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 9 findings at Grove Manor Estates. 6 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
9 findings · 6 repeatEmergency call responseMissing documentation of hourly safety checks.▼
How quickly staff answer a resident's emergency call button.
The Residence has chosen to manually document hourly safety checks of Residents living in the Special Care Residence 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 March 2023 through the date of compliance review had multiple instances where staff failed to document the hourly safety checks of the 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.)
Resident care plansFour of the 22 records were missing documentation of a current assessment noting that the Resident can independently navigate around a bed rail/ U-bar were missing.Repeat finding▼
The written plan describing the care each resident is assessed to need.
AGE reviewed seven Resident Records reviewing documentation 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.
Four records were missing documentation of a reassessment and service plan review being completed every six months.
AGE reviewed the Residence records of 22 Residents utilizing bed rails / U-bars or similar devices from calendar year 2023 through the date of the Compliance Review to determine compliance with the required assessment by a physical/occupational therapist every six months.
Four of the 22 records were missing documentation of a current assessment noting that the Resident can independently navigate around a bed rail/ U-bar were missing.
This was also cited at the previous compliance review.
General Requirements for an ALR: Service Plan Development and Requirements
651 CMR 12.04(7)(b) 651 CMR 12.04(8)(c) 651 CMR 12.08(1)(s)
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.
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 2023, through the date of the Compliance Review.
Documentation of the target date and person responsible for follow up action were missing for the 2023 and 2024 calendar years.
AGE reviewed the Residence’s quarterly medication documentation audits from March 2023, through the date of the Compliance Review to ensure compliance with SAMM, LMA and Residence policies.
Documentation of the target date and staff person responsible for the follow-up was missing for the 2023 and 2024 calendar years.
AGE observed three PC staff and one nurse providing medication assistance to eight Residents to ensure the Residence has developed and implemented systems that support and promote safe SAMM / LMA.
AGE observed two Resident’s family filled medication cassettes without a label of the Resident’s name and Unit number.
AGE observed one Resident’s family filled medication cassette not secured in the medication storage unit.
AGE observed one Resident’s medication storage unit that contained one medication from a prior day that had not been administered.
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)(c)
Incident reportingThe Residence filed 19 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 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 19 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)(e)
Controlled medication handlingControlled Substance policy is missing steps for safe storage and disposal.▼
How tightly the residence tracks medications that are subject to abuse.
AGE reviewed the Controlled Substance policy and procedure to provide safeguards to prevent theft and dispose of controlled substances prescribed to Residents who participate in SAMM.
The Residence policy does not include steps regarding the safeguards for storage and disposal of controlled substances.
General Requirements for an ALR: Controlled Substances
651 CMR 12.04(14)(b)
RecordkeepingInconsistent documentation of personnel record requirements.▼
Records the residence is required to keep.
AGE reviewed the personnel records of seven staff members to determine compliance with personnel record requirements.
Three records were missing documentation of a signed job description.
Two Personal Care (PC) records were missing documentation of current licensure or certification.
Record Requirements: Personnel Record Requirements
651 CMR 12.05(3)(a)(c)
Resident recordsInconsistent documentation of 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 current Correspondence Log, for both the Traditional and Special Care Residence, required to communicate information necessary to maintain the continuity of care for all Residents.
The Residence did not use the Traditional Correspondence Log to communicate all significant or pertinent information necessary to maintain the continuity of care for all Residents.
This was also cited at the previous compliance review.
Record Requirements: Correspondence Log
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 seven staff members to determine compliance with Health Screening requirements.
Four 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.
Staff trainingInconsistent documentation of Introductory Visits. Biannual SAMM and PC evaluations were not consistently documented for all PC staff.Repeat finding▼
Training and skills checks the residence must give and document for its staff.
AGE reviewed the records of seven 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:
Two records were without documentation to support that Introductory Visits were consistently conducted with all applicable staff.
AGE reviewed the records of five Personal Care (PC) staff to determine compliance with SAMM skills and Personal Care evaluation requirements in the calendar year 2023 through the date of the Compliance Review.
Documentation confirming the completion of SAMM and skills evaluations every six months was missing from three records for the 2024 calendar year.
This was also cited at the previous compliance review.
Training Requirements: -Introductory Visits and Review -Supervision
651 CMR 12.07(7) 651 CMR 12.07(8)
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 of completion of bed rail assessments for all Residents using a bed rail/ U-bar.
Documentation of completion of a revised Controlled Substance policy and procedure to provide safeguards for storage and disposal of controlled substances.
Documentation of completion of all Personnel Record requirements for all personnel.
Documentation to support that Introductory Visits were consistently conducted with all applicable staff.
Documentation confirming the completion of SAMM and skills evaluations for all PCA staff.