F921 in Massachusetts. Pick another state for the same tag.
Against expectation — 2025
Massachusetts cites F921 less often than its own record predicts
Versus expected share0.27×
0.27 times the national share — cited less often here than elsewhere.
Share of Massachusetts citations0.23%
Of every deficiency written in Massachusetts in 2025, this is the portion that was F921.
Massachusetts0.23%
National0.85%
Share of all citations that were F921.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Massachusetts surveyors wrote
F921 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.
K · Immediate jeopardy, patternJuly 10, 2025
Based on observations, records reviewed, and interviews, for one of three resident units (2-West Unit), which had a resident census of 27, nine of whom were identified to be at risk for elopement, the Facility failed to ensure they maintained a safe and functional environment for residents, staff, and visitors, when the alarm on the stairwell fire door malfunctioned, the alarm was removed, and then a staff member zip tied the fire door closed, preventing the door from opening in case of an emergency for seven days from 06/18/2025 through 06/24/2025. …
D · No harm, potential for more than minimal, isolatedJune 9, 2026
Based on observation, record review, and interview, the facility failed to provide a safe, functional environment associated with following the manufacturer's guidelines for maintaining mechanical lift slings for three Residents (#49, #59, and #67) out of a total sample of 27 residents, who required the use of mechanical lift slings for transfers. Specifically, for Resident's #49, #59, and #67, the facility failed to ensure that mechanical lift slings were air dried after laundering, when facility staff did not follow the manufacturer instructions not to tumble dry and used the facility dryer to dry the mechanical lift slings, placing the residents at risk for the use of improper fitting slings shrunk by the dryer and associated discomfort and pain with sling use.Findings include:Review of… …
B · No harm, potential for minimal, patternMarch 31, 2026
Based on observations and staff interviews, the facility failed to ensure a functional, safe, and clean environment. Specifically, the facility failed to ensure residents and/or staff properly disposed of cigarette butts in designated smoking receptacles.Findings include:Review of the Centers for Medicare & Medicaid Services (CMS) circular letter, dated November 10, 2011, titled Smoking Safety in Long Term Care Facilities indicated but was not limited to the following: -Metal containers with self-closing covers into which ashtrays can be emptied must be readily available.Review of the facility's policy titled Smoking Policy and Procedure, undated, indicated but was not limited to:-It is the policy of [Corporate Name] to provide a safe environment for residents, staff and visitors through… …
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