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.
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity GHarm
Abuse & neglect
Isolated; actual harm that is not immediate jeopardy.Corrected 2024-01-06Record 225332-20231107-F600
F677Provide care and assistance to perform activities of daily living for any resident who is unable.Scope/severity HHarm
Care planning
Pattern; actual harm that is not immediate jeopardy.Corrected 2023-12-19Record 225332-20231107-F677
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity KHarm
Care planningFalls
Pattern; immediate jeopardy to resident health or safety.Corrected 2023-12-19Record 225332-20231107-F689
F803Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.Scope/severity JHarm
Food & nutrition
Isolated; immediate jeopardy to resident health or safety.Corrected 2023-12-19Record 225332-20231107-F803
F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.Scope/severity JHarm
Records
Isolated; immediate jeopardy to resident health or safety.Corrected 2023-12-19Record 225332-20231107-F835
F837Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.Scope/severity JHarm
Records
Isolated; immediate jeopardy to resident health or safety.Corrected 2023-12-19Record 225332-20231107-F837
F940Develop, implement, and/or maintain an effective training program for all new and existing staff members.Scope/severity KHarm
Records
Pattern; immediate jeopardy to resident health or safety.Corrected 2023-12-19Record 225332-20231107-F940
F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-12-19Record 225332-20231107-F550
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 2023-12-19Record 225332-20231107-F552
F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-12-19Record 225332-20231107-F561
F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-12-19Record 225332-20231107-F580
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 2023-12-19Record 225332-20231107-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 2023-12-19Record 225332-20231107-F609
F610Respond appropriately to all alleged violations.Scope/severity EStandard
Abuse & neglect
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-12-19Record 225332-20231107-F610
F626Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-12-19Record 225332-20231107-F626
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-12-19Record 225332-20231107-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 2023-12-19Record 225332-20231107-F657
F658Ensure services provided by the nursing facility meet professional standards of quality.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-01-06Record 225332-20231107-F658
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-12-19Record 225332-20231107-F684
F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-12-19Record 225332-20231107-F686
F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-12-19Record 225332-20231107-F690
F692Provide enough food/fluids to maintain a resident's health.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-12-19Record 225332-20231107-F692
F695Provide safe and appropriate respiratory care for a resident when needed.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-12-19Record 225332-20231107-F695
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 2023-12-19Record 225332-20231107-F712
F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Scope/severity EStandard
Staffing
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-12-19Record 225332-20231107-F725
F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Scope/severity EStandard
Staffing
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-12-19Record 225332-20231107-F726
F740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-12-19Record 225332-20231107-F740
F741Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.Scope/severity DStandard
Care planningStaffing
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-12-19Record 225332-20231107-F741
F745Provide medically-related social services to help each resident achieve the highest possible quality of life.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-12-19Record 225332-20231107-F745
F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-12-19Record 225332-20231107-F756
F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-12-19Record 225332-20231107-F757
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 2023-12-19Record 225332-20231107-F758
F759Ensure medication error rates are not 5 percent or greater.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-12-19Record 225332-20231107-F759
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 FStandard
Medication
Widespread; no actual harm, potential for more than minimal harm.Corrected 2023-12-19Record 225332-20231107-F761
F791Provide or obtain dental services for each resident.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-12-19Record 225332-20231107-F791
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 2023-12-19Record 225332-20231107-F801
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 2024-01-06Record 225332-20231107-F842
F865Have a plan that describes the process for conducting QAPI and QAA activities.Scope/severity FStandard
Records
Widespread; no actual harm, potential for more than minimal harm.Corrected 2023-12-19Record 225332-20231107-F865
F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Scope/severity FStandard
Records
Widespread; no actual harm, potential for more than minimal harm.Corrected 2023-12-19Record 225332-20231107-F867
F880Provide and implement an infection prevention and control program.Scope/severity FStandard
Infection control
Widespread; no actual harm, potential for more than minimal harm.Corrected 2023-12-19Record 225332-20231107-F880
F881Implement a program that monitors antibiotic use.Scope/severity FStandard
Infection control
Widespread; no actual harm, potential for more than minimal harm.Corrected 2023-12-19Record 225332-20231107-F881
F882Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.Scope/severity FStandard
Infection control
Widespread; no actual harm, potential for more than minimal harm.Corrected 2023-12-19Record 225332-20231107-F882
F941Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.Scope/severity FStandard
Records
Widespread; no actual harm, potential for more than minimal harm.Corrected 2023-12-19Record 225332-20231107-F941
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 2023-12-19Record 225332-20231107-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 2023-12-19Record 225332-20231107-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 2023-12-19Record 225332-20231107-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 2023-12-19Record 225332-20231107-F945
F946Provide training in compliance and ethics.Scope/severity FStandard
Records
Widespread; no actual harm, potential for more than minimal harm.Corrected 2023-12-19Record 225332-20231107-F946
F949Provide behavior health training consistent with the requirements and as determined by a facility assessment.Scope/severity FStandard
Records
Widespread; no actual harm, potential for more than minimal harm.Corrected 2023-12-19Record 225332-20231107-F949
F732Post nurse staffing information every day.Scope/severity CPaperwork
Staffing
Widespread; potential for minimal harm.Corrected 2023-12-19Record 225332-20231107-F732