Massachusetts inspects every assisted living residence at least once every two years. At its most recent compliance review on May 29, 2024, the state cited 6 findings at Bridges by EPOCH at Andover. 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
6 findings · 2 repeatIncident reportingThe Residence filed 13 incident reports greater than 24 hours after the occurrence of the incident during the period reviewed.Repeat finding▼
Telling the state, on time, when something happens to a resident.
EOEA reviewed the Residences records and submitted incident reports from the last quarter of calendar year 2022 through the day of the compliance review for evidence that all occurrences of an incident or accident that has or may have a Significant
Negative Effect on a Resident’s health, safety or welfare were reported to EOEA within 24 hours after the occurrence of the incident during the period reviewed.
The Residence filed 13 incident reports greater than 24 hours after the occurrence of the incident during the period reviewed.
This was also cited at the previous compliance review.
General Requirements for an ALR-Emergency Preparedness Plan and Reporting Requirements: Reporting Resident Specific Emergencies
651 CMR 12.04(11) (e)
Emergency call responseIn the months of December 2022, July 2023, and April 2024 there were 258 e-call response times over the 10 minutes required by the Residence policy.Repeat finding▼
How quickly staff answer a resident's emergency call button.
EOEA reviewed the Personalized Emergency Response procedures developed to provide timely assistance to a Resident in the event of an emergency needs situation.
In the months of December 2022, July 2023, and April 2024 there were 258 e-call response times over the 10 minutes required by the Residence policy.
The Residence has chosen to manually document hourly safety checks of Residents living in the Special Care Residence (SCR) to comply with the regulations to provide timely assistance to a Resident in the event of an emergency needs situation.
Documentation of hourly checks in all four neighborhoods for May 2024, had multiple instances where staff failed to document the hourly safety checks of the SCR Residents during the hours of 7:00pm and 7:00am.
This was also cited at the previous compliance review.
General Requirements for an ALR - Service and Service Coordination Requirements: Emergency Response
651 CMR 12.04(2)(b)(3.)(b.)(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 22 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 2024.
General Requirements for an ALR: -Service Plan Requirements
651 CMR 12.04(8)(a) 651 CMR 12.08(1)(s)
Staff trainingMissing documentation of required LGBTQ training.▼
Training and skills checks the residence must give and document for its staff.
EOEA reviewed six personnel records to determine compliance with training requirements.
Four records were missing documentation to confirm completion of the required LGBTQ training.
Training Requirements: LGBTQ
M.G.L. c. 19A, § 43 651 CMR 12.04(1)€
Staff health screeningHealth Screening requirements not completed for all staff.▼
Health checks the residence must document for the people it employs.
EOEA reviewed the personnel records of six staff members to determine compliance with Health Screening requirements.
Five records were missing documentation to confirm receipt or declination of the seasonal influenza vaccine.
Staffing Requirements: -Health Screening Requirement
651CMR 12.06(4)(8)(c)
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. 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 areas in each Special Care Unit.
General Requirements for an ALR- Special Care- Physical Plant
651 CMR 12.04(4)(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 state also asked for specific proof, listed here as written.▼
Submit to EOEA the following:
Documentation that all applicable Residents have an up-to-date bed rail assessment that meets EOEA requirements.
Documentation of training for all staff regarding safeguard secure storage with chemicals on the Special Care Units.