Based on observation, interview, and schedule review, the facility 1. Failed to ensure there was sufficient staff available to provide nursing services and care required to meet the residents needs; and 2. Failed to ensure there was sufficient clinical staff to assure resident safety for one Resident (#93). Findings include: 1. During an interview on 4/12/22 at 3:30 P.M., the Ombudsman said the family members of residents had been complaining about the facility not having enough staffing and not replacing staff when there was a call-out, especially in the evenings. On 4/14/22 at 11:00 A.M., the surveyor held a group meeting with 10 residents in attendance. During the meeting, residents said there were not enough staff working on the units and sometimes on the 3:00 P.M. to 11:00 P.M. …
F725 citations in Massachusetts
Sufficient nursing staff · Nursing and Physician Services Deficiencies
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Massachusetts cites F725 less often than its own record predicts
0.50 times the national share — cited less often here than elsewhere.
Of every deficiency written in Massachusetts in 2025, this is the portion that was F725.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Massachusetts surveyors wrote
F725 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 and interview, the facility failed to ensure there was sufficient staffing to provide necessary treatment and care to Residents on one of four nursing units ([NAME]). Subsequently, multiple residents were not provided incontinent care for 17 hours and skin checks revealed newly developed pressure areas for two Residents (#10 and #63). Findings include: Review of the Facility Assessment Tool, dated, 7/29/24, indicated: The purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Staffing plan: Licensed nurses providing direct care: 16-18 per day; Nurse aides: 20-28 per day. Direct care staff Nurses 1:21 ratio (days and evenings) 1:41 nights. …
Based on observations, interviews, and record reviews, the facility failed to ensure there was adequate staffing to provide nursing care and related services timely and as required to meet the needs of four residents (#32, #99, #56, and #127) out of a total sample of 24 residents. Specifically, the facility failed to:1. ensure that staff responded timely to Resident #32's call light when the Resident waited 35 minutes for staff to answer his/her call light. 2. ensure that Resident #99 was awake and assisted with the breakfast meal timely, when staff delayed providing the breakfast meal trays to the [NAME] Terrace unit residents, and Resident #99 was provided his/her breakfast meal 71 minutes after the meal truck arrived on the unit. 3. …
The short window
Recent years
| Year | Share of Massachusetts citations | vs expected |
|---|---|---|
| 2023 | 0.45% | 0.56× |
| 2024 | 0.76% | 0.95× |
| 2025 | 0.39% | 0.50× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Massachusetts surveyors cite →
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