Citations in Massachusetts
Statistics, citations and compliance trends for long-term care facilities in Massachusetts.
Statistics for Massachusetts (Last 12 Months)
Financial Impact (Last 12 Months)
Latest citations in Massachusetts
A CNA failed to treat a severely cognitively impaired resident with dignity and respect while redirecting the resident near the nurses' station. Witnesses reported the CNA used demeaning language such as "you're nasty" and "you're gross," and placed a hand on the resident's chest while telling the resident to move away. The resident had Parkinson's disease, schizophrenia, and a BIMS score indicating severe cognitive impairment, and the DON confirmed the interaction was not respectful or professional.
Failure to immediately report abuse and resident altercation allegations: Staff did not promptly notify administration after an LPN witnessed possible verbal and physical abuse between a CNA and a resident, instead leaving a note that was not found until days later. Staff also delayed reporting a resident-to-resident physical altercation involving two residents, with the DON learning of it nearly five hours after it occurred, despite policy requiring immediate reporting.
Incomplete abuse investigation and inaccurate DPH reporting: The Facility failed to document a thorough investigation and timely final report after an allegation that one resident punched another resident in the nose. The HCFRS report listed the wrong time and witness information, while the investigation file showed the incident occurred earlier and included staff witness statements, but no documentation supported the alleged push by the other resident or an interview with the reported resident witness. The DON said she could not explain the discrepancies and reported the time based on when staff notified her.
A resident who was dependent on staff and required assist of one for ceiling-lift transfers was being moved from a wheelchair to bed when a CNA did not fully secure all sling loops to the overhead lift. As the resident was raised and the wheelchair was moved away, one upper loop detached, the resident slipped from the sling, and was lowered to the floor, hitting his/her head and sustaining a small eyebrow swelling and lip bleeding.
Incomplete wound care documentation for multiple residents: Nurses signed the TAR showing daily dressing changes were completed for residents with pressure wounds and other wounds, but the records did not include wound appearance, drainage type or amount, odor, or treatment effectiveness. The DON stated she expected documentation of wound location, drainage, pain, and signs of infection with each dressing change, and noted the TAR did not provide a place to record specific wound characteristics.
Failure to Protect Resident Information: A CNA took a screenshot of a resident’s facility face sheet and sent it to another person without the resident’s knowledge or consent. The image included the resident’s name, DOB, room number, allergies, BP, respiratory rhythm, and other PHI, and the resident was alert and oriented with a BIMS of 15 and diagnoses of DM2 and COPD.
Failure to Treat a Cognitively Impaired Resident with Dignity and Respect
Penalty
Summary
The Facility failed to ensure a severely cognitively impaired resident was treated with dignity and respect when a CNA interacted with the resident in a demeaning and derogatory manner during redirection. The resident had diagnoses including Parkinson's disease, schizophrenia, and unsteadiness on feet, and the Quarterly MDS dated 01/04/26 showed a BIMS score of 3 out of 15, indicating severe cognitive impairment. The resident's behavior care plan noted a history of wandering intrusively and aggression toward staff, and directed staff to redirect the resident in a calm manner, divert attention, and remove the resident from the situation as needed. Several staff members reported that while the resident wandered near the nurses' station and stood too close to the CNA, the CNA responded by using disrespectful language and physical contact. Witnesses stated the CNA told the resident, "You're nasty," "You're gross," and "get your nastiness away from me," while also holding up a hand and placing a hand on the resident's chest to move him/her away. Nurse #1 stated the resident did not appear to react to the contact or lose balance and walked away, and also stated she advised the CNA that the resident should have been redirected in a respectful and professional manner. The DON confirmed the investigation determined the CNA failed to treat the resident with dignity and respect during the interaction.
