Massachusetts inspects every assisted living residence at least once every two years. At its most recent compliance review on October 16, 2024, the state cited 3 findings at Springhouse. 1 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
3 findings · 1 repeatQuality 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.
EOEA 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.
EOEA observed two CNA care staff and one Nurse staff providing medication assistance to six Residents to ensure the Residence has developed and implemented systems that support and promote safe SAMM and LMA:
Two Residents had SAMM medication sheets which were missing signatures for date [redacted].
One Resident [redacted] bottle documented date opened [redacted] which was expired at date of site visit.
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)
Resident care plansBed rail assessments▼
The written plan describing the care each resident is assessed to need.
EOEA reviewed the records of six Residents to determine compliance with requirements for Screening and Assessment, Service Plan Development and Service Plan Requirements.
EOEA reviewed the Residence records of 9 Residents utilizing bed rails/ U-bars or similar devices for the period of 2023 through the date of the Compliance Review to determine compliance with the required assessment by a physical/occupational therapist every six months.
Documentation of an assessment confirming that the Resident can independently navigate around the bed rail/U-bar were missing for three Residents for the calendar year 2023 and 2024.
General Requirements for an ALR: Service Plan Requirements
651 CMR 12.08(1)(s)- Circular Letter 13-1
Memory care unitChemicals not secured in the common kitchen areas in SCR units.▼
Extra requirements that apply to units caring for residents with dementia.
EOEA reviewed the Special Care Unit. All Special Care Residences shall be administered in accordance with the following safeguards: 1. The Residence shall develop and implement policies and procedures to assess and reduce the risk of potential hazards in the physical environment related to the special characteristics of the population. 2.Entry and exit doors in the common use areas within Special Care Residences shall be secured in accordance with local, state, and federal laws and regulations. All doors must automatically unlock in case of fire, power outage or emergency situation. Such policies and procedures must include an annual written statement describing in detail how the physical characteristics of any Special Care Residence have been or will be modified to promote the safety of its Residents.
EOEA observed the Special Care Unit:
The Special Care Unit, EOEA noted chemicals not secured in the common kitchen area in the Special Care Unit.
EOEA observed Special Care Unit windows were easily manipulated to open to the full extent with the unsecure window tilt blockers located in the common areas
Corrective Actions.
General Requirements for an ALR: Special Care- Physical Plant
651 CMR 12.04(4)(a)4, 1
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 EOEA the following:
1 Documentation of training for all staff regarding safeguard secure storage with chemicals on the Special Care Units.
Documentation that all applicable Residents have an up-to-date bed rail assessment that meets EOEA requirements
Documentation of secure unit testing of windows in the common areas of the Special Care Memory unit.