Based on record reviews and interviews, for one Resident (#77), out of a total sample of 23 residents, the facility failed to provide appropriate and sufficient staff to provide behavioral health care services as indicated in the facility assessment. Specifically, for Resident #77 with a known history of agitation, aggression, ongoing intrusive wandering into other residents' rooms, physically abusing other residents, being physically abused by other residents, and sexually inappropriate behaviors (including indecent exposure) toward female staff and residents, the facility failed to ensure staff had appropriate competencies and skill sets to effectively manage his/her behavioral health needs, including developing non-pharmacological interventions. …
F741 citations in Massachusetts
Quality of Life and Care Deficiencies
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2024
Massachusetts cites F741 more often than its own record predicts
1.83 times the share F741 takes of citations nationally.
Of every deficiency written in Massachusetts in 2024, this is the portion that was F741.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Massachusetts surveyors wrote
F741 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 eight of eight sampled residents with substance use disorders (Resident #1, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8 and Resident #9), the facility failed to ensure that staff were trained and provided the necessary competencies to meet the needs of residents with substance use disorders (SUD) in order to attain or maintain their safety and sobriety. - The Facility failed to ensure they provided adequate numbers of qualified competent staff who had knowledge and expertise in caring for residents with SUD or addiction, including the availability and safe administration of [MEDICATION NAME] (a medication used to treat narcotic overdose in an emergent situation). …
Based on observation, interviews, and record review, the facility failed to ensure staff had the skills necessary to meet the behavioral needs of one Resident (#10), out of a sample of 19 residents. Specifically, the facility failed to ensure staff had training in areas such as mental health needs and care of cognitively impaired residents. Findings include: Review of the Facility Assessment, updated 6/1/24, indicated but was not limited to the following: - To achieve strong clinical out-comes, we continue to strive to develop skill set/competency of associates. …
The short window
Recent years
| Year | Share of Massachusetts citations | vs expected |
|---|---|---|
| 2023 | 0.08% | 1.53× |
| 2024 | 0.09% | 1.83× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Massachusetts surveyors cite →
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