Massachusetts inspects every assisted living residence at least once every two years. At its most recent compliance review on February 4, 2025, the state cited 9 findings at Windrose at Weymouth. 7 of them had already been cited at the previous review. Across the 145 Massachusetts residences with a published report, the median is 6. The state also restricted the residence from admitting new residents until the corrective action was completed — the most serious outcome of a compliance review.
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. Where the state withheld private details, such as a resident's medication or the date of an incident, the text reads [redacted].
Facility details
What the state found
9 findings · 7 repeatFood and dietary servicesInsufficient dietary reviews.Repeat finding▼
Meals, dietary review and how the kitchen is run.
AGE reviewed Residence’s dietary plan reviews from the last quarter of the calendar year 2023 through the date of the Compliance Review to confirm consistency with the most recent edition of the Dietary Guidelines.
Dietary Reviews missing one six-month review in calendar year 2023. The second half of the 2024 calendar year lacked the inclusion of the required language designating that the meal selections meet the minimum dietary standards of the daily recommended allowances of sodium, sugar and fat content as established by the Food and Nutrition Board of the National Research Council of the National Academy of Sciences
This was also cited at the previous compliance review.
General Requirements for an ALR: Dietary Reviews
651 CMR 12.04(2}(b)4.
Memory care unitSafety issues identified in the Special Care Residence (SCR). Bi-annual Special Care Residence (SCR) operations review not completed in accordance with the regulation.▼
Extra requirements that apply to units caring for residents with dementia.
AGE reviewed the Special Care Residence (SCR) operations review from the last quarter of calendar year 2023 through the date of the Compliance Review to verify that the SCR is being operated with all the required safeguards:
Documentation to support the required operations review was conducted for the last quarter of calendar year 2023 and calendar year 2024 was missing.
AGE observed the Special Care Unit:
AGE noted chemicals not secured in the common kitchen area.
The laundry room door was unlocked.
AGE identified issues with operational safeguards related to secure entry and exit doors:
Entry and exit door alarms were not responded to by staff on duty as required by Residence policy when triggered by AGE during door alarm testing.
General Requirements for an ALR: Special Care
651 CMR 12.04(4(a)4. 651 CMR 12.04(4(d)
Resident care plansInconsistent with documenting all requirements of Assessments and Service Plans.Repeat finding▼
The written plan describing the care each resident is assessed to need.
AGE reviewed four Resident Records looking at documentation from the Resident’s date of move-in through the date of the Compliance Review to determine compliance with the requirements for Screenings, Assessments and Service Plan Development and Requirements.
Two records were missing documentation of a reassessment and service plan review being completed every six months.
This was also cited at the previous compliance review.
General Requirements for an ALR: - Service Plan Requirements
651 CMR 12.04(8)( c)
Quality assurance programMissing or incomplete components of the Quality Assurance and Performance Improvement requirements. Insufficient documentation of the Evidenced Informed Falls Prevention ProgramRepeat finding▼
The residence's own program for auditing and improving the care it gives.
AGE 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 the last quarter of calendar year 2023 through the date of the Compliance Review.
Documentation that the Residence identified a target date for follow-up action, staff responsible for follow-up and documented clear outcomes were missing for calendar year 2024.
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 and 2024 calendar years reviewed.
Documentation for Resident Safety Assurances was missing for the 2023 and 2024 calendar years reviewed.
AGE reviewed the Residence’s quarterly medication documentation audits from the last quarter of calendar year 2023 through the date of the Compliance Review to ensure compliance with SAMM and LMA Residence policies.
Documentation of a quarterly medication review summary was missing for the last quarter of the 2024 calendar year.
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), (b), (d), (e)
Incident reportingThe Residence filed 14 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.
AGE reviewed the Residence records and incident reports from the last quarter of calendar year 2023 through the date of the compliance review to determine whether the Residence complied with the requirement that reports are accurate, including all details associated with the incident and that the filing of qualifying incidents are received by AGE within 24 hours after the occurrence of the incident or accident.
AGE received a concern on [redacted], from [redacted] [redacted] shared information which involved multiple Residents of Windrose at Weymouth regarding quality-of-care concerns. After a review of all related information provided to AGE from [redacted], AGE determined that the Residence did not report the incidents accurately.
The Residence filed 14 incident reports greater than 24 hours after the occurrence of the incident or accident.
This was also cited at the previous compliance review.
General Requirements for an ALR: Reporting Resident Specific Emergencies
651 CMR 12.04(11)(d), (e)
Resident recordsMissing documentation required for Personnel Records. Missing information necessary for the continuity of care.Repeat finding▼
Records that keep a resident's care information complete and available to staff.
AGE reviewed the personnel records of four staff members to determine compliance with Personnel Record requirements.
Four personnel records did not contain signed and dated job descriptions.
AGE reviewed the documentation maintained in the 90-day correspondence log to communicate information necessary to maintain the continuity of care for Residents.
The log did not consistently document all significant or pertinent information necessary to maintain the continuity of care for all Residents.
The correspondence log was missing for the month of November 2024.
