Massachusetts inspects every assisted living residence at least once every two years. At its most recent compliance review on November 6, 2024, the state cited 5 findings at Windrose at Woburn. 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 repeatResident screening and assessment · Resident care plansInconsistent with documenting all requirements of Assessments and Service Plans.▼
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 July 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 missing documentation of an assessment of the Resident’s need for assistance in emergency situations.
Five (5) SCR records were missing documentation that Residents have supervised access to a heating element.
Two (2) records were missing documentation of a Service Plan reassessment required within 30-days after the commencement of residency.
Four (4) SCR records were missing documentation of individualized enrichment activities provided to the resident.
Two (2) records were missing documentation of a reassessment and service plan review being completed every six months.
General Requirements for an ALR: - Screening and Assessment - Service Plan Development and Requirements
651 CMR 12.04(1)(d) 651 CMR 12.04(7)(a)(5),(b) 651 CMR 12.04(8)(a)(3),(c)
Quality assurance programMissing or incomplete components of the Quality Assurance and Performance Improvement requirements. Insufficient documentation of the Evidenced Informed Falls PreventionRepeat 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, Safety Assurances, and Medication Quality from July 21, 2022, through the date of the Compliance Review.
Resident Safety Assurances
Documentation of an Evidenced Informed Falls Prevention Program review being included in the annual safety review process was missing for the 2023 calendar year reviewed.
EOEA reviewed the Residence’s quarterly medication documentation audits from July 21, 2022 through the date of the Compliance Review to ensure compliance with SAMM and Residence policies.
Documentation to support that the required quarterly medication audit was conducted for the last two quarters of the 2022 calendar year was missing.
This was also cited at the previous compliance review.
General Requirements for an ALR: Service and Service Coordination: Quality Assurance and Performance Improvement
651 CMR 12.04(10)(b)(c)(2),(d),(e)
Incident reportingThe Residence filed 74 incident reports greater than 24 hours after the occurrence of the incident or accident.Repeat finding▼
Telling the state, on time, when something happens to a resident.
EOEA reviewed the Residence records and incident reports from July 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 74 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)
Staff trainingBiannual skills evaluations were not consistently documented for all PC staff.▼
Training and skills checks the residence must give and document for its staff.
EOEA reviewed the records of three (3) Personal Care (PC) staff to determine compliance with Personal Care evaluation requirements in the calendar year 2022 through the date of the Compliance Review.
Documentation confirming the completion of Personal Care (PC) skills evaluations every six months was missing from two (2) records.
Training Requirements: Supervision
651 CMR 12.07(8)
Information given to residentsMissing Full Disclosure of Rights and Services.Repeat finding▼
What the residence must tell residents in writing about services, costs and rights.
EOEA reviewed five (5) Resident records to determine compliance with record requirements.
Documentation of the required notification of the right to bring a Representative prior to the first meeting was missing in two (2) records.
Documentation of the receipt of a consumer guide developed by EOEA during the Residence’s first formal meeting with a prospective Resident was missing in two (2) records.
Documentation that a Disclosure of Rights and Services was received by the Resident or Representative at the first meeting was missing in two (2) records.
This was also cited at the previous compliance review.
Resident Rights and Disclosures: Resident 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 that all care staff have completed a current Personal Care (PC) skills evaluation with a nurse.