Massachusetts inspects every assisted living residence at least once every two years. At its most recent compliance review on August 14, 2025, the state cited 8 findings at Heritage Woods. 3 of them had already been cited at the previous review. Across the 145 Massachusetts residences with a published report, the median is 6. The state also restricted the residence from admitting new residents until the corrective action was completed — the most serious outcome of a compliance review.
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
8 findings · 3 repeatEmergency call responseDuring the months of May, June and July 2025, there were 14 e-call response times over the 7-minute limit.▼
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 May, June and July 2025, there were 14 e-call response times over the 7-minute limit.
The Residence has chosen to manually document hourly safety checks of Residents living in the Special Care Residence (SCR) to provide timely assistance in the event of an emergency needs situation during the hours of 7:OO p.m. and 7:OO a.m.
Documentation of hourly safety checks from May 1, 2025, through the date of the compliance review for all SCR Residents had multiple instances where staff failed to document the hourly safety checks of the Residents during the hours required.
The Residence has chosen to manually document 24-hour, hourly safety checks of Residents living in the Traditional setting who demonstrate exit Seeking behaviors. These safety checks are a temporary action until permanent safeguards can be initiated, or the Resident is transferred to an SCR.
[redacted] the Residence initiated 24-hour, hourly safety checks [redacted] Documentation of hourly safety checks from [redacted] had multiple instances where staff failed to document the hourly safety checks every hour for each 24-hour period. Documentation of hourly safety checks from 8/11 /25 through the date of the compliance review was missing.
General Requirements for an ALR: Emergency Response
651 CMR12.04(2)(b)3.b., 651 CMR12.04(2)(b)3.c.
Memory care unitPhysical 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.
Age identified deficiencies with operational safeguards related to the risk of potential hazards in the physical environment:
Two heating elements were operable and unsecured from SCR Residents.
Cleaning chemicals were unsecured in the kitchenette and accessible by Residents.
One secure SCR emergency door alarm was not audible by Residence staff from all areas of the SCR.
AGE identified that all SCR windows could be opened by the use of ti[t-in batches which bypass the window blockers.
General Requirements for an ALR: Special Care
651 CMR12.04(4)(a)4.
Resident care plansMissing Required Documentation▼
The written plan describing the care each resident is assessed to need.
AGE reviewed the documentation of five Resident Records from May 22, 2025, 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 a physician evaluation required prior to moving into the Residence.
General Requirements for an ALR: Service Plan Development
651 CMR12.04(7)
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 f Medication Quality from May 22, 2025, through the date of the Compliance Review.
AGE reviewed the Residence's quarterly medication documentation audits from Nay 22, 2025, through the date of the Compliance Review to ensure compliance with SANM and Residence policies.
Documentation of the target date and person responsible for follow-up action was missing for the third quarter of 2025.
AGE observed four 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 family-filled medication cassettes without proper labeling.
AGE observed expired medication in one Resident's medication storage unit. AGE observed unprescribed over the counter medications unsecured or stored with SAMM medications in six Residents' medication storage units.
AGE observed medications, which had been refused by Residente during previous medication administration times but were still present in four Residents' medication storage units.
AGE observed care staff providing assistance outside the scope of SAMM by helping with one resident.
AGE observed care staff providing assistance outside the scope of SAMM by dispensing medications from bottles, which is considered "dosing”, for one Resident.
This was also cited at the previous compliance review.
General Requirements for an ALR- Service and Service Coordination: Quality Assurance and Performance Improvement (QAPI)
651 CMR12.04(10)(c), (d), (e)
Controlled medication handlingIncomplete Policy. Inconsistent CS count documentation.▼
How tightly the residence tracks medications that are subject to abuse.
AGE reviewed the Controlled Substance (CS) policy and procedure for Residents who participate in SAMM.
& The Residence's Controlled Substance policy was incomplete and did not address procedures to identify discrepancies.
& Documentation of CS counts by staff was inconsistent on multiple dates in the months of June, July and August 2025.
General Requirements for an ALR: Controlled Substances (CS)
651 CMR12.04(14)(a)
Resident progress notesInconsistent documentation of significant events.▼
The running notes staff keep on how each resident is doing day to day.
AGE reviewed ten Residents' records to determine compliance with record requirements.
Documentation of significant occurrences in the progress notes was missing for Four residents specifically concerning that had been reported to AGE.
Resident Record: Progress Notes
651 CMR12.05(1)(c)
RecordkeepingMissing Personnel Records.Repeat finding▼
Records the residence is required to keep.
AGE reviewed the personnel records of ten staff members to determine compliance with personnel record requirements.
Four personnel records were missing documentation of a signed job description.
This was also cited at the previous compliance review.
Record Requirements: Personnel Record Requirements
651 CMR12.05(3)(a)
Staff trainingMissing staff orientation. Biannual SAMM and skills 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 personnel records of ten staff members to determine compliance with orientation requirements.
6Documentation of General Orientation was missing in four staff records.
AGE reviewed the records of nine Personal Care (PC) staff to determine compliance with SAMM skills and Personal Care evaluation requirements for 2025.
& Documentation confirming the completion of SAMM and personal care skills evaluations every six months was missing from two records for the 2025 calendar year reviewed.
This was also cited at the previous compliance review.
Training Requirements: General Orientation Supervision
651 CMR12.07(1); 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.▼
Specific Corrective Actions. Submit to AGE the following:
Documentation confirming that all current Traditional Residents with exit seeking behaviors identified on the day of the site visit have a 1:1 supervision 24-hours a day.
Documentation confirming a completed care staff in-service training regarding the importance of safety checks in both traditional and Special Care settings.
Documentation confirming a management plan to monitor safety checks to ensure checks are completed based on service plan requirements.
Documentation confirming a medication Quality Review and a medication storage unit / apartment inspection for all SAMM Residents.
5. Documentation confirming SAMM training for Personal Care Staff emphasizing the scope and restrictions of SAMM assistance.
Documentation confirming training regarding Controlled Substance policies and procedures for Personal Care staff.
Documentation confirming training of both Residence management and Personal Care staff on progress notes and the appropriate notation of significant occurrences or changes to a Resident's status.
Documentation confirming current 2025 biannual SAMM and personal care skills evaluations have been completed by a nurse for alt Personal Care staff.
Other notes from the reviewParts of the state's report that do not belong to a single finding, shown as written.▼
AGE is exercising the discretionary authority granted to it under 651 CMR 12.09(4)(b) through (d) and modifying the Residence's Certification. AGE is requiring the Residence to implement the previously described corrective actions. The Residence must continue to cease the enrollment of new Residents.
Pursuant to 651 CMR 12.10(4), AGE 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 AGE a complete and accurate list of the names and addresses of every Resident 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.4 The submission of the corrective action plan will not after 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.
AGE may conduct a compliance review at any time to determine the Residence's compliance with the implementation of the corrective actions submitted in response to the modification of its Certification.