This was also cited at the previous compliance review.
Record Requirements: -Personnel Record Requirements -Correspondence Log
651 CMR 12.05(3)(a) 651 CMR 12.05(4)
Staff health screeningMissing documentation of employee Health Screening Requirements.Repeat finding▼
Health checks the residence must document for the people it employs.
AGE reviewed the personnel records of four staff members to determine compliance with Health Screening requirements.
Two records were missing documentation to confirm seasonal influenza vaccinations or declination statements for the 2024/2025 flu season.
This was also cited at the previous compliance review.
Staffing Requirements: Health Screening Requirements
651 CMR 12.06(8)(e)(1)
StaffingMissing documentation of Staffing Level Reviews▼
Who the residence employs and what it must document about them.
AGE reviewed the Residence records to determine compliance with Staffing Level requirements.
Documentation to confirm the Residence conducted quarterly staffing level assessments was missing for calendar year 2024.
Staffing Requirements: Staffing Levels
651 CMR 12.06(4)(a)
Staff trainingMissing annual training needs assessments. Inconsistent documentation of Introductory Visits. Biannual SAMM evaluations were not consistently documented for all PC staff Missing LGBTQ TrainingRepeat finding▼
Training and skills checks the residence must give and document for its staff.
AGE reviewed the Residence’s documentation for evidence of compliance with the training needs assessment regulation.
Documentation to support that the Residence has conducted a training needs assessment for calendar years 2023 and 2024 were missing.
AGE reviewed the records four 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 service or with any change of condition of the Resident:
Three records were without documentation to support that Introductory Visits were consistently conducted with all applicable staff prior to or within 48 hours, or at the time of change in the Resident’s condition.
AGE reviewed four personnel records to determine compliance with training requirements.
Two records were missing documentation to confirm completion of required LGBTQ training.
AGE reviewed the records of three Personal Care (PC) staff to determine compliance with Personal Care evaluation requirements in the calendar year 2024 through the date of the Compliance Review.
Documentation confirming the completion of Personal Care evaluation requirements was missing for calendar year 2024.
Corrective Actions.
This was also cited at the previous compliance review.
Training Requirements: -Training Needs Assessment -Introductory Visits and Review -Supervision -LGBTQ
651 CMR 12.07(5), (7), (8) M.G.L. c. 19A, § 43 651 CMR 12.04(1)(e)
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.▼
Specific Corrective Actions.
Submit to AGE the following:
Documentation of an SCR operational safeguards review related to secure entry and exit doors and procedures to reduce the risk of potential hazards in the physical environment.
Documentation of current training for all staff on procedures on SCR Units door alarm response times.
Documentation of Personal Care Staff training for PC skills assessments and evaluations with a nurse including a focus training on skin integrity.
Documentation of completion of all Personnel Record requirements for all personnel.
Documentation of a newly completed Training Needs Assessment.
Documentation of Training for all staff on Communication policy and procedures with the PACE Provider(s).
Evidence that all management and staff with incident reporting responsibilities have completed training regarding proper reporting requirements to ensure that all reports are accurate and include all details associated with the incident.
Documentation of a completed Resident Safety Assurance Policy and Procedure Review.
DETERMINATION:
Due to the significance of findings, AGE is exercising the discretionary authority granted to it under 651 CMR 12.09(4)(c), (d) to require corrective action and modify the Residence’s Certification. Under the conditions of this modification, effective as of the date of this letter, the Residence is required to cease the enrollment of new Residents. The Residence must submit to AGE a current copy of its Resident census as of the date of this letter and subsequently submit a copy of its Resident census by the close of business on Friday each week the Residence’s Certification remains modified. The Residence shall submit to AGE these requested documents for the prior month no later than the closing of business on the 15th day of each month until further notice. The requested documents are:
Current Resident Roster noting all new move-ins and transfers to the Residence for the previous month.
Audit / findings report to verify the SCR is complying with all the required safeguards.
Evidence that management and staff with incident reporting responsibilities have completed training regarding proper reporting requirements to ensure that all reports are accurate and include details associated with the incident.
Pursuant to 651 CMR 12.10(4), AGE must transmit a notice regarding the modification to each Resident or Legal Representative and appropriate governmental agencies. Upon receipt of this letter, the Residence must immediately submit to AGE a complete and accurate list of the names and addresses of every Resident and/or their Legal Representative. The list must include every Resident’s Unit number and date of move-in and be in Word or Excel format.
The Residence must address all findings and comply with the corrective actions listed within 30 days.2 The submission of the corrective action plan will not alter the modification of the Residence’s Certification. The modification of the Residence’s Certification and cessation of enrollment of new Residents will continue until further notice and will remain in effect until such time as the Assisted Living Certification Unit determines that the Residence has sufficiently addressed and corrected all findings and demonstrated regulatory compliance. Failure to comply with the required corrective actions in a timely manner may lead to further action, including the suspension or revocation of the Certification.
AGE may conduct a compliance review at any time to determine the Residence’s compliance with the implementation of the corrective actions submitted in response to the modification of its Certification.