The Branches of Framingham

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

During the months of December 2023 and September 2024, there were 573 e-call response times over the fifteen (15) minutes required by Residence policy.

EOEA 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.

EOEA identified issues with operational safeguards related to secure entry and exit doors and procedures to reduce the risk of potential hazards in the physical environment:

SCR entry and exit door alarms were not operational when triggered.

Cleaning chemicals were stored in unsecured under-sink cabinets.

EOEA reviewed three (3) Resident Records looking at documentation from the Resident’s date of move-in through the date of the Compliance Review to determine compliance with the requirements for Screenings, Assessments and Service Plan Development and Requirements.

Two (2) records were missing documentation of a reassessment review being completed every six months.

On the date of the Compliance Review, October 22, 2024, one (1) Resident Record was missing a six-month Assessment and Service Plan review which was due [redacted] The Resident Record was also missing a change of condition Assessment and Service Plan review related to an incident reported to EOEA on [redacted]

EOEA 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 December 7, 2023 through the date of the Compliance Review.

EOEA observed one (1) Personal Care (PC) staff and one (1) nurse providing medication assistance to five (5) Residents to ensure the Residence has developed and implemented systems that support and promote safe SAMM and LMA.

EOEA observed two (2) compromised medication blister packs in one (1) Resident’s medication storage unit.

EOEA reviewed the Residence records and incident reports from December 2023 through the date of the compliance review to determine whether the Residence complied with the requirement that reports are accurate including all details associated with the incident and the filing of qualifying incidents are received by EOEA within 24 hours after the occurrence of the incident or accident.

EOEA received a complaint submitted on [redacted] describing an incident where a Resident of The Branches of Framingham [redacted] EOEA reviewed reports submitted by the ALR for this Resident during this time period. A report had been submitted to EOEA [redacted] on [redacted]. After a review of all related Resident Records, EOEA has determined that the Residence did not report the incident accurately, nor did it include all the details associated with the incident, especially the [redacted], which were known by the Residence at the time the report was submitted.

The Residence filed 13 incident reports greater than 24 hours after the occurrence of the incident or accident.

EOEA reviewed the Controlled Substance (CS) procedure to provide safeguards to prevent theft from Residents who participate in SAMM / LMA.

EOEA observed two (2) Residents’ Controlled Substance logs had discrepancies when compared to the actual on-hand count. One Resident had one (1) additional [redacted] when compared to the log. One Resident had one (1) less [redacted] when compared to the log.

EOEA reviewed the documentation maintained in two 90-day correspondence logs to communicate information necessary to maintain the continuity of care for Residents.

The Traditional log did not consistently document all significant or pertinent information necessary to maintain the continuity of care for all Residents.

The SCR correspondence log dated 9/21/24 did not contain information regarding staff [redacted]

Corrective Actions.