CMS · Massachusetts Department of Public Health publishes each citation’s tag, official description and scope/severity letter. The surveyor’s written findings are in the Statement of Deficiencies (CMS-2567) for each survey, linked above.
F554Allow residents to self-administer drugs if determined clinically appropriate.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-06-10Record 225317-20250610-F554
F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-06-10Record 225317-20250610-F607
F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-06-10Record 225317-20250610-F609
F610Respond appropriately to all alleged violations.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-06-10Record 225317-20250610-F610
F694Provide for the safe, appropriate administration of IV fluids for a resident when needed.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-06-10Record 225317-20250610-F694
F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-06-10Record 225317-20250610-F761
F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Scope/severity DStandard
Food & nutrition
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-07-01Record 225317-20250610-F804
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity DStandard
Food & nutrition
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-06-10Record 225317-20250610-F812
F865Have a plan that describes the process for conducting QAPI and QAA activities.Scope/severity EStandard
Records
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-06-10Record 225317-20250610-F865
F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Scope/severity EStandard
Records
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-06-10Record 225317-20250610-F867
F880Provide and implement an infection prevention and control program.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-06-10Record 225317-20250610-F880
F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Scope/severity BPaperwork
Dignity & rights
Pattern; potential for minimal harm.Corrected 2025-06-10Record 225317-20250610-F582
F553Allow resident to participate in the development and implementation of his or her person-centered plan of care.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-07-05Record 225317-20240613-F553
F576Ensure residents have reasonable access to and privacy in their use of communication methods.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-07-05Record 225317-20240613-F576
F585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-07-05Record 225317-20240613-F585
F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-07-05Record 225317-20240613-F609
F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedScope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-07-05Record 225317-20240613-F655
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-07-05Record 225317-20240613-F656
F658Ensure services provided by the nursing facility meet professional standards of quality.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-07-05Record 225317-20240613-F658
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-07-05Record 225317-20240613-F684
F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-07-05Record 225317-20240613-F758
F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-07-05Record 225317-20240613-F761
F800Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.Scope/severity DStandard
Food & nutrition
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-07-05Record 225317-20240613-F800
F801Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-06-27Record 225317-20240613-F801
F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-07-05Record 225317-20240613-F804
F805Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.Scope/severity DStandard
Food & nutrition
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-07-05Record 225317-20240613-F805
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-07-05Record 225317-20240613-F812
F880Provide and implement an infection prevention and control program.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-07-05Record 225317-20240613-F880
F881Implement a program that monitors antibiotic use.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-07-05Record 225317-20240613-F881
F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Scope/severity FStandard
Environment
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-07-05Record 225317-20240613-F925
F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Scope/severity BPaperwork
Dignity & rights
Pattern; potential for minimal harm.Corrected 2024-07-05Record 225317-20240613-F582
F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Scope/severity GHarm
Dignity & rights
Isolated; actual harm that is not immediate jeopardy.Corrected 2023-03-20Record 225317-20230223-F580
F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Scope/severity HHarm
Care planning
Pattern; actual harm that is not immediate jeopardy.Corrected 2023-03-20Record 225317-20230223-F686
F688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.Scope/severity GHarm
Care planning
Isolated; actual harm that is not immediate jeopardy.Corrected 2023-03-21Record 225317-20230223-F688
F692Provide enough food/fluids to maintain a resident's health.Scope/severity GHarm
Care planning
Isolated; actual harm that is not immediate jeopardy.Corrected 2023-03-24Record 225317-20230223-F692
F551Give the resident's representative the ability to exercise the resident's rights.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-03-24Record 225317-20230223-F551
F552Ensure that residents are fully informed and understand their health status, care and treatments.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-05-15Record 225317-20230223-F552
F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-03-24Record 225317-20230223-F607
F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-03-24Record 225317-20230223-F609
F610Respond appropriately to all alleged violations.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-03-24Record 225317-20230223-F610
F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedScope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-03-24Record 225317-20230223-F655
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-05-15Record 225317-20230223-F656
F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-03-24Record 225317-20230223-F657
F658Ensure services provided by the nursing facility meet professional standards of quality.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-03-28Record 225317-20230223-F658
F685Assist a resident in gaining access to vision and hearing services.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-03-24Record 225317-20230223-F685
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity DStandard
Care planningFalls
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-03-24Record 225317-20230223-F689
F711Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.Scope/severity DStandard
Staffing
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-03-24Record 225317-20230223-F711
F712Ensure that the resident and his/her doctor meet face-to-face at all required visits.Scope/severity DStandard
Staffing
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-03-24Record 225317-20230223-F712
F744Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-03-24Record 225317-20230223-F744
F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-03-24Record 225317-20230223-F758
F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-03-24Record 225317-20230223-F761
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-03-24Record 225317-20230223-F812
F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-05-15Record 225317-20230223-F842
F880Provide and implement an infection prevention and control program.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-02-24Record 225317-20230223-F880
F881Implement a program that monitors antibiotic use.Scope/severity FStandard
Infection control
Widespread; no actual harm, potential for more than minimal harm.Corrected 2023-03-24Record 225317-20230223-F881
F885Report COVID19 data to residents and families.Scope/severity FStandard
Infection control
Widespread; no actual harm, potential for more than minimal harm.Corrected 2023-02-24Record 225317-20230223-F885
F886Perform COVID19 testing on residents and staff.Scope/severity FStandard
Infection control
Widespread; no actual harm, potential for more than minimal harm.Corrected 2023-05-15Record 225317-20230223-F886
F888Ensure staff are vaccinated for COVID-19Scope/severity FStandard
Infection control
Widespread; no actual harm, potential for more than minimal harm.Corrected 2023-03-24Record 225317-20230223-F888
F908Keep all essential equipment working safely.Scope/severity EStandard
Environment
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-05-15Record 225317-20230223-F908
F942Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.Scope/severity FStandard
Dignity & rights
Widespread; no actual harm, potential for more than minimal harm.Corrected 2023-03-24Record 225317-20230223-F942
F943Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.Scope/severity FStandard
Abuse & neglect
Widespread; no actual harm, potential for more than minimal harm.Corrected 2023-03-24Record 225317-20230223-F943
F944Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.Scope/severity FStandard
Records
Widespread; no actual harm, potential for more than minimal harm.Corrected 2023-03-24Record 225317-20230223-F944
F945Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.Scope/severity FStandard
Infection control
Widespread; no actual harm, potential for more than minimal harm.Corrected 2023-02-24Record 225317-20230223-F945
F642Ensure a qualified health professional conducts resident assessments.Scope/severity BPaperwork
Care planningRecords
Pattern; potential for minimal harm.Corrected 2023-03-24Record 225317-20230223-F642