Based on observation, record review, policy review, and interview, the facility failed to ensure the proper care and treatment of a peripherally inserted central catheter (PICC) and/or midline catheter device in accordance with the facility policy/protocols. Specifically, the facility failed: 1. For one Resident (#20), who had a history of chronic embolism and thrombosis (formation of a blood clot within blood vessels or arteries limiting the natural flow of blood), out of a total sample of three residents with peripheral lines in place, to ensure physician's orders were in place and implemented for the care and treatment of two out of two midline catheters and two out of two PICCs to include monitoring for signs and symptoms of intravenous (IV) related complications, catheter lumen… …
F694 citations in Massachusetts
Quality of Life and Care Deficiencies
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Massachusetts cites F694 more often than its own record predicts
1.92 times the share F694 takes of citations nationally.
Of every deficiency written in Massachusetts in 2025, this is the portion that was F694.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Massachusetts surveyors wrote
F694 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, record review, policy review and interview, the facility failed to ensure that care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of the facility policy titled PICC line dressing change dated 10/2021 included but was not limited to: -PICC dressings are changed 24 hours after the initial placement of the line -Transparent dressings are changed every 7 days of sooner if the integrity of the dressing is compromised -Only sterile tapes, sterile wound closure strips or manufactured catheter securement devices (preferred) will be used to stabilize and maintain the position of the catheter. …
Based on observations, record review and interviews, the facility failed to ensure for one resident (#129) out of a total sample of 25 residents, that standards in quality nursing care were provided in accordance with the physician's orders. Specifically, for Resident #129:A. facility staff failed to implement the order to check the external length of the IV (intravenous) catheter with the dressing change and as needed. and B. facility staff failed to obtain an order and document an intravenous dressing change dated 6/14/26, which was outside of the established physician's orders to change the intravenous catheter every seven days.Findings include:Review of the [NAME] & [NAME] article, when to use a midline catheter, dated April 2025 indicated: Monitor catheter migration by measuring and… …
The short window
Recent years
| Year | Share of Massachusetts citations | vs expected |
|---|---|---|
| 2023 | 0.83% | 2.91× |
| 2024 | 0.67% | 2.41× |
| 2025 | 0.62% | 1.92× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Massachusetts surveyors cite →
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction