Based on observations, record review and interviews, the facility failed to provide an environment free from accidents and hazards for two Residents (#9 and #39) out of a total sample of 25 residents. Specifically,1. For Resident #9, the facility failed to identify Resident #9's needs to receive 1:1 supervision with meals upon admission, and while eating unsupervised in his/her room, the Resident choked and required the Heimlich maneuver to be administered by facility staff. The Resident was subsequently transferred to the hospital, admitted to the intensive care unit, intubated and required a bronchial scope to remove a piece of chicken from his/her bronchial tube (the main airway leading to the lung), placing the resident at the likelihood of serious harm or death.2. …
F689 citations in Massachusetts
Accidents and supervision · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Massachusetts cites F689 less often than its own record predicts
0.61 times the national share — cited less often here than elsewhere.
Of every deficiency written in Massachusetts in 2025, this is the portion that was F689.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Massachusetts surveyors wrote
F689 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 required food items to be served in separate containers, the Facility failed to ensure he/she was free from incidents/accidents resulting in serious injury. On 06/13/26, Resident #1's mashed potatoes were portioned and served to him/her in a covered container with an unvented (without steam hole, holds temperature of food item longer) lid, when Resident #1 attempted to eat the mashed potatoes, they were too hot so he/she spit them out and they landed on his/her right thigh, which caused him/her to sustain a second-degree burn (partial thickness, involves both the outer (epidermis) and underlying layer (dermis) of skin, they cause pain, redness, swelling, and blistering) to the top of his/her… …
Based on records reviewed and interviews for one of three sampled residents (Resident #1), whose primary residence was in a different state, and while in the facility required restricted visitations, the Facility failed to ensure he/she was provided an adequate level of staff supervision, when on 6/20/26 Resident # 1 was seen by a staff member standing at the nursing station, with nursing staff in the same area, talking to a visitor, a short time later Resident #1 left the Facility with the visitor for a social leave, without signing out in accordance with to the Facility Policy and he/she chose not to return to the Facility.Findings include: Review of the Facility Policy titled, Resident Sign Out/ Sign in Procedure, undated, indicated residents leaving the facility independently or with… …
The short window
Recent years
| Year | Share of Massachusetts citations | vs expected |
|---|---|---|
| 2023 | 3.40% | 0.69× |
| 2024 | 3.57% | 0.66× |
| 2025 | 3.36% | 0.61× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Massachusetts surveyors cite →
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