Based on records reviewed and interviews for one of three sampled residents (Resident #1) who had a gastrostomy tube (G tube, placed through the abdomen into the stomach, for feedings, liquids and medications) in place to meet his/her nutritional and fluid intake needs, and whose physician's orders included formula feeds, water flushes and medication administration through the G tube, the Facility failed to ensure that Resident #1 was provided with appropriate treatment and services when his/her G tube was replaced by a Facility Nurse, and formula feeding and water flushes were administered into the incorrectly positioned G tube resulting in a change in Resident #1's condition, with subsequent need for transfer and admission to the Hospital. …
F693 citations in Massachusetts
Tube feeding · Quality of Life and Care Deficiencies
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Massachusetts cites F693 less often than its own record predicts
0.99 times the national share — cited less often here than elsewhere.
Of every deficiency written in Massachusetts in 2025, this is the portion that was F693.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Massachusetts surveyors wrote
F693 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 observation, interview, and record review, the facility failed to provide necessary care and services relative to enteral feeding (delivery of nutrients through a feeding tube into the stomach/intestines), for one Resident (#12) out of a total sample of 23 residents. Specifically, for Resident #12, the facility failed to ensure that the accurate amount of water flushes as ordered by the Physician, and the appropriate tube feed flush procedure was being administered via the Resident's enteral feeding tube, when more than the ordered amount of water flushes was administered, placing the Resident at risk for gastrointestinal complications. …
The short window
Recent years
| Year | Share of Massachusetts citations | vs expected |
|---|---|---|
| 2023 | 0.72% | 0.95× |
| 2024 | 0.64% | 0.91× |
| 2025 | 0.69% | 0.99× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Massachusetts surveyors cite →
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