Massachusetts inspects every assisted living residence at least once every two years. At its most recent compliance review on April 17, 2025, the state cited 5 findings at Compass on the Bay. 2 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 · 2 repeatEmergency call responseE-call policy doesn’t identify an expected response time. Missing documentation of hourly safety checks.▼
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.
The policy developed by the Residence does not specify the amount time the staff is expected to respond to an e-call in a timely manner”. Management stated the maximum response time is eight minutes.
The Residence has chosen to 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 from March 1, 2025 through the date of the compliance review for five SCR Residents 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)(b), (c)
Memory care unitMissing components of an Operational Review. Physical hazards identified in the Special Care Residence.▼
Extra requirements that apply to units caring for residents with dementia.
AGE reviewed the Special Care Residence (SCR) operations on the date of the Compliance Review to verify that the SCR is complying with all the required safeguards.
Documentation to support the required SCR operations review was incomplete for the first half of the 2024 calendar year reviewed.
Age identified deficiencies with operational safeguards related to the risk of potential hazards in the physical environment:
Cleaning chemicals were unsecured in the kitchenette and accessible by Residents.
General Requirements for an ALR: Special Care
651 CMR 12.04(4)(a)(2),(3), (4),(5),(6),(d)
Resident 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.
AGE reviewed the documentation of five Resident Records from March 2023 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 service plan review required within 30 days after the commencement of residency.
Documentation of a service plan review required every six months or after a change in Resident condition, was missing for four records.
General Requirements for an ALR: - Screening and Assessment - Service Plan Development and Requirements
651 CMR 12.07(b) 651 CMR 12.04(8)(a)(3)(c)
Quality assurance programMissing or incomplete components of the Quality Assurance and Performance Improvement requirements. Unsafe SAMM.Repeat 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 March 24, 2023, through the date of the Compliance Review.
Documentation of the date the audit was completed was missing for the 2023 and 2024 calendar years reviewed.
Documentation of a target date for follow up action to findings was missing for 2024 calendar year reviewed.
Resident Safety Assurances
Documentation of the date the audit was completed was missing for the 2023 and 2024 calendar years reviewed.
Documentation of a target date for follow up action to findings was missing for 2024 calendar year reviewed.
Documentation of the staff person responsible for follow-up action to findings was missing for the 2023 and 2024 calendar years reviewed.
AGE reviewed the Residence’s quarterly medication documentation audits from March 24, 2023, through the date of the Compliance Review to ensure compliance with SAMM and Residence policies.
Documentation of the person responsible for conducting the audit was missing for the first quarter of the 2024 calendar year reviewed.
Documentation of specific findings was missing for the second quarter of 2023 and the fourth quarter of the 2024 calendar years reviewed.
Documentation of the target date for follow up action and staff person responsible for follow-up was missing for the fourth quarter of 2023, the first three quarters of 2024 and the first quarter of 2025.
Documentation of a specific outcome was missing for the third quarter of the 2023 calendar year reviewed.
AGE observed two Personal Care (PC) staff providing medication assistance to six Residents to ensure the Residence has developed and implemented systems that support and promote safe SAMM.
AGE observed one Resident’s expired medication stored in a cabinet outside the resident’s unit waiting for disposal.
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)(a),(b),(c)(2),(d),(e)
Incident reportingThe Residence filed 29 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 March 24, 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 29 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)
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.