Massachusetts inspects every assisted living residence at least once every two years. At its most recent compliance review on September 5, 2024, the state cited 5 findings at Sunrise of Leominster. 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
5 findings · 2 repeatEmergency call responseIn the month of June 2023 there were 40 e-call response times over the ten minutes required by the Residence 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.
In the month of December 2022 there were 25 e-call response times over the ten minutes required by the Residence policy.
In the month of June 2023 there were 40 e-call response times over the ten minutes required by the Residence policy.
In the month of July 2024 there were five e-call response times over the ten minutes required by the Residence policy.
General Requirements for an ALR - Service and Service Coordination Requirements: Emergency Response
651 CMR 12.04(2)(b)(3.)(b.)(c.)
Resident care plans · Bed rail safetyInconsistent with documenting all requirements of Assessments and Service Plan Development.▼
Resident care plans: The written plan describing the care each resident is assessed to need.
Bed rail safety: Assessing the risk before a resident's bed is fitted with rails.
The state cited these together under one finding.
EOEA reviewed six Resident Records to determine compliance with requirements for Service Plan Development.
Six records were missing documentation of signatures of the Resident or Legal Representative on Service Plan Assessments.
EOEA reviewed the Residence records of five 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 determining that the Resident can independently navigate around the bed rail / assistive device was missing for four Residents.
General Requirements for an ALR: -Service Plan Development -Bed Rail Assessments
651 CMR 12.04(6) 651 CMR 12.04(7) 651 CMR 12.04(8)(a)(3)(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 2022, 2023 and 2024.
EOEA observed two PCA staff providing medication assistance to five Residents to ensure the Residence has developed and implemented systems that support and promote safe SAMM:
Two Residents were missing a label with their name and unit number identification on two Family Filled 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)(c)
Incident reportingThe Residence filed 54 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 October 13, 2022 through September 5, 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 54 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)
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.
Corrective Actions.
Record Requirements: Correspondence Log
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 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.