Based on observations, record review and interviews, the facility failed to notify one Resident's (#172) physician and legal guardian of a change in condition out of a total sample of 27 residents. Specifically, the facility failed to notify the physician of Resident #172's refusing medication, exit seeking behavior, an elopement from the facility and multiple other attempts of elopements from the facility, including through a second story window, resulting in Resident #172 from falling out of a second-floor window and requiring acute hospitalization with a fracture of the fourth lumbar vertebrae with mild retropulsion into the spinal canal (bone fragments in spinal cord), fractures of the second and third lumbar vertebrae, hematoma of the psoas muscle (lower back muscle), and fractures of… …
F580 citations in Massachusetts
Notifying of changes · Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Massachusetts cites F580 more often than its own record predicts
1.48 times the share F580 takes of citations nationally.
Of every deficiency written in Massachusetts in 2025, this is the portion that was F580.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Massachusetts surveyors wrote
F580 findings written in Massachusetts, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on observations, record review and interviews, the facility failed to notify four Resident's (#24, #6, #21 and #9) physicians and legal guardian of a change in condition out of a total sample of 34 residents. Specifically:1.) For Resident #24, who developed a left-hand contracture in July 2025, the facility failed to notify the provider that the Resident's occupational therapy (OT) evaluation was delayed 49 days, that OT treatment was not being completed at necessary frequency, that his/her hand orthotic was not being tolerated because of increased pain and decreased range of motion, or that left-hand contracture was worsening, resulting in the amputation of the left fifth finger.2.) For Resident #6, the facility failed to notify the legal guardian of a worsening contracture of the… …
Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had a Legal Guardian in place who informed the Facility that she was to be contacted for everything, the Facility failed to ensure that staff promptly notified his/her Guardian when he/she requested a social leave of absence from the Facility with a visitor.Findings include:Review of the Facility Policy titled, Guardianship, undated, indicated the Facility will recognize and honor the authority of court-appointed guardians while protecting each resident's rights.The Policy indicated that the Facility would obtain and maintain guardianship documentation, verify the guardian's authority, involve the guardian in decision making as appropriate, and document any restrictions affecting the resident's… …
The short window
Recent years
| Year | Share of Massachusetts citations | vs expected |
|---|---|---|
| 2023 | 2.23% | 1.56× |
| 2024 | 2.29% | 1.51× |
| 2025 | 2.20% | 1.48× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Massachusetts surveyors cite →
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