Massachusetts inspects every assisted living residence at least once every two years. At its most recent compliance review on May 7, 2025, the state cited 6 findings at Keystone Place at Buzzards Bay. 5 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
6 findings · 5 repeatEmergency call responseIn the months of December 2023, June 2024, and February 2025 there were 1,047 e-call response times over the 10 minutes required by Residence policy.Repeat finding▼
How quickly staff answer a resident's emergency call button.
AGE reviewed response times and tests of the emergency response system from calendar year 2023 through the date of the Compliance Review to determine compliance with Service Coordination requirements.
In the months of December 2023, June 2024, and February 2025 there were 1,047 e-call response times over the 10 minutes required by Residence policy.
Documentation of monitoring e-call response times over the 10-minute limit was inconsistent for the calendar years reviewed.
Documentation of the Residence physically testing the system to ensure functionality was missing for the calendar years reviewed.
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 for six Residents had multiple instances where staff failed to document the hourly safety checks of the Residents during the hours required.
This was also cited at the previous compliance review.
General Requirements for an ALR: Emergency Response
651 CMR 12.04(2)(b)(3)
Resident care plansAGE reviewed the Residence records of 19 Residents utilizing bed rails / U-bars or similar devices to determine compliance with the required assessment by a physical/occupational therapist every six monthsRepeat finding▼
The written plan describing the care each resident is assessed to need.
AGE reviewed SEVEN Resident Records reviewing documentation from 2023 through the date of the Compliance Review to determine compliance with the requirements for Service Plan Development and Requirements.
Three SCR records were missing documentation that the Resident is provided 24-hour per day, onsite awake staff.
AGE reviewed the Residence records of 19 Residents utilizing bed rails / U-bars or similar devices to determine compliance with the required assessment by a physical/occupational therapist every six months
Seven records were missing documentation of current assessment noting that the Resident can independently navigate around a bed rail/ U-bar or similar devices.
This was also cited at the previous compliance review.
General Requirements for an ALR: Service Plan Development and Requirements
651 CMR 12.04(7)(a)(1)(2)
Quality assurance programMissing or incomplete components of the Quality Assurance and Performance Improvement requirements. Unsafe SAMM and LMARepeat 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 calendar year 2023 through the date of the Compliance Review
Documentation of the review date was missing for the 2023 and 2024 reviews.
Resident Safety Assurances
Documentation of the review date and staff responsible for follow-up action was missing for the 2023 and 2024 reviews.
Documentation of Evidence Informed Falls Prevention Program was missing for the 2023 calendar year.
AGE reviewed the Residence’s quarterly medication documentation audits from May 2023 through the date of the Compliance Review to ensure compliance with SAMM and LMA Residence policies.
Documentation of a quarterly medication review summary identifying the staff responsible for follow-up action was missing in the last two quarters of 2023.
AGE observed three Personal Care (PC) staff and one nurse providing medication assistance to nine Residents to ensure the Residence has developed and implemented systems that support and promote safe SAMM.
AGE observed two bottles of over-the-counter medications without pharmacy label in the medication storage unit for two Residents.
AGE observed medications to be administered under LMA stored in the SAMM medication storage unit of three Residents:
AGE observed three Residents’ medication storage units containing medication that were not pharmacy-filled and pharmacy labeled.
AGE observed one Resident’s medication storage unit with physician prescribed orders for an as needed (PRN) medication to be paired with separate medication whenever the PRN requested by the Resident.
The Medication Administration Record (MAR) documented that the PRN medication was last provided on May 5, 2025. However, the documentation of the PRN assistance did not include separate documentation of the paired medication as prescribed. The absence of a supply of the paired medication made it impossible to determine if the Resident received the second (paired) medication at the last administration.
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)(b), (c)(2), (d), (e)
Controlled medication handlingInaccurate CS count procedure.▼
How tightly the residence tracks medications that are subject to abuse.
AGE reviewed the Controlled Substance (CS) policy and procedure to prevent the theft or diversion of controlled substances prescribed to Residents who participate in SAMM/LMA.
Documentation to support the Residence Controlled Substance count audits in accordance with the stated frequency as described in its Controlled Substance policy was missing for all years reviewed.
General Requirements for an ALR: Controlled Substances (CS)
651 CMR 12.04(14)(a), (b)
Incident reportingThe Residence filed 30 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 May 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 30 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)
Staff trainingInconsistent documentation of Introductory Visits.Repeat finding▼
Training and skills checks the residence must give and document for its staff.
AGE reviewed the records of 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:
Seven records were without documentation of nurses’ signature verifying that Introductory Visits were conducted in accordance with the requirements of the regulation.
AGE reviewed the records of three Personal Care (PC) staff to determine compliance with Personal Care and SAMM skills evaluation requirements in the calendar year 2024 through the date of the Compliance Review.
The Residence did not document an evaluation of personal care and SAMM skills every six months for three staff in calendar years 2024 and 2025.
This was also cited at the previous compliance review.
Training Requirements: Introductory Visits and Review Supervision
651 CMR 12.07(7)
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 Introductory Visits for all Residents have been completed by Residence’s nurse for all PC staff.
Documentation of a newly completed Medication Quality Plan Review, including a Medication Storage Unit audit, for all Residents on SAMM and LMA.
Within 24 hours of receipt of this Compliance Review Report submit evidence to confirm the prescribed PRN medication order, from LMA finding noted above, has been reviewed by the Residence, including Residence nurses that provide LMA, and that both the PRN and the accompanying medication to be paired are stored in the Resident medication storage unit.
Documentation confirming that all applicable residents have a current bed rail assessment and that bed rails have been removed from Residents who have been assessed to not need bedrails.
Documentation of current training for all care and nursing staff related to the Residence Controlled Substance Policy and the accurate count and reporting of inaccuracies of Controlled Substances.