Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was a functional quadriplegic (complete immobility due to severe disability or frailty from another medical condition without injury to the brain or spinal cord), was essentially non-verbal, unable to participate in his/her care, and was totally dependent on staff to meet all of his/her care needs, the Facility failed to ensure he/she was provided with nursing care and treatment that met professional standards of quality, when on [DATE], after Nurse #1 was notified by Nurse Aide (NA #1) that during care Resident #1 began to slide out of bed and she (NA #1) lowered him/her to the floor, although Nurse #1 said she assessed Resident #1 for the potential for injury prior to moving him/her off the… …
F658 citations in Massachusetts
Professional standards of care · Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Massachusetts cites F658 more often than its own record predicts
2.85 times the share F658 takes of citations nationally.
Of every deficiency written in Massachusetts in 2025, this is the portion that was F658.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Massachusetts surveyors wrote
F658 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 records reviewed and interviews, for one of three sampled residents (Resident #1) who during the overnight shift (11:00 P.M. to 7:00 A.M.) on 1/30/25 into 1/31/25, had an unwitnessed fall, was found on the floor by staff complaining of pain, the facility failed to ensure he/she was provided care and services that met professional standards of nursing practice, when although Resident #1 was crying out in pain, without completing any type of assessment, Nurse #1 picked Resident #1 up off the floor, initially put him/her in a wheelchair, then transferred him/her again by picking him/her up out of the wheelchair, put him/her in bed, and left the room. …
Based on records reviewed an interviews, for one of three sampled residents (Resident #1), who did not have an order for application of a hot pack for treatment of pain, the Facility failed to ensure services provided met professional standards of nursing practice related to obtaining a Physician's Order prior to administering a treatment, when on 05/23/26, Resident #1 complained of left lower extremity pain and nursing applied a disposable hot pack without contacting his/her Physician and without obtaining a Physician's Order, as required.Findings include:Pursuant to Massachusetts General Law (M.G.L), chapter 112, individuals are given the designation of registered nurse and practical nurse which includes the responsibility to provide nursing care. …
The short window
Recent years
| Year | Share of Massachusetts citations | vs expected |
|---|---|---|
| 2023 | 3.71% | 2.32× |
| 2024 | 4.64% | 2.83× |
| 2025 | 5.09% | 2.85× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Massachusetts surveyors cite →
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