The Maynard

Based on staff record reviews and staff interview, the facility failed to ensure personal and social data was maintained on staff and included in the staff record. Evidence: 1. Record for staff 2, hired 9/8/2025, did not contain the required personal and social data. 2. During an interview with LI on 11/10/2025, staff 4 confirmed the personal and social information/data, such as employee?s date of birth or name and phone number of the emergency contact, was not included in staff 2?s employee record.

Based on record reviews and staff interview the facility failed to ascertain, prior to admission, whether a potential resident was a registered sex offender, document the findings in the resident's record and the date the information was obtained. Evidence: 1. Record for resident 3, admitted 5/24/2025, did not contain evidence of a registered sex offender search. 2. During an interview with the LI on 11/10/2025, staff 4 confirmed the facility failed to ascertain, prior to admission, whether a resident 1 was a registered sex offender, document the findings in resident 1?s record and the date the information obtained.

Based on record review and staff interview, the facility failed to ensure at or prior to the time of admission, there was a written agreement or acknowledgment of notification, that was dated and signed by the resident or the appropriate legal representative and by the licensee or administrator. Evidence: 1. Resident 2 admitted 3/10/2025 did not have a resident agreement in the resident record. 2. During an interview with LI on 11/10/2025, staff 4 confirmed the facility failed to ensure there was a written admission agreement signed by the resident or the legal representative and the administrator.

Based on resident record review and staff interview, the facility failed to provide an orientation, upon admission, for new residents and their legal representatives, which included emergency response procedures, mealtimes, and use of the call system. Acknowledgment of having received the orientation must be dated by the resident and, as appropriate, his legal representative, with documentation kept in the resident's record. Evidence: 1. Record for resident 1, admit date 12/17/2024, did not contain a documented orientation that was signed by the resident or legal representative. 2. Record for resident 2, admit date 3/10/2025, did not contain a documented orientation that was signed by the resident or legal representative. 3. Record for resident 3, admit date 5/24/2025, did not contain a documented orientation that was signed by the resident or legal representative. 4, Record for resident 4, admit date 6/6/2025, did not contain a documented orientation that was signed by the resident or legal representative. 5. Staff 4 presented an acknowledgement of the resident handbook as what was used to comply with this standard, but this document does not contain the required information as required per the standard. 6. During an interview with the LI on 11/10/2025, staff 4 confirmed there was no documented orientation for residents 1, 2, 3, and 4 and their respective legal representatives, which included emergency response procedures, mealtimes, and use of the call system.

Based on record review and staff interview, the facility failed to ensure that the preliminary plan of care was developed to address the basic needs of the resident to adequately protect the health, safety, and welfare of the resident. Evidence: 1. Record for resident 3, admitted 5/24/2025, did not contain a preliminary plan of care. 2. During an interview with the LI on 11/10/2025, staff 4 acknowledged the facility failed to ensure the preliminary plan of care was developed to address the basic needs of resident 3.

Based on resident record review and staff interview, the facility failed to ensure the rights and responsibilities of residents in assisted living facilities were reviewed annually with each resident or legal representative and each staff person with written acknowledgement of having been so informed, along with the date of the review, filed in the resident?s and staff?s record. Evidence: 1. Record for resident 2, admitted 3/10/2025, did not contain a signed acknowledgement that the rights and responsibilities of residents had been reviewed. 2. Record for resident 3, admitted 5/24/2025, did not contain a signed acknowledgement that the rights and responsibilities of residents had been reviewed. 3. During an interview with the LI on 11/10/2025, staff 4 acknowledged that the review of rights and responsibilities of residents had not been completed as required.

Based on record review and staff interview, the facility failed to ensure Do Not Resuscitate (DNR) Orders for withholding cardiopulmonary resuscitation from a resident in the event of cardiac or respiratory arrest were only carried out in a licensed assisted living facility when both a valid written order had been issued by the resident's attending physician and the written order was included on the individualized service plan. Evidence: 1. Resident 4, admitted 6/6/2025, had a signed physician?s Do Not Resuscitate (DNR) order dated 9/26/2025. Individualized service plan ( ISP

Based on staff record reviews and staff interview, the facility failed to obtain a sworn statement or affirmation disclosing whether the person has a criminal conviction or is the subject of any pending criminal charges within or outside the Commonwealth. Evidence: 1. The Licensing Inspector (LI) requested all sworn statements for all new staff hired since the last mandated inspection conducted on 10/28/2024 and 10/29/2024. 2. Staff 15, hired 9/30/2025, contained a sworn statement dated 10/3/2025. 3. During an interview with the LI on 11/10/2025, staff 4 acknowledged the sworn statement for staff 15 was dated after the hire date and should be obtained when employment application is submitted.

Based on staff record reviews and staff interview, the facility failed to obtain an original criminal history record report for each employee within 30 days of employment. Evidence: 1. The Licensing Inspector (LI) requested all criminal history record reports (CHRR) for all new staff hired since the last mandated inspection conducted on 10/28/2024 and 10/29/2024. 2. Staff 13, hired 4/14/2025, contained a CHRR dated 11/10/2025 (date of the inspection). 3. During an interview with the LI on 11/10/2025, staff 4 acknowledged the facility ran the CHRR for staff 13 on the day of the inspection and thus failed to obtain the required reports within 30 days of employment as required by the standard.

