Massachusetts inspects every assisted living residence at least once every two years. At its most recent compliance review on April 11, 2024, the state cited 4 findings at Bridges by EPOCH at Westwood. 1 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
4 findings · 1 repeatEmergency call responseMissing documentation of hourly safety checks.▼
How quickly staff answer a resident's emergency call button.
The Residence has chosen to electronically document hourly safety checks of Residents living in the Special Care Residences (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 59 SCR Residents reviewed by EOEA from April 9, 2024 through April 10, 2024 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.
General Requirements for an ALR: Emergency Response
651 CMR 12.04(2)(b)(3)(c)
Quality assurance programMissing Quality Assurance and Performance Improvement requirements.▼
The residence's own program for auditing and improving the care it gives.
EOEA reviewed documentation indicated below, from August 2023 through the date of the compliance review, to ensure the Residence has established an effective, ongoing quality improvement and assurance program for Resident Safety Assurances, and the Medication Quality Plan.
and the Westwood Police met at the Residence on -resulting in a police investigation. EOEA reached out to the Executive Director to request supportive documentation regarding any internal Residence investigation. The Executive Director stated that no internal investigation had been started and no action had been taken. On the day of the compliance review, the Executive Director stated that she had not taken further ste s to document an investigation and that the employee suspected of misuse ohad been allowed to continue working with the Residence until the conclusion of the police investigation. The Executive Director's actions are contrary to the Residence's Resident Abuse Policy:
The Executive Director did not document an investigation into the allegation of the misuse of Resident finances including an incident timeline, interviews, and notification of corporate leadership as required by the Resident Abuse Policy. The Resident Abuse Policy requires forms including an "incident timeline," the "reporting abuse interview questions," and an "investigation statement." The Resident Abuse Policy states: "When abuse is observed by, reported by or suspected by any employee, resident or visitor the following steps will be required... All alleged violations of abuse will be investigated by the community. The Executive Director or designee will lead the investigation." The Resident Abuse Policy also provides:
"The Manager on Duty or the Executive Director has a responsibility for the following:
When the alleged perpetrator is known, the Manager on Duty or the Executive Director shall remove the person from the community.
The Manager on Duty or the Executive Director shall Notify the VP of Ops and VP of Wellness
The Manager on Duty or the Executive Director shall notify the appropriate Department Head(.]"
The Resident Abuse Policy also requires that an investigation be initiated into the alleged incident during the shift it occurred or when staff was notified.
Documentation of a target date and staff person responsible for follow-up action was missing for the last two quarters of the 2023 calendar year reviewed.
General Requirements for an ALR: Quality Assurance and Performance Improvement
651 CMR 12.04(10)(b), (c), (d), (e)
Incident reportingThe Residence filed 17 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 August 2023 through the date of the compliance review to determine whether the Residence complied with the requirement of filing qualifying incidents with EOEA within 24 hours after the occurrence of the incident or accident.
The Residence filed 17 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(1 l)(e)
Resident progress notesInconsistent documentation of significant events.▼
The running notes staff keep on how each resident is doing day to day.
EOEA reviewed five (5) Residents' records to determine compliance with record requirements.
Inconsistent documentation of significant occurrences in the Progress Notes for two (2) Residents including:
Documentation of an allegation of Resident financial abuse was missing.
Corrective Actions.
Resident Record: Progress Notes
651 CMR 12.05(l)(c)
Some paragraphs were omitted because the original file published by the state contains malformed words or text errors.
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.▼
DETERMINATION:
Due to the significance of findings, EOEA is exercising the discretionary authority granted to it under 651 CMR 12.09(4)(b) thru (d) to require corrective action and modify the Residence's Certification. Effective May 24, 2024, under the conditions of this Modification, the Residence may continue to operate and admit new Residents and shall submit the requested documentation below to EOEA no later than the close of business on June 24, 2024. The requested documents are:
Evidence that all management and staff have completed Resident Abuse Policy training regarding proper investigation, documentation and reporting requirements.
Evidence that Residence management has notified the Residents, and/or their legal representatives by letter and/or e-mail that an allegation of misuse of Resident finances has occurred and that an employee has been identified and terminated.
Evidence that all associated Residence records required by policy as well as the specific Resident's records have been updated to reflect the scope of the reported allegation of financial abuse.
Pursuant to 651 CMR 12.10(4), EOEA 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 EOEA 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.1 The submission of the corrective action plan will not alter the modification of the Residence's Certification. The modification of the Residence's Certification 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.
EOEA may conduct a compliance review at any time to determine the Residence's compliance with implementation of the corrective actions submitted in response to the 1nodification of its ALR certification status.