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 2026-04-15Record 225752-20260303-F551
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 2026-04-15Record 225752-20260303-F658
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 2026-04-15Record 225752-20260303-F689
F730Observe each nurse aide's job performance and give regular training.Scope/severity EStandard
Staffing
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-04-15Record 225752-20260303-F730
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 2026-04-15Record 225752-20260303-F880
F881Implement a program that monitors antibiotic use.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-04-15Record 225752-20260303-F881
F887Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-04-15Record 225752-20260303-F887
F908Keep all essential equipment working safely.Scope/severity FStandard
Environment
Widespread; no actual harm, potential for more than minimal harm.Corrected 2026-04-15Record 225752-20260303-F908
F909Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.Scope/severity EStandard
Environment
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-04-15Record 225752-20260303-F909
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 BPaperwork
Care planningRecords
Pattern; potential for minimal harm.Corrected 2026-04-15Record 225752-20260303-F657
F838Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.Scope/severity CPaperwork
Records
Widespread; potential for minimal harm.Corrected 2026-04-15Record 225752-20260303-F838
F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-05-31Record 225752-20250429-F550
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 2025-05-31Record 225752-20250429-F565
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 2025-06-03Record 225752-20250429-F585
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 2025-06-03Record 225752-20250429-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 EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-06-03Record 225752-20250429-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 2025-05-31Record 225752-20250429-F658
F699Provide care or services that was trauma informed and/or culturally competent.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-05-31Record 225752-20250429-F699
F742Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-05-31Record 225752-20250429-F742
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 2025-06-03Record 225752-20250429-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 2025-06-03Record 225752-20250429-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 FStandard
Medication
Widespread; no actual harm, potential for more than minimal harm.Corrected 2025-06-03Record 225752-20250429-F761
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 2025-06-03Record 225752-20250429-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 2025-06-03Record 225752-20250429-F880
F881Implement a program that monitors antibiotic use.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-06-03Record 225752-20250429-F881
F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-06-03Record 225752-20250429-F883
F887Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-06-03Record 225752-20250429-F887
F909Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.Scope/severity FStandard
Environment
Widespread; no actual harm, potential for more than minimal harm.Corrected 2025-06-03Record 225752-20250429-F909
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 2024-05-31Record 225752-20240514-F551
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 2024-05-31Record 225752-20240514-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 2024-05-31Record 225752-20240514-F658
F727Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.Scope/severity FStandard
Staffing
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-05-31Record 225752-20240514-F727
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 2024-05-31Record 225752-20240514-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 2024-05-31Record 225752-20240514-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 DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-05-31Record 225752-20240514-F761
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 2024-05-31Record 225752-20240514-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 2024-05-31Record 225752-20240514-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 2024-05-31Record 225752-20240514-F883