All American Assisted Living at Raynham

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 January 2025, there were 777 e-call response times over the ten-minute limit in accordance with the Resident’s policy.

AGE reviewed the Special Care Residence (SCR) operations review from calendar year 2023 through the date of the Compliance Review to verify that the SCR is being administered with all the required safeguards

The documentation supporting the required SCR operations was incomplete for the 2023 and 2024 calendar years.

AGE reviewed seven Resident Records reviewing documentation from April 2023 through the date of the Compliance Review to determine compliance with the requirements for Screenings, Assessments and Service Plan Development and Requirements.

Four records were missing documentation of a service plan review required within 30 days after the commencement of residency.

Five records were missing documentation of Resident goals.

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 March 2023, through the date of the Compliance Review.

Documentation of the audit was missing for the 2023 calendar year.

Documentation of the audit was missing for the 2023 calendar year.

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

Documentation of the summary of findings, the target date and person responsible for follow up action, and the outcome of any action taken were missing for the 2023 and 2024 calendar years.

AGE observed two PC staff and one nurse providing medication assistance to six Residents to ensure the Residence has developed and implemented systems that support and promote safe SAMM / LMA.

AGE observed one PC staff place one Resident’s medications in the PC’s ungloved hand not in accordance with the Residence’s medication hygiene policies.

AGE observed one Resident’s medication storage unit contained prescribed medication without pharmacy label.

AGE observed two Resident’s family filled medication planners without a label of Resident’s name.

AGE observed one Resident’s family filled medication planners were labeled with the incorrect room number.

AGE observed one PC staff did not sign on the SAMM documentation sheet after completing the medication observation.

AGE observed one Resident’s medication storage unit contained three loose unidentifiable tablets.

AGE observed one expired medication in one Resident's medication storage unit.

AGE observed one Resident’s medication storage unit contained [redacted] without a noted open date/beyond use date.

AGE observed one Resident’s medication storage unit contained medication that was not pharmacy-filled.

AGE observed two Resident’s medication storage units contained one over the counter medication and one as needed medication without orders from an authorized prescriber.

AGE reviewed the Residence’s Emergency Plan to ensure compliance that the Residence can address potential disasters and emergencies.

Documentation of elopement drills for all shifts was missing for the 2023 calendar year.

Documentation of a fire drill for the third shift was missing in the 2023 calendar year.

AGE reviewed the Residence records and incident reports from April 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 62 incident reports greater than 24 hours after the occurrence of the incident or accident.

AGE reviewed the Controlled Substance policy and procedure to provide safeguards to prevent theft and dispose of controlled substances prescribed to Residents who participate in SAMM from April 2023 through the date of the Compliance Review.

Documentation showing the Residence conducted required Controlled Substance count audits was missing for all reviewed years.

AGE reviewed the current Correspondence Log, 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 Traditional and Special Care Correspondence Logs to communicate all significant or pertinent information necessary.

AGE reviewed the personnel records of seven staff members to determine compliance with Health Screening requirements.

Four records were missing documentation to confirm seasonal influenza vaccinations or declination statements for the 2024/2025 flu season.

AGE reviewed the Residence records to determine compliance with annual training needs assessment requirements.

Documentation of annual training needs assessments was missing for the 2023 and 2024 calendar years reviewed.

AGE reviewed the records of seven Residents to determine compliance with the requirements that a nurse reviews the Resident’s service plan with all relevant personal care workers within the 48 hours after the provision of service or with any change of condition for the Resident:

Two records were without documentation to support that Introductory Visits were consistently conducted with all applicable staff.