F656 in Massachusetts. Pick another state for the same tag.
Against expectation — 2025
Massachusetts cites F656 more often than its own record predicts
Versus expected share1.32×
1.32 times the share F656 takes of citations nationally.
Share of Massachusetts citations4.55%
Of every deficiency written in Massachusetts in 2025, this is the portion that was F656.
Massachusetts4.55%
National3.44%
Share of all citations that were F656.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Massachusetts surveyors wrote
F656 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, isolatedFebruary 9, 2026
Based on record review and interviews, the facility failed to develop, maintain, and implement an active, interdisciplinary, person centered care plan to address a known elopement risk for one Resident (#83), in a sample of 25, despite documented severe cognitive impairment (BIMS=3 on 11/24/25), exit seeking behavior, and a high risk elopement score of 14 (11/18/25). The facility resolved the elopement/wandering care plan on 11/28/25 without IDT review or subsequent risk reassessment, and did not implement effective interventions (e.g., wander alert specifications, door/elevator supervision) consistent with assessed needs. …
Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), who was non-ambulatory and per his/her care plan required the assistance of two staff members with a mechanical lift for all transfers, the Facility failed to ensure staff consistently implemented and followed his/her care plan interventions for transfers, when on 03/14/26, Certified Nurse Aide #1 transferred Resident #1 by herself using a stand pivot transfer technique, Resident #1 was later diagnosed with a left ankle fracture. Findings include:Review of the Facility Policy titled Care Plans, Comprehensive Person-Centered, dated as revised March 2022, indicated that care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. …
D · No harm, potential for more than minimal, isolatedAugust 5, 2026
Based on observation, interview, and record review, the facility failed to develop a person-centered care plan for one Resident (#12), out of a total sample of 18 residents. Specifically, the facility failed to develop a comprehensive person center care plan for Resident #12's implanted venous access device.Findings include: Review of the facility policy titled Care Plans-Comprehensive, revised July 2023, indicated but was not limited to:-An individualized, comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, emotional and psychological needs is developed for each resident.-Our facility's Care Planning/Interdisciplinary team, in coordination with the resident, his/her family or representative develops and maintains a… …
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