Based on record review, and interviews, the facility failed to notify the State Mental Health Authority for a resident review (person-centered assessment taking into account all relevant information) after a significant change in mental condition occurred for one Resident (#1) out of a total sample of 15 residents. Specifically, the facility failed to complete and request a Preadmission Screening and Resident Review Level II screen (PASRR- an evaluation done to determine if a resident has an intellectual or developmental disability and/or serious mental illness and if a Resident is in need of additional specialized support services at the facility) after Resident #1 received emergency mental health support due to mental illness on two occasions.Findings include:Review of the facility… …
F646 citations in Massachusetts
Resident Assessment and Care Planning Deficiencies
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Massachusetts cites F646 more often than its own record predicts
1.18 times the share F646 takes of citations nationally.
Of every deficiency written in Massachusetts in 2025, this is the portion that was F646.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Massachusetts surveyors wrote
F646 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 interviews and records reviewed, the facility failed to notify the State mental health authority promptly after a significant change in the mental condition for resident review for one Resident (#83) out of 18 total sampled residents which increased the Resident's risk for not receiving specialized services in a timely manner. Specifically, facility staff failed to notify the State mental health authority of the need for resident review when: - Resident #83 exhibited a new onset of paranoia (unwarranted or delusional belief that one is being persecuted, harassed, or betrayed by others, occurring as part of a mental condition), delusions (unshakable belief in something that is untrue; type of psychotic disorder [collection of symptoms that affect the mind, where there has been some… …
The short window
Recent years
| Year | Share of Massachusetts citations | vs expected |
|---|---|---|
| 2023 | 0.15% | 3.07× |
| 2024 | 0.21% | 4.56× |
| 2025 | 0.08% | 1.18× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Massachusetts surveyors cite →
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