Massachusetts inspects every assisted living residence at least once every two years. At its most recent compliance review on January 3, 2025, the state cited 5 findings at Village at Willow Crossings. 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. 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
5 findings · 3 repeatEmergency call responseIn the month of April 2023 there were 320 e-call response times over the 15 minutes required by the Residence policy▼
How quickly staff answer a resident's emergency call button.
The Executive Office of Aging & Independence reviewed response times and tests of the emergency response system from the calendar years 2023 to 2024 to determine compliance with Service Coordination requirements.
In the month of April 2023 there were 320 e-call response times over the 15 minutes required by the Residence policy
In the month of December 2023 there were 187 e-call response times over the 15 minutes required by the Residence policy.
In the month of November 2024 there were 160 e-call response times over the 15 minutes required by the Residence policy.
General Requirements for an ALR - Service and Service Coordination Requirements: Emergency Response
651 CMR 12.04(2)(b)(3.)(b.)(c.)
Resident screening and assessment · Resident care plansThe Executive Office of Aging & Independence reviewed the records of 10 Residents to determine compliance with requirements for Screening and Assessment, Service Plan Development and Service Plan Requirements.Repeat finding▼
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.
The Executive Office of Aging & Independence reviewed the records of 10 Residents to determine compliance with requirements for Screening and Assessment, Service Plan Development and Service Plan Requirements.
Three records were without documentation to confirm that assessments noted the name and scope of any Legal Representative.
Two records were missing documentation of assessment results for Resident allergies.
Two records were missing documentation of assessment results for Resident diagnosis.
Two records were without documentation confirming the description of services not affiliated with the Assisted Living Residence.
Three records were missing documentation of a Service Plan reassessment required within 30-days after the commencement of residency.
Three 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: Screening and Assessment Service Plan Development and Requirements
651 CMR 12.04(6)(b) 651 CMR 12.04(7)(a)(1.)(2.) 651 CMR 12.04(7)(b) 651 CMR 12.04 (8)(a)(2.)(c.) 651 CMR 12.04 (8)(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.
The Executive Office of Aging & Independence 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 2023 and 2024.
The Executive Office of Aging & Independence observed one PCA staff providing medication assistance to five Residents and one nurse providing medication administration to five Residents to ensure the Residence has developed and implemented systems that support and promote safe SAMM and LMA:
Two Resident’s family filled cassettes were not labeled with the Resident’s name and room number.
One Resident’s [redacted] was not dated when opened.
This was also cited at the previous compliance review.
General Requirements for an ALR: Quality Assurance and Performance Improvement
651 CMR 12.04(10)(c)
Incident reportingThe Residence filed 12 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.
The Executive Office of Aging & Independence reviewed the Residence records and submitted incident reports from January 4, 2023 through January 3, 2025 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 Executive Office of Aging and Independence within 24 hours after the occurrence of the incident or accident.
The Residence filed 12 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 recordsComputerized resident records system did not consistently provide an auditable record of Service Plan entries. Inconsistent documentation of information necessary for the continuity of care.▼
Records that keep a resident's care information complete and available to staff.
The Executive Office of Aging & Independence reviewed the computerized records systems which must meet the equivalent requirements in 651 CMR 12.05 for permanency and accessibility, and which provide an auditable record of entries to be used as an alternative or supplement.
Three Resident Service Plan records were not auditable by the Executive Office of Aging & Independence.
The Executive Office of Aging & Independence reviewed the current 90-day Correspondence Logs for the Traditional and 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 to maintain the continuity of care for all Residents.
Corrective Actions.
Record Requirements: Resident Record Correspondence Log
651 CMR 12.05(1)(b) 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.