East Longmeadow Memory Care

EOEA reviewed the Residence’s records and submitted incident reports for the 2022 calendar year through the day of the compliance review 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 during the period reviewed.

The Residence filed six incident reports greater than 24 hours after the occurrence of the incident during the period reviewed.

EOEA reviewed the Residence’s emergency management plan to ensure compliance that the Residence can address potential disasters and emergencies.

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 calendar years 2022 and 2023.

Documentation of Service Plan reviews for calendar years 2022 and 2023 were not made available at the date of the compliance review.

Resident Safety Assurances

Documentation of the Evidence Informed Falls Prevention Program monitoring the effectiveness of the program was missing for calendar years 2022 and 2023.

Documentation of Resident Safety Assurance was missing for calendar year 2023.

EOEA reviewed the Residence’s quarterly medication documentation audits for the calendar year 2023 through the date of Compliance Review to ensure compliance with SAMM and LMA protocols and Residence policies.

The Residence was missing the first, third, and fourth quarters for calendar year 2023, and was missing the first quarter for calendar year 2024.

EOEA observed two RCA staff and one Nurse providing medication assistance to five Residents to ensure the Residence has developed and implemented systems that support and promote safe SAMM and LMA:

SAMM:

Two RCA staff pre-signed the SAMM sheet prior to assisting residents with medication observation.

LMA:

One nurse pre-signed the LMA medication administration sheet prior to assisting residents with medication administration.

EOEA reviewed five Resident Records to determine compliance with requirements for the Screening and Assessment, Service Plan Development and Service Plan Requirements.

Two records were without documentation to confirm the initial assessment was conducted by a nurse.

Three records were missing documentation to assess the ability of the Resident to manage medication, including the ability to take medication on an as-needed basis.

Three records were missing documentation of the Legal Representative and the scope of authority.

Four records were missing documentation of a Service Plan reassessment required within 30-days after the commencement of residency.

Three records were missing documentation of a reassessment and service plan review completed every six months.

Five SCR service plan records were missing Documentation of individualized enrichment activities provided to the resident.

Four records were missing documentation of the required supervised access cooking capacity.

Four records were missing documentation that the Residence provides 24-hour per day on-site staff and keys, or access codes that may be readily available to specified shift staff.

Four records were missing documentation of assessment results for Resident allergies.

Four records were missing documentation of assessment results for Resident diagnosis.

EOEA reviewed the Special Care Residence (SCR) operations review from the last quarter of calendar year 2022 through the date of the Compliance Review to verify that the SCR is being administered with all the required safeguards.

Documentation to support the required SCR operations reviews required during the period of review were missing.

Documentation that all applicable staff from all shifts participated in elopement drills was missing for the 2022 and 2023 calendar year reviewed.

Documentation that all applicable staff from all shifts participated in evacuation drills was missing for the 2022 and 2023 calendar year reviewed.

EOEA reviewed the records to determine if the Residence developed and implemented a process for determining its staffing levels.

Documentation of a plan or review conducted at least quarterly for the appropriateness of staffing levels was missing from all four quarters of calendar year 2023 and the third and fourth quarter of calendar year 2022.

EOEA reviewed the records of five 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 Personal Care Services or with any change of condition for the Resident.

Five records were missing signature documentation to support the fact that Introductory Visits have been conducted with all applicable staff prior to or within 48 hours after the provision of Personal Care Services.

EOEA reviewed the records of three Personal Care (PC) staff to determine compliance with Personal Care and SAMM skills evaluation requirements in the calendar year 2022 through the date of the Compliance Review.

Documentation confirming the completion of Personal Care (PC) skills evaluations and SAMM evaluations every six months was missing from three records.

EOEA reviewed five personnel records to determine compliance with training requirements.

Five records were missing documentation to confirm completion of required LGBTQ training.

Corrective Actions.