Failure to Immediately Report Abuse and Resident Altercation Allegations
Penalty
Summary
The facility failed to follow its Abuse, Neglect and Exploitation policy requiring allegations of abuse to be reported immediately to administration. On 01/24/26, Nurse #1 witnessed an incident involving possible verbal and physical abuse between CNA #1 and Resident #1, including the CNA pushing the resident and making derogatory statements. Instead of immediately notifying facility administration by phone, Nurse #1 wrote a note describing the event and slid it under the Nursing Supervisor's office door, where it was not discovered until 01/27/26. The DON stated she first learned of the allegation on 01/27/26 and confirmed the expectation was for all allegations of abuse to be reported immediately. The facility also failed to follow its Resident to Resident Altercation policy requiring suspected altercations to be reported immediately to a supervisor. On 04/28/26 around 3:45 P.M., Resident #3 punched Resident #2 in the face after Resident #2 approached Resident #3 in the hallway, resulting in a nosebleed and ED transfers for both residents. Although staff were aware of the altercation, they did not notify a supervisor immediately and instead reported it to the DON at about 8:30 P.M., nearly five hours later. The DON stated that facility policy requires all allegations of abuse, including resident-to-resident altercations, to be reported to administration immediately.
Incomplete abuse investigation and inaccurate DPH reporting
Penalty
Summary
The Facility failed to ensure that, after being notified on 04/28/26 of an allegation that Resident #3 punched Resident #2 in the nose, it obtained and maintained evidence of a thorough investigation and submitted a final investigation report to the Massachusetts Department of Public Health (DPH) within five working days. The Facility policy titled Abuse, Neglect and Exploitation required the Administrator to follow up with government agencies and report final investigation results within five working days, but the Facility did not have documentation showing that the final investigative findings were completed and submitted to DPH by 05/05/26. The HCFRS report submitted by the Facility stated that Resident #3 became angry with Resident #2 and punched him/her in the face at 8:30 P.M., causing a nosebleed, and identified Resident #4 as the only witness. However, the Facility’s investigation file contained incident documentation and witness statements showing the altercation occurred around 3:45 P.M., not 8:30 P.M., and identified two staff members as witnesses. The file did not contain documentation supporting that Resident #2 pushed Resident #3 was investigated, and there was no interview or written statement from Resident #4. During interview, the DON stated she was not sure why there were discrepancies between the investigation and what was reported to DPH, and said the time was reported as 8:30 P.M. because that was when staff notified her of the incident.
Mechanical Lift Transfer Not Fully Secured
Penalty
Summary
A resident who was dependent on staff for all care and had diagnoses including cerebral palsy and a seizure disorder was being transferred from a wheelchair to a bed using an overhead mechanical lift when the transfer was not completed safely. The resident’s care plan required assist of one staff person for transfers with the ceiling lift. During the transfer, Certified Nurse Aide #1 did not completely secure all of the lift pad loops to the overhead lift before raising the resident. When the resident was elevated and the wheelchair was moved out of the way, one upper right loop detached from the lift and the resident began slipping out of the lift pad. CNA #1 then lowered the resident to the floor, and the resident hit his/her head on the floor. The resident was observed lying on the floor with the sling still underneath him/her and had a small area of swelling above the right eyebrow and a small amount of bleeding from the lip. The facility’s investigation and staff interviews confirmed that the loop had not been fully attached before the lift was used. CNA #1 stated she thought all loops were secured but later realized the upper right loop had come undone during the transfer. The nurse who responded found the resident on the floor with minor injuries, and the ADON and DON both determined that the incident occurred because the lift pad was not fully secured to the mechanical lift.
