Based on record review, observation and interview, the facility failed to ensure that its staff revised the care plan for one Resident (#5) out of 19 sampled residents after he/she sustained an unwitnessed fall on 8/29/22 and had a subsequent unwitnessed fall of similar circumstances on 8/31/22 that resulted in an impacted proximal humerus fracture [A proximal humerus fracture is a break of the upper part of the bone of the arm (humerus)]. Findings include: Resident #5 was admitted to the facility in November 2015, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment, dated 8/17/22, indicated Resident #5 had severe cognitive impairment as evidenced by a score of 8 out of 15 on the Brief Interview for Mental Status (BIMS). …
F657 citations in Massachusetts
Care plan timing and revision · Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Massachusetts cites F657 less often than its own record predicts
0.54 times the national share — cited less often here than elsewhere.
Of every deficiency written in Massachusetts in 2025, this is the portion that was F657.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Massachusetts surveyors wrote
F657 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, for two of three sampled residents (Resident #1 and Resident #2), the facility failed to ensure they reviewed and revised their Comprehensive Care Plans following the completion of their Minimum Data Set assessment.Findings include:Review of the Facility Policy and Procedure titled Care Plan Policy, revised May 2025, indicated the following:-The Care Planning/Interdisciplinary Team develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain.- The resident's comprehensive care plan is developed within seven days of the completion of the resident's comprehensive assessment (MDS). …
Based on records reviewed and interviews, the facility failed to ensure Comprehensive Care Plans were reviewed and revised by the interdisciplinary team (IDT) after each assessment, including both the comprehensive and quarterly review assessments, for three Residents (#2, #4, and #16), out of a sample of 12 residents.Findings include:Review of the facility's policy titled Care Plans, Comprehensive Person-Centered, dated as last revised 9/16/2020, indicated but was not limited to:-The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.-The IDT includes: -The Attending Physician; -A registered nurse (RN) who has responsibility for the resident; -A… …
The short window
Recent years
| Year | Share of Massachusetts citations | vs expected |
|---|---|---|
| 2023 | 1.25% | 0.58× |
| 2024 | 1.10% | 0.57× |
| 2025 | 1.00% | 0.54× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Massachusetts surveyors cite →
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