Medical records · Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F842 in Massachusetts. Pick another state for the same tag.
Against expectation — 2025
Massachusetts cites F842 more often than its own record predicts
Versus expected share1.97×
1.97 times the share F842 takes of citations nationally.
Share of Massachusetts citations4.40%
Of every deficiency written in Massachusetts in 2025, this is the portion that was F842.
Massachusetts4.40%
National2.24%
Share of all citations that were F842.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Massachusetts surveyors wrote
F842 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 21, 2022
Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure they maintained a complete and accurate medical record, when on [DATE], his/her temporary Guardianship expired and became a permanent Guardianship, the Director of Social Services, who was made aware of the change, failed to update Resident #1's medical record with the new Guardianship paperwork.
As a result, on [DATE], Resident #1, who was not his/her own responsible person, left the Facility without an escort, was transported to a medical appointment by a chair van service, and while at the appointment, Resident #1 eloped and has not been located since. …
D · No harm, potential for more than minimal, isolatedAugust 5, 2026
Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), who upon admission had both upper and lower dentures, the Facility failed to ensure they maintained a complete and accurate medical record, when nursing assessments did not include or identify he/she had dentures in place and there was no other nursing department documentation related to oral care provided to him/her associated with having dentures. Findings Include:Review of the Facility's Policy tilted Documentation-Clinical, dated as revised 12/29/2025, indicated the following: -the purpose is to ensure accuracy and completeness of clinical documentation.-facility must make a comprehensive assessment of a resident's needs, strengths, areas of risk, goals, life history and preferences using the… …
B · No harm, potential for minimal, patternMarch 10, 2026
Based on record review and interview, the facility failed to maintain medical records that are complete, accurate, and systemically organized within accepted professional standards of practice for two Residents (#79 and #104) of 24 sampled residents. Specifically, the facility failed to ensure their Weekly Skin Integrity Data Collection Assessments were documented.Findings include:1. Resident #79 was admitted to the facility in August 2021 with diagnoses which included dementia and peripheral vascular disease (PVD, when blood vessels outside the heart and brain become narrowed or blocked, reducing blood flow, usually to the legs). Review of the Minimum Data Set (MDS) assessment, dated 1/29/26, indicated Resident #79 was at risk for pressure ulcer/injuries. …
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