F641 in Massachusetts. Pick another state for the same tag.
Against expectation — 2025
Massachusetts cites F641 more often than its own record predicts
Versus expected share1.09×
1.09 times the share F641 takes of citations nationally.
Share of Massachusetts citations2.01%
Of every deficiency written in Massachusetts in 2025, this is the portion that was F641.
Massachusetts2.01%
National1.84%
Share of all citations that were F641.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Massachusetts surveyors wrote
F641 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, isolatedFebruary 13, 2018
Based on interviews and records reviewed, for one of six sampled residents (Resident #6) the Facility failed to ensure the accuracy of Resident #6's assessment when areas of extensive bruising in multiple stages of healing were identified during a Hospital emergency department visit on 1/7/18 and 1/8/18 and were not documented in his/her clinical record.
Findings include:
Surveyor #1 interviewed the Hospital Nurse at 2:30 P.M. on 2/7/18. The Hospital Nurse said Resident #6 arrived at the Hospital during the Evening shift on 1/7/18 with extensive bruising on his/her upper and lower extremities, left hip and left side of his/her back. …
D · No harm, potential for more than minimal, isolatedAugust 11, 2026
Based on record review and interview, for one of three sampled residents (Resident #1), whose admission diagnoses included aphasia (brain disorder that affects how you speak and understand language) the Facility failed to ensure his/her Minimum Data Set (MDS) assessment accurately reflected his/her cognitive status regarding his/her Brief Interview for Mental Status (BIMS) score. Findings include: Review of the Resident Assessment of Cognitive Patterns Policy, dated 6/30/25, indicated it was the policy of the Facility to use the MDS properly in order to determine the resident's attention, orientation, and ability to register and recall new information. …
B · No harm, potential for minimal, patternJune 1, 2026
Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment was complete and accurate to reflect the status of two Residents (#13 and #1), out of a sample of 18 residents. Specifically, the facility:1. Failed for Resident #13 to ensure an MDS was accurately coded for a significant weight gain not prescribed by the physician; and2. Entered a diagnosis of schizoaffective disorder for Resident #1 on four MDSs without documentation of a physician detailed evaluation as indicated in the Resident Assessment Instrument (RAI) Manual. Findings include:
1. …
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