Based on record reviews and staff interview, the facility failed to ensure direct care staff attended at least 18 hours of training annually. Evidence: 1. Record of staff training logs indicated the following: staff 3 (hire date 5/09/2023) completed nine hours from 5/09/2023 to 5/08/2024; staff 4 (hire date 7/07/2022) completed 12.5 hours from 7/07/2023 to 7/06/2024. 2. On 10/29/2024, staff 1 confirmed there were no additional training records.

Based on document reviews and staff interview, the facility failed to obtain verification that staff received a copy of their current job description. Evidence: 1. Job description for staff 2 (hire date 4/14/2024) was not signed and there was no verification that staff 2 received a copy. 2. A new job description for staff 3 (hire date 6/07/2022) was not signed when position changed from resident assistant to medication care manager. There was no verification that staff 3 received a copy of the new job description. 3. On 10/29/2024, staff 1 confirmed that job descriptions were not signed and there was no additional documentation.

Based on direct observation and staff interview, the facility failed to ensure the posted listing of all staff who had certification in first aid (FA) and cardiopulmonary resuscitation (CPR) was current. Evidence: 1. On 10/28/2024, the licensing inspector observed the posted list of staff with FA/CPR which was dated 8/01/2022. 2. On 10/28/2024, staff 1 confirmed the posted list had not been updated since 8/01/2022.

Based on record reviews and staff interview, the facility failed to ensure residents or their legal representatives were informed annually of the sex offender registry and failed to maintain written acknowledgement on file. Evidence: 1. Files for residents 1, 2, 3 and 4 did not have written acknowledgement of an annual notification of the sex offender registry. 2. On 10/28/2024, staff 1 confirmed notice of the sex offender registry had never been provided to the residents on an annual basis.

Based on direct observation and staff interview, the facility failed to ensure the current weekly menu was posted. Evidence: 1. On 10/28/2024, the licensing inspector observed the printed menu posted on the resident information board for week 10/20/2024 through 10/26/2024. 2. On 10/28/2024, staff 1 confirmed the current week?s menu was not posted.

Based on document review and staff interview, the facility failed to ensure a dietary oversight of special diets was completed at least every six months. Evidence: 1. The facility record included a dietary oversight completed on 4/10/2023. 2. On 10/28/2024, upon request, the facility did not provide any additional documentation of dietary oversight. 3. On 10/28/2024, staff 1 confirmed dietary oversight had not been completed since 4/10/2023.

Based on observation and staff interviews, the facility failed to ensure at least one pharmacy reference book, drug guide, or medication handbook for nurses was no more than two years old. Evidence: 1. On 10/28/2024, the licensing inspector observed a Nursing Drug Handbook dated 2021 in the medication area. 2. On 10/28/2024, staff 1 and staff 3 confirmed the Nursing Drug Handbook dated 2021 was the only available drug reference book.

Based on observation and staff interview, the facility failed to ensure single-use and dedicated medical supplies and equipment were appropriately labeled and stored. Evidence: 1. On 10/28/2024, the licensing inspector checked the medication cart with staff 3 and observed glucose pens did not have identifiable information or prescription labels for residents 3, 4, and 10. 2. On 10/28/2024, staff 3 confirmed the glucose pens did not have identifiable information or prescription labels.

Based on observation, document review and staff interview, the facility failed to ensure medications ordered for as-needed ( PRN

Based on direct observation and staff interview, the facility failed to ensure the telephone numbers for the fire department, rescue squad, police, and Poison Control Center were posted by each telephone shown on the fire and emergency evacuation plan. Evidence: 1. On 10/28/2024, the licensing inspector and staff 1 conducted a facility walk through and observed that emergency numbers were not posted at the desk telephones noted on the emergency evacuation plan. 2. On 10/28/2024, staff 1 confirmed that emergency numbers were not posted by desk telephones noted on the emergency evacuation plan.

Based on document reviews and staff interview, the facility failed to ensure a record of the required fire and emergency evacuation drills were kept at the facility. Evidence: 1. Record of required fire and emergency evacuation drills were requested for October 2023 through October 2024. The drills for November 2023 and December 2023 were missing. 2. On 10/28/2024, staff 1 stated drills had been completed monthly but documentation for November 2023 and December 2023 could not be found.

Based on document reviews and staff interview, the facility failed to obtain criminal history record reports (CRRs) on or prior to the 30th day of employment for 10 out of 53 new staff hired since the last inspection on 10/05/2023. Evidence: 1. On 10/28/2024, staff 1 provided a list of staff hired since 10/05/2023. 2. The following staff did not have CRRs completed and on file: staff 6 (hired 3/14/2024); staff 7 (hired 6/10/2024); staff 8 (hired 8/12/2024); staff 9 (hired 8/26/2024); staff 10 (hired 8/26/2024); staff 11 (hired 1/02/2024); staff 12 (hired 1/04/2024); staff 13 (hired 3/18/2024); staff 14 (hired 3/03/2024); staff 15 (hired 9/23/2024). 3. On 10/29/2024, staff 1 confirmed the 10 staff did not have CRRs completed and on file.

Based upon observation and record review, the facility failed to ensure that the initials of the direct care staff administering the medication were included on the Medication Administration Records ( MAR

Based upon observation, the facility failed to post a ?No Smoking Oxygen in Use? sign on the door of a room containing oxygen tanks and an oxygen concentrator. Evidence: 1. On 10/5/2023 LI observed oxygen tanks and oxygen concentrator in the room of Resident #2. 2. LI did not observe a ?No Smoking Oxygen in Use? sign on the door of Room #2.