Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who required two staff members assistance with the mechanical sling lift for all transfers, the Facility failed to ensure he/she was free from neglect, when on 06/03/25 Certified Nurse Aide (CNA) #1, although she was aware of facility policy and that Resident #1 required an assist of two staff persons for transfers with a mechanical sling lift, CNA #1 transferred Resident #1 by herself, and he/she fell from lift on to the floor. CNA #1 also did not immediately report the fall to nursing so Resident #1 could be assessed for potential injury prior to being moved, but instead physically picked Resident #1 up off the floor by herself and put him/her back into bed. …
F600 citations in Massachusetts
Abuse and neglect · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Massachusetts cites F600 less often than its own record predicts
0.29 times the national share — cited less often here than elsewhere.
Of every deficiency written in Massachusetts in 2025, this is the portion that was F600.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Massachusetts surveyors wrote
F600 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 observation, record review and interview the facility failed to ensure two Residents (#36 and #24) were free from abuse out of a total sample of 34 residents. Specifically,1.) For Resident #36, despite repeated emails sent by the Resident to the facility Administrator, Director of Nursing and Social Worker, the facility failed to prevent sexual abuse and protect the Resident from psychological harm due to the fear he/she lived with from this abuse and lack of protection provided by the facility. …
Based on observations, record review, and interviews, the facility failed to ensure one Resident (#66) was free from neglect out of a total sample of 27 residents. Specifically, for Resident #66, the facility neglected to provide the necessary care for incontinence management. Findings include: Resident #66 was admitted to the facility in November 2024 with diagnoses that included metabolic encephalopathy, acute kidney failure, dementia and aphasia. Review of Resident #66's most recent Minimum Data Set (MDS) Assessment, dated 7/11/25, indicated that the Resident could not participate in the Brief Interview for Mental Status (BIMS) exam and was assessed by staff to be severely impaired with cognitive skills for daily decision making. …
The short window
Recent years
| Year | Share of Massachusetts citations | vs expected |
|---|---|---|
| 2023 | 0.64% | 0.36× |
| 2024 | 0.88% | 0.38× |
| 2025 | 0.77% | 0.29× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Massachusetts surveyors cite →
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction