F659 in Massachusetts. Pick another state for the same tag.
Against expectation — 2025
Massachusetts cites F659 less often than its own record predicts
Versus expected share0.99×
0.99 times the national share — cited less often here than elsewhere.
Share of Massachusetts citations0.04%
Of every deficiency written in Massachusetts in 2025, this is the portion that was F659.
Massachusetts0.04%
National0.04%
Share of all citations that were F659.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Massachusetts surveyors wrote
F659 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.
G · Actual harm, isolatedNovember 19, 2019
Based on records reviewed and interviews, for one of three sampled residents (Resident #2), the Facility failed to ensure only qualified staff provided care, when a Unit Assistant ambulated Resident #2 to the bathroom, left him/her alone on the toilet, and as a result, Resident #2 fell and sustained a fractured left wrist.
Findings include:
A Nurse Progress Note, dated 11/9/19, indicated Resident #2 was ambulated to the bathroom, assisted to a seated position on the toilet, and a staff member (later identified as Unit Assistant #1) exited the bathroom and closed the door. …
D · No harm, potential for more than minimal, isolatedAugust 5, 2025
Based on records reviewed and interviews, the Facility failed to ensure that Certified Nurse Aide (CNA) #1 had completed competency training prior to use of the Hoyer Lift for resident transfers.Findings include:The Facility Policy, titled Mechanical Lift, dated as reviewed 09/2024, indicated at least two nursing assistants were needed to safely move a resident with a mechanical lift, and staff must be trained in and demonstrate competency in the use of lift devices.A Hoyer Lift is a device that allows caregivers to safely transfer an individual between a bed, wheelchair, shower chair, or another surface. …
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