information complete and available to staff.
EOEA reviewed the current 90-day Correspondence Logs for the Traditional and Special Care Residences required to communicate information necessary to maintain the continuity of care for all Residents.
The Residence did not use the Correspondence Logs to communicate all significant or pertinent information necessary to maintain the continuity of care for all Residents.
Record Requirements: Correspondence Log
651 CMR 12.05(4)
Staff trainingIncomplete documentation of Introductory Visits.Repeat finding▼
Training and skills checks the residence must give and document for its staff.
EOEA reviewed the records of eight Residents to determine compliance with the requirements that a nurse review the Resident’s service plan with all relevant personal care workers.
Seven 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, at the time of move-in.
Corrective Actions.
This was also cited at the previous compliance review.
Training Requirements: Introductory Visit and Review
651 CMR 12.07(7)
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 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.