F604 in Massachusetts. Pick another state for the same tag.
Against expectation — 2025
Massachusetts cites F604 more often than its own record predicts
Versus expected share2.64×
2.64 times the share F604 takes of citations nationally.
Share of Massachusetts citations1.00%
Of every deficiency written in Massachusetts in 2025, this is the portion that was F604.
Massachusetts1.00%
National0.38%
Share of all citations that were F604.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Massachusetts surveyors wrote
F604 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.
G · Actual harm, isolatedSeptember 3, 2024
Based on interviews and records reviewed, for one of three sampled residents (Resident #1) who was moderately cognitively impaired, with behaviors that included unsafe rising and disrobing, the Facility failed to ensure Resident #1 was free from the use of a physical restraint imposed for the purpose of staff convenience when on 08/14/24 during the overnight shift, sometime between 5:30 A.M. and 6:00 A.M. (exact time unknown), Certified Nurse Aide (CNA) #1 and CNA #2 transferred Resident #1 into his/her a tilt back wheelchair, CNA #1 then placed a blanket across Resident #1's torso/lap area, then tied the blanket behind his/her wheelchair securing it snuggly in place, and then both CNA's left the room to care for other residents. …
D · No harm, potential for more than minimal, isolatedJune 16, 2026
Based on interviews and records reviewed, for one of three sampled residents (Resident #1) who was severely cognitively impaired, unable to make their needs known and was dependent on staff for bed mobility, the Facility failed to ensure Resident #1 was free from the use of physical restraints when, on 5/27/26 during the overnight shift, Certified Nurse Aide #1 observed and reported to Nurse #1, that Resident #1, who was in bed, had each corner of the bed sheet that was on top of him/her, tied to the straps emanating (originating) from the beds air mattress, that was beneath him/her. …
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