Based on interview, record review and the Facility Assessment, the facility failed to ensure the Governing Body provided oversight and accountability for quality of care related to comprehensive wound care management. Specifically: 1. The Governing Body failed to ensure the facility provided consistent and effective nursing staff education and training to provide competent quality of care and effective wound care management as outlined per the Facility Assessment. 2. The Governing Body failed to ensure the facility had implemented an effective wound care program that is supervised by a physician for pressure ulcer (wounds that occur when the skin and tissue are damaged by prolonged pressure, usually on bony areas like the hips, heels, or elbows) prevention and care. …
F837 citations in Massachusetts
Administration Deficiencies
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Massachusetts cites F837 less often than its own record predicts
0.71 times the national share — cited less often here than elsewhere.
Of every deficiency written in Massachusetts in 2025, this is the portion that was F837.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Massachusetts surveyors wrote
F837 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 interview and record review, including review of the Facility Assessment and facility policies, the facility failed to ensure that the governing body provided oversight and accountability for: 1. ensuring the facility was sufficiently staffed per the Facility Assessment; 2. ensuring quality of care related to abuse was maintained for one Resident (#62); and 3. ensuring quality of care related to safety & hazards in the facility was maintained for two Residents (#30 and 35) out of a total sample of 29 residents. …
Based on interview and record review, the facility failed to ensure that the governing body provided oversight and accountability for: 1. The maintenance of an effective QAPI program. 2. The provision of an infection control/antibiotic stewardship program. Findings include: Review of the facility policy titled, Quality assurance Performance Improvement Plan, dated January 2025, indicated that the Administrator has responsibility and is accountable to the governing body for ensuring that QAPI is implemented throughout our facility. QAPI activities and discussion will be a standing item on our governing body board meeting agendas. …
The short window
Recent years
| Year | Share of Massachusetts citations | vs expected |
|---|---|---|
| 2023 | 0.11% | 1.53× |
| 2024 | 0.12% | 1.34× |
| 2025 | 0.04% | 0.71× |
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