F655 in Massachusetts. Pick another state for the same tag.
Against expectation — 2025
Massachusetts cites F655 more often than its own record predicts
Versus expected share1.53×
1.53 times the share F655 takes of citations nationally.
Share of Massachusetts citations1.00%
Of every deficiency written in Massachusetts in 2025, this is the portion that was F655.
Massachusetts1.00%
National0.66%
Share of all citations that were F655.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Massachusetts surveyors wrote
F655 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.
J · Immediate jeopardy, isolatedJanuary 24, 2019
Based on records reviewed and interviews the Facility failed for one of three residents (Resident #1) to ensure that Resident #1's representative was provided a summary of the Base Line Care Plan, which included Admission Physician Orders. On 12/17/18, Resident #1 was admitted to the Facility and documentation indicated Resident #1 was cognitively impaired.
Findings include:
The Admission Consents, dated 12/17/18, indicated Resident #1 did not sign the consents included in the Admission documents. Resident #1's Health Care Proxy signed all Resident #1's Admission consents. …
Based on observation, interview and record review, the facility failed to ensure it completed a baseline care plan for one Resident (#60) out of 30 sampled residents. Specifically, the facility failed to complete a baseline care plan to address a surgical wound to the lower leg with a leg splint and failed to implement care plan interventions resulting in the development of a Stage 3 pressure injury to the lower back requiring antibiotic treatment and hospitalization , right buttock Stage 2 pressure injury, right lateral foot stage 1 pressure injury, right outer calf DTI (Deep Tissue Injury), and right heel DTI. …
D · No harm, potential for more than minimal, isolatedMay 28, 2026
Based on record review and interview, the facility failed to develop and implement a baseline care plan that includes the instructions needed to provide effective and person-centered care for one Resident (#109) out of a total sample of 28 residents. Specifically, for Resident #109, the facility failed to develop a baseline care plan related to smoking and his/her need for supervised smoking. Findings include:Review of the facility policy titled Interim Care Plan, dated as last revised on 11/5/25, indicated but was not limited to the following:It is the policy of this facility to develop an interim care plan for each resident admitted . The purpose of the interim care plan is to guide care until the comprehensive care plan is complete.1. …
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