Massachusetts inspects every assisted living residence at least once every two years. At its most recent compliance review on August 1, 2024, the state cited 6 findings at Duxbury House at The Village Memory Care Residence. 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 repeatResident screening and assessment · Resident care plansInconsistent with documenting all requirements of Assessments and Service Plans. Inconsistant Bedrail assessments.▼
Resident screening and assessment: Checking, before and during residency, that the residence can meet a resident's needs.
Resident care plans: The written plan describing the care each resident is assessed to need.
The state cited these together under one finding.
EOEA reviewed five (5) Resident Records reviewing documentation from November 2022 through the date of the Compliance Review to determine compliance with the requirements for Screenings, Assessments and Service Plan Development and Requirements.
Five (5) records were without documentation to confirm the initial assessment was conducted by a nurse.
Documentation of individualized enrichment activities provided to the resident was missing in five (5) Special Care Residence (SCR) records.
EOEA reviewed the Residence records of five (5) Residents utilizing bed rails / U-bars or similar devices for the period of 2022 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 four (4) Residents noting that the Resident can independently navigate around a bed rail/ U-bar for the calendar years reviewed was missing.
General Requirements for an ALR: - Screening and Assessment - Service Plan Development and Requirements
651 CMR 12.04(6)(a) 651 CMR 12.04(8)(a)(3) 651 CMR 12.08(1)(s)
Incident reportingLate submissions of Resident-specific incidents reports.Repeat finding▼
Telling the state, on time, when something happens to a resident.
EOEA reviewed the Residence records and incident reports from November 2022 through the date of the Compliance Review to determine whether the Residence complied with the requirement to qualifying incidents to EOEA within 24 hours after the occurrence of the incident or accident.
The Residence filed eleven (11) incident reports greater than 24 hours after the occurrence of the incident or accident.
This was also cited at the previous compliance review.
Emergency Preparedness Plan and Reporting Requirements: Reporting Resident Specific Emergencies
651 CMR 12.04(11)(e)
Resident recordsMissing information necessary for the continuity of care.▼
Records that keep a resident's care information complete and available to staff.
EOEA reviewed the documentation maintained in two 90-day correspondence logs to communicate information necessary to maintain the continuity of care for Residents.
The second-floor log did not consistently document 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 health screeningMissing documentation of employee Health Screening Requirements.▼
Health checks the residence must document for the people it employs.
EOEA reviewed the personnel records of five (5) staff members to determine compliance with Health Screening requirements.
Two (2) records were missing documentation to confirm seasonal influenza vaccinations or declination statements for the 2023 / 2024 flu season.
Staffing Requirements: Health Screening Requirements
651 CMR 12.06(8)(e)(1)
Staff trainingInconsistent documentation of Introductory Visits.Repeat finding▼
Training and skills checks the residence must give and document for its staff.
EOEA reviewed the records of five (5) Residents to determine compliance with the requirements that a nurse review 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:
Three (3) records were without documentation to support that Introductory Visits were consistently conducted with all applicable staff prior to or within 48 hours, at the time of move-in or at the time of change in the Resident’s condition.
This was also cited at the previous compliance review.
Training Requirements: Introductory Visits
651 CMR 12.07(7)
Information given to residentsLate presentation of Disclosures of Rights and Services.▼
What the residence must tell residents in writing about services, costs and rights.
EOEA reviewed five (5) Resident records to determine compliance with Resident rights and disclosure requirements.
Documentation of the Residence providing, at the first formal meeting, a Disclosure of Rights and Services as well as informing the Resident of the right to be accompanied by a Legal Representative was missing for three (3) Residents.
Resident Rights and Required Disclosures: Resident Rights and Disclosures
651 CMR 12.08
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 state also asked for specific proof, listed here as written.▼
B. Specific Corrective Actions.
Submit to EOEA the following:
Documentation confirming that all applicable residents have a current bed rail assessment.
Documentation confirming Introductory Visits for all Residents have been completed by a nurse for all PC staff.