Massachusetts inspects every assisted living residence at least once every two years. At its most recent compliance review on July 16, 2025, the state cited 6 findings at Bridges by EPOCH at Mashpee. 4 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
6 findings · 4 repeatEmergency call responseDuring the months of July 2024, and June 2025, there were 58 e-call response times over the 10-minute limit in accordance with the Resident’s policy.Repeat finding▼
How quickly staff answer a resident's emergency call button.
AGE reviewed the Personalized Emergency Response procedures developed to provide timely assistance to a Resident in the event of an emergency.
During the months of July 2024, and June 2025, there were 58 e-call response times over the 10-minute limit in accordance with the Resident’s policy.
The Residence has chosen to manually document hourly safety checks of Residents living in the Special Care Residence (SCR) to comply with the regulation to provide timely assistance to a Resident in the event of an emergency needs situation.
Documentation of hourly safety checks for June and July 2025 had multiple instances where staff failed to document the hourly safety checks of the SCR Residents during the hours of 7:00 p.m. and 7:00 a.m.
This was also cited at the previous compliance review.
General Requirements for an ALR: Emergency Response
651 CMR 12.04(2)(b)(3.)(b.)(c.)
Resident care plansInconsistent with documenting all requirements of Assessments and Service Plans. Inconsistent with documenting bed rail assessments.Repeat finding▼
The written plan describing the care each resident is assessed to need.
AGE reviewed six Resident Records to determine compliance with requirements for the Screening and Assessment, Service Plan Development and Service Plan Requirements.
Six records were missing documentation of the disclosure of 24/7 awake staffing in the Special Care Residence.
Six records were missing documentation of the manner the Residence provides personal emergency response.
Two records were missing documentation of individualized enrichment activities provided to the Residents in the SCR.
AGE reviewed the Residence records of all 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 to ensure the Resident can independently navigate around the bedrail/U-bar was missing for three Residents utilizing a bed rail/ U-bar in the 2025 calendar year.
This was also cited at the previous compliance review.
General Requirements for an ALR: Service Plan Requirements
651 CMR 12.04(7)(a) 651 CMR 12.04(8)(a)(2.)(a.) 651 CMR 12.04(8)(a)(3.) 651 CMR 12.08(1)(s)
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.
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 May 2023, through the date of the Compliance Review.
AGE observed two nurses providing medication administration to six Residents to ensure the Residence has developed and implemented systems that support and promote safe SAMM and LMA.
AGE observed one nurse did not practice hand hygiene prior to medication administration for one Resident.
General Requirements for an ALR: Quality Assurance and Performance Improvement
651 CMR 12.04(10)(c)
Incident reportingThe Residence filed 28 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 May 2023 through the date of the Compliance Review to determine whether the Residence complied with the requirement to report qualifying incidents to AGE within 24 hours after the occurrence of the incident or accident.
The Residence filed 28 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)(a)(4)
Resident recordsInconsistent documentation of information necessary for the continuity of care.▼
Records that keep a resident's care information complete and available to staff.
AGE reviewed the current Correspondence Logs for the three Special Care Residences, required to communicate information necessary to maintain the continuity of care for all Residents.
The Residence did not use the Correspondence Logs to communicate all significant or pertinent information necessary.
Record Requirements: Correspondence Log
651 CMR 12.05(4)
Staff trainingMissing or incomplete components of staff orientation. Inconsistent documentation of Introductory Visits.Repeat finding▼
Training and skills checks the residence must give and document for its staff.
AGE reviewed the personnel records of six staff members to determine compliance with orientation requirements.
Documentation of General Orientation for five staff records was missing.
AGE reviewed the records of six Residents to determine compliance with the requirements that a nurse reviews 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 for the Resident:
Four records were without documentation to support that Introductory Visits were consistently conducted with all applicable staff.
This was also cited at the previous compliance review.
Training Requirements: -General Orientation -Introductory Visits and Review
651 CMR 12.07(1-2),(7)
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.▼
Submit to AGE the following:
Documentation confirming completed bed-rail assessments for all Residents requiring a bed-rail assessment.
Documentation to support that all employees have received the required general orientation components.
Documentation to support that Introductory Visits were consistently conducted with all applicable staff.