Inspection Reports for
Compass on the Bay
1380 Columbia Rd, South Boston, MA 02127, United States, MA
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Inspection Report — Apr 17, 2025
Routine
Date: Apr 17, 2025
Visit Reason
Biennial state compliance review of the assisted living residence by the Massachusetts Executive Office of Aging & Independence (AGE) on April 17, 2025.
Findings
The state cited 5 findings, including 2 repeat findings, which is below the state median of 6. The action taken was a plan of correction required.
Citations (5)
Emergency call response: The policy does not specify an expected response time and documentation of hourly safety checks for Special Care Residence residents had multiple missing instances.
Memory care unit: Documentation to support the required Special Care Residence operations review was incomplete for the first half of 2024, and unsecured cleaning chemicals were accessible to residents.
Resident screening and assessment · Resident care plans: Two resident records were missing documentation of a service plan review within 30 days of residency start, and four records lacked documentation of six-month or change-of-condition service plan reviews.
Quality assurance program: Documentation was missing for audit dates, target dates for follow-up actions, responsible staff, specific findings, and outcomes across 2023 and 2024 calendar years. An expired medication was observed stored outside a resident’s unit (repeat finding).
Incident reporting: The residence filed 29 incident reports more than 24 hours after the occurrence of the incident or accident (repeat finding).
Report Facts
Findings: 5
Repeat findings: 2
State median findings: 6
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