Based on records reviewed, policy reviews and interviews, the Facility which had a known area of concern related to the continued spread of Candida Auris (C. Auris, a type of yeast that can cause severe illness and spreads easily among patients in healthcare facilities, which can cause a range of infections from superficial (skin) infections to more severe, life-threatening infections) an infectious disease on Unit #1, which specializes in care and treatment of residents' requiring a tracheostomy and/or ventilator to breathe, with new cases of the infection identified in December 2024 and several more new cases identified in January 2025, the Facility failed to ensure they developed, implemented and maintained a Quality Assurance and Performance Improvement (QAPI) program that was… …
F865 citations in Massachusetts
QAPI program · Administration Deficiencies
Have a plan that describes the process for conducting QAPI and QAA activities.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Massachusetts cites F865 more often than its own record predicts
1.46 times the share F865 takes of citations nationally.
Of every deficiency written in Massachusetts in 2025, this is the portion that was F865.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Massachusetts surveyors wrote
F865 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 document review, the facility failed to develop, implement, and maintain a Quality Assurance and Performance Improvement (QAPI) program which addressed the full range of care and services, was comprehensive and data-driven, and focused on indicators of outcomes of quality of life, quality of care, and services to residents in the facility. Specifically, the facility failed to ensure an ongoing QAPI program was implemented, maintained and addressed concerns related to pressure ulcers and wounds in the facility. …
Based on interview and record review, the facility failed to develop, implement and maintain a Quality Assurance and Performance Improvement (QAPI) program, which focuses on indicators of outcomes of quality of life, quality of care, and services to residents in the facility. Specifically, the facility failed to ensure a QAPI plan was implemented to a.) address concerns regarding resident grievance process and b.) failed to evaluate and implement a safe smoking environment for six residents identified as active smokers. …
The short window
Recent years
| Year | Share of Massachusetts citations | vs expected |
|---|---|---|
| 2023 | 0.23% | 1.32× |
| 2024 | 0.27% | 1.48× |
| 2025 | 0.35% | 1.46× |
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