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.
F551Give the resident's representative the ability to exercise the resident's rights.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-07-14Record 225461-20250617-F551
F645PASARR screening for Mental disorders or Intellectual DisabilitiesScope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-07-14Record 225461-20250617-F645
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 2025-07-14Record 225461-20250617-F756
F851Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.Scope/severity FStandard
Records
Widespread; no actual harm, potential for more than minimal harm.Corrected 2025-07-14Record 225461-20250617-F851
F880Provide and implement an infection prevention and control program.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-07-14Record 225461-20250617-F880
F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-06-19Record 225461-20240508-F582
F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-06-19Record 225461-20240508-F584
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 2024-06-19Record 225461-20240508-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 2024-06-19Record 225461-20240508-F656
F677Provide care and assistance to perform activities of daily living for any resident who is unable.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-06-19Record 225461-20240508-F677
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity EStandard
Care planningFalls
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-06-19Record 225461-20240508-F689
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 2024-06-19Record 225461-20240508-F690
F695Provide safe and appropriate respiratory care for a resident when needed.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-06-19Record 225461-20240508-F695
F699Provide care or services that was trauma informed and/or culturally competent.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-06-19Record 225461-20240508-F699
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 EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-06-19Record 225461-20240508-F756
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 2024-06-19Record 225461-20240508-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 2024-06-19Record 225461-20240508-F761
F851Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.Scope/severity FStandard
Records
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-06-19Record 225461-20240508-F851
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 2024-06-19Record 225461-20240508-F880
F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-06-19Record 225461-20240508-F883
F641Ensure each resident receives an accurate assessment.Scope/severity BPaperwork
Care planningRecords
Pattern; potential for minimal harm.Corrected 2024-06-19Record 225461-20240508-F641
F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Scope/severity BPaperwork
Care planningRecords
Pattern; potential for minimal harm.Corrected 2024-06-19Record 225461-20240508-F842
F565Honor the resident's right to organize and participate in resident/family groups in the facility.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-02-24Record 225461-20230113-F565
F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-02-24Record 225461-20230113-F584
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 EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-02-24Record 225461-20230113-F585
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 2023-02-24Record 225461-20230113-F658
F661Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-02-24Record 225461-20230113-F661
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 2023-02-24Record 225461-20230113-F685
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity EStandard
Care planningFalls
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-02-24Record 225461-20230113-F689
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 2023-02-24Record 225461-20230113-F761
F790Provide routine and 24-hour emergency dental care for each resident.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-02-24Record 225461-20230113-F790
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 2023-02-24Record 225461-20230113-F812
F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-02-24Record 225461-20230113-F842
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 2023-02-24Record 225461-20230113-F880
F881Implement a program that monitors antibiotic use.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-02-24Record 225461-20230113-F881
F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Scope/severity DStandard
Environment
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-02-24Record 225461-20230113-F921