Massachusetts inspects every assisted living residence at least once every two years. At its most recent compliance review on October 10, 2024, the state cited 4 findings at The Cordwainer. 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
4 findingsIncident reportingThe Residence filed 36 incident reports greater than 24 hours after the occurrence of the incident during the period reviewed.▼
Telling the state, on time, when something happens to a resident.
EOEA reviewed the Residences records and submitted incident reports from the last quarter of calendar year 2022 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 36 incident reports greater than 24 hours after the occurrence of the incident during the period reviewed.
General Requirements for an ALR-Emergency Preparedness Plan and Reporting Requirements: Reporting Resident Specific Emergencies
651 CMR 12.04(11) (e)
Emergency call responseIn the month of September 2024 there were 25 e-call response times over the eight 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 last quarter of 2022 through the day of the compliance review to determine compliance with Service Coordination requirements.
In the month of August 2023 there were 15 e-call response times over the eight minutes required by the Residence policy.
In the month of September 2024 there were 25 e-call response times over the eight 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 screening and assessmentInconsistent with documenting all requirements of Assessments and Service Plans.▼
Checking, before and during residency, that the residence can meet a resident's needs.
EOEA reviewed five Resident Records to determine compliance with requirements for the Screening and Assessment, Service Plan Development and Service Plan Requirements.
Four records were without documentation to confirm the initial assessment was conducted by a nurse.
General Requirements for an ALR: Screening and Assessment
651 CMR 12.04(6)(a)
Quality assurance programMissing or incomplete components of the Quality Assurance and Performance Improvement requirements.▼
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 last quarter of 2022 and the calendar years 2023 and 2024.
Documentation of Service Plan reviews for calendar years 2023 and 2024 were missing the target date for follow-up action and clear documented outcomes.
Resident Safety Assurances
Documentation of the Safety Policy and Procedures review for calendar years 2023 and 2024 were missing the target date for follow-up action and staff responsible for follow-up.
EOEA reviewed the Residence’s quarterly medication documentation audits for the last quarter of 2022 and calendar years 2023 through the date of Compliance Review to ensure compliance with SAMM and LMA protocols and Residence policies.
The Residence was missing the follow up action for set target date, staff responsible for follow-up and clear documented outcomes in the last quarter of calendar year 2022 and for calendar years 2023 and 2024.
EOEA observed one RSA staff providing medication assistance to two Residents and two Nurse providing medication administration to three Residents to ensure the Residence has developed and implemented systems that support and promote safe SAMM and LMA:
One Resident had one PRN pharmacy filled medication bubble pack with a compromised hole punch on one date.
Two Resident’s had one PRN pharmacy filled medication bubble pack with a compromised slice on one date.
Corrective Actions.
General Requirements for an ALR: Quality Assurance and Performance Improvement
651 CMR 12.04(10)(c)
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.