F835 in Massachusetts. Pick another state for the same tag.
Against expectation — 2025
Massachusetts cites F835 more often than its own record predicts
Versus expected share1.05×
1.05 times the share F835 takes of citations nationally.
Share of Massachusetts citations0.31%
Of every deficiency written in Massachusetts in 2025, this is the portion that was F835.
Massachusetts0.31%
National0.29%
Share of all citations that were F835.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Massachusetts surveyors wrote
F835 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.
J · Immediate jeopardy, isolatedJune 16, 2025
Based on record review and interviews, the facility failed to ensure it provided appropriate administrative oversight, specific to clinical management and building safety, when one Resident (#172) fell from his/her second-floor bedroom window during an elopement attempt, resulting in an acute hospitalization with a fracture of the fourth lumbar vertebrae with mild retropulsion into the spinal canal (bone fragments in spinal cord), fractures of the second and third lumbar vertebrae, hematoma of the psoas muscle (lower back muscle), and fractures of the ninth through 12 ribs.
Specifically, the facility administration failed to:
1. Ensure the facility's environment was safe for a Resident with a known risk of elopement from a window;
2. …
E · No harm, potential for more than minimal, patternAugust 20, 2025
Based on observations, interviews, and records reviewed, the facility failed to provide effective administration related to necessary care and services for one Resident (#4), out of a total sample of 20 residents when the facility reviewed Resident #4's clinical status of a laryngectomy (surgical procedure in which one's voice box is removed, separating one's airway from the mouth, nose, and esophagus, resulting in the ability to breathe only through an opening in the front of the neck) tube prior to the Resident's admission to the facility and accepted and admitted Resident #4, with a laryngeal tube in place, to the facility.Specifically, the facility administration failed to:-Develop policies and procedures relative to necessary care and services for residents with laryngeal tubes,… …
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