Based on interviews, and records reviews, the facility failed to provide appropriate notice of discharge for a facility-initiated discharge, when the Resident did not initiate a request of discharge for one Resident (#72) out of three closed records. Specifically, the facility failed to provide appropriate notice of discharge to Resident #72 when: -the facility determined that the Resident was acting Against Medical Advice (AMA) by driving his/her personal vehicle to a scheduled eye surgery appointment. -the facility notified the Resident he/she was discharged upon return to the facility from the scheduled eye surgery appointment. …
F622 citations in Massachusetts
Transfer and discharge · Resident Rights Deficiencies
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Massachusetts cites F622 less often than its own record predicts
0.33 times the national share — cited less often here than elsewhere.
Of every deficiency written in Massachusetts in 2025, this is the portion that was F622.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Massachusetts surveyors wrote
F622 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 record review, and interview, the facility failed to ensure that the required transfer documentation was completed and the required transfer documentation communicated the appropriate information to the receiving health care institution for five Residents (#64, #18, #39, #11 and #29), out of a total sample of 19 residents. Specifically, the facility failed to ensure that Residents #64, #18, #39, #11, and #29, were transferred to the hospital with important information relative to the Residents' medical histories and the reasons for transfer, putting the Residents at risk for complications and adverse events upon transfer to the hospital. Findings include: 1. …
Based on interview, record and policy review, the facility failed to ensure that the required transfer documentation was completed, and that the transfer documentation communicated the appropriate information to the receiving health care institution for one Resident (#40), out of a total sample of 16 residents. Specifically, the facility failed to ensure that Resident #40 was transferred to the emergency room with a form/packet that included important information relative to the Resident's medical history and the reason for transfer, putting the Resident at risk for complications and adverse events upon transfer to the hospital. …
The short window
Recent years
| Year | Share of Massachusetts citations | vs expected |
|---|---|---|
| 2023 | 0.15% | 0.60× |
| 2024 | 0.31% | 0.95× |
| 2025 | 0.04% | 0.33× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Massachusetts surveyors cite →
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