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
Failure to Timely Notify Physician and HCP of Change in Condition: A resident with paraplegia, DM, a chronic stage IV pressure injury, and other chronic conditions reported new right-hand weakness and inability to grasp utensils at breakfast and again at lunch. Nursing assessed the resident but did not promptly notify the MD or HCP; the HCP was only informed later when she visited and noticed right-sided facial drooping. The resident was then sent to the ED and admitted with an acute CVA, right upper extremity weakness, right facial droop, and dysarthria.
Incomplete and inaccurate wound care documentation: A resident with frostbite-related wounds and daily wound care orders had missing nursing notes for refused or uncompleted dressing changes, and the TAR also showed wound care as completed when an LPN said she had not performed it. The DON confirmed there was no additional documentation supporting completion of the right toe dressing changes, and the record lacked documentation of wound status, refusals, and treatment completion.
A resident with multiple diagnoses, including pelvic fractures, CVA, MDD, anxiety, GERD, HTN, and HLD, had a care plan and nutrition eval documenting a preference for skim milk. The resident said staff never provided skim milk and told him/her only low-fat milk was available. The dietician confirmed skim milk was the stated preference and should have been provided, while invoices and kitchen observation showed only whole milk and 1% milk on hand, with no skim milk available.
Medication Order Omission During Admission Reconciliation: A newly admitted resident with CHF and acute kidney failure had a hospital order for Furosemide 80 mg daily, but nursing failed to transcribe the order correctly during admission reconciliation. The omission was missed by the second nurse review and the 24-hour chart check was not completed, resulting in three missed consecutive doses of the diuretic.
Failure to Send Individual Discharge Notice to Ombudsman: A resident with MS, major depressive d/o, anxiety d/o, and tobacco use was transferred to the ED for evaluation, but the facility did not send the Ombudsman a copy of the resident’s individual transfer/discharge notice. Instead, the DSW faxed a weekly report listing generic discharge locations, which did not include specific addresses, and stated she was unaware that the Ombudsman office required the actual notices.
A resident with MS, MDD, and anxiety disorder was transferred to the hospital after an altercation involving an electric wheelchair. On return, the hospital discharge summary called for risperidone 0.5 mg daily, but nursing did not clarify the order with the MD and instead transcribed facility orders for risperidone 0.5 mg in the morning plus 0.25 mg at bedtime. The MAR showed the resident received the extra antipsychotic doses for several days before the DON identified the transcription error.
Failure to Timely Notify Physician and HCP of Change in Condition
Penalty
Summary
The facility failed to promptly notify the resident’s physician and Health Care Proxy of a significant change in condition after the resident reported new right-hand weakness and inability to grasp utensils at breakfast and again at lunch. The resident was cognitively intact, had a history that included paraplegia, diabetes mellitus, a chronic stage IV pressure injury, obstructive uropathy with a chronic indwelling catheter, and bilateral DVTs. The facility policy required prompt notification of the resident, the physician, and the resident’s representative when there was a change requiring notification or a significant change in physical, mental, or psychosocial condition. According to the resident, he/she told the nurse after breakfast that he/she could not hold utensils in the right hand, and the nurse checked hand strength. At lunch, the resident still could not grasp utensils and could not eat the meal served because it required utensils. After lunch, additional staff assessed the resident, including checking hand strength and facial movement, and the resident heard discussion about a telehealth appointment, but the resident said that did not occur. The resident’s daughter, who was the Health Care Proxy, was not notified earlier in the day and only learned of the problem when she visited at suppertime. The resident’s daughter observed right-sided facial drooping and nursing then called the physician and EMS, and the resident was transferred to the hospital ED and admitted with an acute CVA, right upper extremity weakness, right facial droop, and dysarthria. The nurse stated he did not call the physician after the first assessment because hand grasps were equal, and later felt the facial asymmetry might have been baseline. The DON stated she was not aware of the initial breakfast complaint and said the facility expected nursing to notify the physician and responsible party of changes in status in a timely manner.
Incomplete and inaccurate wound care documentation
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident who was admitted in March 2026 with diagnoses including hypothermia, superficial frostbite of the hand and foot, and severe sepsis with septic shock. The resident’s admission MDS indicated dependence on staff for bathing, dressing, transfers, and mobility, and that the resident had open lesions and required nonsurgical dressings. Physician orders in June 2026 included daily wound care for the right toes 1-3, left toes 1-5, and right second finger using Vashe or similar cleanser, Alginate or Iodosorb, DPD, and lambs wool between the toes for the right foot. For multiple days in June 2026, the TAR and nurses’ notes did not contain nursing documentation describing the wounds, the dressing changes, or nursing observations for ordered treatments on the left toes and right second finger, and a nurse stated the resident refused dressing changes but that the refusals were not documented. In addition, the TAR showed wound care for the right toes 1-3 as completed on two dates even though the nurse whose initials appeared on the record stated she had not changed the dressing and did not know why the record showed completion; the DON confirmed there was no additional documentation supporting that the right toe dressing change had been completed.
