Massachusetts inspects every assisted living residence at least once every two years. At its most recent compliance review on July 18, 2024, the state cited 5 findings at The Residence at Great Woods. 3 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
5 findings · 3 repeatEmergency call responseIn the month of June 2024 there were 114 e-call response times over the ten minutes required by the Residence policy.Repeat finding▼
How quickly staff answer a resident's emergency call button.
EOEA reviewed response times and tests of the emergency response system from the calendar years 2022 to 2024 to determine compliance with Service Coordination requirements.
In the month of December 2022 there were 19 e-call response times over the ten minutes required by the Residence policy.
In the month of June 2023 there were 41 e-call response times over the ten minutes required by the Residence policy.
In the month of June 2024 there were 114 e-call response times over the ten minutes required by the Residence policy.
EOEA reviewed the Residence records of 22 Residents utilizing bed rails / U-bars or similar devices for the period of 2023 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 determining that the Resident can independently navigate around the bed rail / assistive device was missing for three Residents.
This was also cited at the previous compliance review.
General Requirements for an ALR - Service and Service Coordination Requirements: Emergency Response
651 CMR 12.04(2)(b)(3.)(b.)(c.)
Resident screening and assessmentMissing Bedrail assessments.▼
Checking, before and during residency, that the residence can meet a resident's needs.
General Requirements for an ALR: Screening and Assessment
651 CMR 12.04(6) 651 CMR 12.04(8)(a)(3)(c)
Quality assurance programMissing or incomplete components of the Quality Assurance and Performance Improvement requirements.Repeat finding▼
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 the calendar years 2022, 2023 and 2024.
Documentation of a date the audit was completed on was missing for calendar year 2022.
Resident Safety Assurances
Documentation of a date the audit was completed on was missing for calendar year 2022.
Documentation of a set target date for follow-up action and person responsible for follow up action was missing in calendar year 2023.
Documentation of a set target date for follow-up action and person responsible for follow up action was missing in last two quarters of calendar year 2022, all four quarters of calendar year 2023 and the first quarter of calendar year2024.
EOEA observed one PCA staff providing medication assistance to four Residents and one 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 medications stored outside their medication storage unit.
One Resident’s family filled cassette was missing the name and unit number of the Resident.
One Resident had one medication stored outside their medication storage unit.
This was also cited at the previous compliance review.
General Requirements for an ALR: Quality Assurance and Performance Improvement
651 CMR 12.04(10)(a)-(c)
Incident reportingThe Residence filed 35 incident reports greater than 24 hours after the occurrence of the incident during the period reviewed.Repeat finding▼
Telling the state, on time, when something happens to a resident.
EOEA reviewed the Residence records and submitted incident reports from June 14, 2022 through July 18, 2024 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 or accident.
The Residence filed 35 incident reports greater than 24 hours after the occurrence of the incident during the period reviewed.
This was also cited at the previous compliance review.
General Requirements for an ALR - Emergency Preparedness Plan and Reporting Requirements: Reporting Resident Specific Emergencies
651 CMR 12.04(11)(e)
Resident recordsInconsistent documentation of information necessary for the continuity of care.▼
Records that keep a resident's care information complete and available to staff.
EOEA reviewed the current 90-day Correspondence Log required to communicate information necessary to maintain the continuity of care for all Residents.
The Residence did not use the Correspondence Log to communicate all significant or pertinent information necessary to maintain the continuity of care for all Residents.
Corrective Actions.
Record Requirements: Correspondence Log
651 CMR 12.05(4)
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.