Based on documentation review and interview, the facility failed to ensure direct care staff received mandatory effective communications training. Findings include: Review of the Facility Assessment, dated as reviewed by the Quality Assurance Performance Improvement committee on 6/20/24, failed to indicate Effective Communications Training was required. During an interview on 11/21/24 at 10:44 A.M., the Administrator provided the survey team with printouts of all the staff training that had been completed on their electronic training system in the last 12 months. He said he did not believe it was possible to obtain the content of the classes to provide to the surveyor. In addition, a list of all staff was provided to the survey team that totaled 163 staff members. …
F941 citations in Massachusetts
Administration Deficiencies
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2024
Massachusetts cites F941 more often than its own record predicts
2.48 times the share F941 takes of citations nationally.
Of every deficiency written in Massachusetts in 2024, this is the portion that was F941.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Massachusetts surveyors wrote
F941 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.
The short window
Recent years
| Year | Share of Massachusetts citations | vs expected |
|---|---|---|
| 2023 | 0.11% | 3.84× |
| 2024 | 0.15% | 2.48× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Massachusetts surveyors cite →
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