Based on records reviewed, interviews, and observations for four of seven sampled residents (Resident #2, #3, #4, and #5), the facility failed to ensure that allegations of abuse were immediately and thoroughly investigation and failed to implement interventions to prevent and protect residents from subsequent incidents of abuse when from approximately 08/12/18 to 09/21/18 there were at least nine alleged incidents of Resident #1 abusing four other Residents of the opposite sex and one incident when the Director of Nurses allegedly subjected Resident #1 to abuse and Resident #3 to a situation where the potential for a repeated act of abuse could occur. …
F610 citations in Massachusetts
Investigating alleged violations · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Massachusetts cites F610 less often than its own record predicts
0.48 times the national share — cited less often here than elsewhere.
Of every deficiency written in Massachusetts in 2025, this is the portion that was F610.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Massachusetts surveyors wrote
F610 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, interview, and record review, the facility failed to implement their policy and procedures to investigate and prevent further verbal abuse for one Resident (#141), in a total sample of 33 residents. Specifically, after the facility staff witnessed Resident #105 use racial slurs to verbally abuse Resident #141, the facility failed to implement their policy to conduct a thorough investigation and initiate effective interventions to prevent further resident-to-resident verbal abuse, resulting in the verbal abuse continuing for three weeks and Resident #141 crying and verbalizing wanting to decrease socialization. …
Based on records reviewed and interviews, for two of three sampled residents (Resident #2 and Resident #3), the Facility failed to ensure that on 04/28/26, after being made aware of an allegation that Resident #3 punched Resident #2 in the nose, they obtained and maintained evidence that a thorough investigation into the allegation had been completed and that a final investigation report was submitted to the Massachusetts Department of Public Health (DPH) within five days, as required.Findings include:Review of the Facility Policy titled Abuse, Neglect and Exploitation, dated as implemented February 2023, indicated the Administrator will follow-up with the government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation… …
The short window
Recent years
| Year | Share of Massachusetts citations | vs expected |
|---|---|---|
| 2023 | 1.10% | 0.86× |
| 2024 | 0.73% | 0.51× |
| 2025 | 0.73% | 0.48× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Massachusetts surveyors cite →
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