Incomplete wound care documentation for multiple residents
Penalty
Summary
The facility failed to ensure professional standards of practice were maintained for wound care documentation for three sampled residents whose physician orders included daily wound dressing changes. After nurses completed the dressing changes, the medical record did not include specific wound characteristics such as wound appearance, drainage type and amount, odor, or the effectiveness of treatment, despite facility policy requiring wound assessment and documentation in the medical record. The report also cites National Pressure Injury Advisory Panel guidance stating that dressing change documentation should include wound condition, surrounding skin condition, patient response, and signs of infection or complications. Resident #1 was admitted with Type 2 diabetes mellitus and acute and chronic respiratory failure and had multiple wound orders in March 2026, including treatment for bilateral heel pressure wounds, a stage 4 sacral wound, a right lateral lower leg venous ulcer, and a left foot DTPI. Although nurses signed the TAR indicating daily wound dressing changes were completed, there was no documentation supporting wound appearance, drainage type and amount, or odor during those dressing changes. The resident’s orders changed over the month, including different treatments for the sacral wound and right lower leg wound, but the TAR still lacked the wound-specific documentation described in the report. Resident #4, admitted with paraplegia and polyneuropathy, had orders in May 2026 for an unstageable sacral pressure wound with daily cleansing and dressing changes, followed by a revised order for wound cleanser, gentamycin, Santyl to necrotic areas, and a border foam dressing. Resident #5, admitted with quadriplegia and a history of traumatic brain injury, had orders in May 2026 for a stage 4 sacral pressure wound and a right buttock DTPI with daily wound care that later changed to Vashe solution, collagen, calcium alginate, TRIAD to the peri-wound, and foam border dressings. For both residents, nurses signed the TAR to show the dressing changes were done, but the records did not document wound appearance, drainage type or amount, or odor during the daily treatments.
Failure to Protect Resident Information
Penalty
Summary
The facility failed to protect a resident’s right to privacy and confidentiality when a CNA took a screenshot of the resident’s facility face sheet image and sent it to another person without the resident’s knowledge or consent. The screenshot contained the resident’s personal and health information, including name, date of birth, room number, allergies, blood pressure, and respiratory rhythm, and the facility name was also visible on the computer screen in the image. The resident involved was admitted in January 2026 and had diagnoses of Type 2 Diabetes Mellitus and COPD. The resident’s MDS assessment dated 04/30/26 showed the resident was alert and oriented with a BIMS score of 15. The facility received a report from the county sheriff’s department stating that the CNA reportedly sent a photograph to an inmate at the county jail, and the facility’s investigation identified the CNA as the staff member involved. The facility policy stated that resident medical record information is confidential and may only be released with written consent of the resident or legal representative.
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Compliance trends in Massachusetts
Data through Mar 2026Comparisons below measure the most recent period Apr 2025 – Mar 2026 against the prior period Apr 2024 – Mar 2025 (two equal 12-month windows). The most recent 2 months are excluded because CMS is still publishing them.
Top tags by month · last 24 months
dashed = still reportingMonthly citation counts for the 5 most-cited tags. The dashed tail is the 2-month reporting lag.
Frequency movers
Biggest change in how often each tag is cited, as a rate per 100 inspections (so it isn't skewed by survey volume): Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 2025. The number is the average severity on the A–L scale (A=0…L=11); the letter is the band it falls in. A rise means the same tag is being cited at a more serious level — note the average can move enough to rank here while staying within the same letter. Same 20-citation minimum applies.
Care domain movers
Citations grouped into CFR care domains — F-tags by their §483 regulatory section (CMS State Operations Manual, Appendix PP) — measured as a rate per 100 inspections: Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 2025. Share is the domain's portion of citations this period; avg severity is the mean scope/severity letter and immediate jeopardy the percentage cited at J–L, both over the current period. Domains with at least 20 citations in both periods are shown; the sparkline tracks the last 12 months (left = oldest).
Immediate jeopardies · this period
Citations at the most serious scope/severity — J–L, immediate jeopardy, residents placed at risk of serious harm or death — over Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 2025. "Surveys with an IJ" counts distinct health inspections that had at least one.
Survey activity · by month
faded/dashed = still reportingCitations each month split into complaint-driven (unscheduled, triggered by grievances) vs standard surveys — bars, left axis — with the number of inspections as a line on the right axis. Rising inspections signal more scrutiny; a rising complaint share means more off-cycle surveys. The most recent 2 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 2025; the most recent 2 months are still being reported (dashed).
Penalties · by month
faded = still reportingTotal civil money penalty dollars imposed on the state's facilities each month — how hard the state is enforcing. The most recent 2 months are still being reported, and penalties often lag citations by several months.
Emerging tags
Tags that weren't established last period but surged — an early warning, distinct from movers (which track already-common tags). Criteria: fewer than 20 citations in the prior period, but at least 10 this period and 2.5× their prior volume. The sparkline shows monthly counts over the last 12 months (left = oldest).
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