Failure to Provide Resident’s Preferred Milk
Penalty
Summary
The facility failed to ensure that a resident received the drink of preference identified on the care plan and nutritional assessment. The resident was admitted in February 2026 with diagnoses including fractures of the right and left pelvis, major depressive disorder, cerebral infarction, generalized anxiety disorder, hypothyroidism, GERD, hypertension, and hyperlipidemia. The admission MDS dated 03/24/26 indicated the resident was alert, oriented, his/her own decision maker, and scored 15/15 on the BIMS. The nutrition evaluation dated 3/02/26 documented that the resident was on a low-fat, low-sodium diet, understood the therapeutic diet, and drank skim milk, and the therapeutic diet care plan also listed skim milk only as a preference. During a telephone interview, the resident stated that he/she had spoken with the dietician multiple times about preferring skim milk and never received it, and staff told him/her the facility did not have skim milk and only had low-fat milk. The dietician confirmed that skim milk was the resident’s preference and stated that low-fat milk and skim milk are not exactly the same, and that the resident should have received skim milk. Review of milk invoices showed only whole milk and 1% milk were delivered, with no skim milk included, and an onsite kitchen observation found 1% low-fat milk and whole milk in the refrigerator with no skim milk present. The FSD stated the facility ordered milk weekly and had whole milk and 1% low-fat milk, while the Administrator stated that if skim milk was not ordered or delivered, the facility did not have it and that the resident should have received the preference of skim milk.
Medication Order Omission During Admission Reconciliation
Penalty
Summary
Resident #1, who was newly admitted from an acute care hospital with diagnoses including acute kidney failure and acute on chronic systolic and diastolic congestive heart failure, had a physician order for Furosemide 80 mg by mouth daily beginning on 05/19/26. The Facility’s admission medication reconciliation process required nursing to compare hospital records to Facility orders, transcribe new orders, obtain a second nurse cosignature, and complete a 24-hour chart check to verify all orders had been addressed. Nursing failed to transcribe the Furosemide order correctly into the Facility’s electronic medication ordering system, and the medication was omitted from the admission orders. A nurse supervisor also missed the omission during the second review, and the 24-hour chart check was not completed. As a result, Resident #1 had no Facility documentation supporting administration of Furosemide on 05/19/26, 05/20/26, and 05/21/26, and the resident missed three consecutive doses of the diuretic.
Failure to Send Individual Discharge Notice to Ombudsman
Penalty
Summary
The Facility failed to ensure that a copy of the Notice of Intent to Discharge was sent to a representative of the Office of the Long-Term Care Ombudsman for Resident #1, who required transfer to the Hospital Emergency Department for an evaluation. The Facility Transfer or Discharge Notice Policy, last revised 11/2024, stated that a resident and/or representative would receive a 30-day written notice of an impending transfer or discharge and that a copy of the notice would be sent to the Office of the State Long-Term Care Ombudsman. Resident #1 was admitted in July 2025 and had diagnoses including multiple sclerosis, major depressive disorder, anxiety disorder, and tobacco use. The care plan related to the resident’s wish to discharge to the community, initiated 7/16/25, indicated the resident would communicate understanding of the discharge plan and included preparing and giving contact information for community referrals as needed. During interview, the Ombudsman stated the Facility did not send individual discharge notices, but instead sent a Weekly Report titled Ombudsman Notification of Facility Initiated Transfer/Discharge, which listed residents discharged during the prior week with only a generic location such as home or hospital and did not include the specific address where residents were discharged. The Director of Social Service provided copies of these reports and stated she faxed the report instead of each resident’s discharge or transfer notice because that was the practice of her predecessor and she was not aware the Ombudsman Office required additional information or that regulations required copies of discharge notices.
Medication Reconciliation Error Led to Extra Antipsychotic Doses
Penalty
Summary
Resident #1, who had diagnoses including multiple sclerosis, major depressive disorder, and anxiety disorder, was transferred to the hospital after an incident in which he/she intentionally drove an electric wheelchair into a staff member's leg. At the time of transfer, the resident's physician orders included risperidone 0.25 mg once daily in the evening. The facility's medication reconciliation policy required accurate comparison of pre-discharge and post-discharge medications to prevent unintended changes or omissions during transitions of care. Upon readmission, the hospital discharge summary stated the resident should continue risperidone 0.5 mg daily and did not include any recommendation, instruction, or order for risperidone 0.25 mg. There was no documentation that nursing clarified the risperidone orders with the physician when the resident returned to the facility. Instead, the facility's physician orders dated 06/25/26 listed risperidone 0.5 mg in the morning and risperidone 0.25 mg at bedtime, and the MAR showed the resident received risperidone 0.5 mg every morning and risperidone 0.25 mg at bedtime from 06/26/26 through 06/29/26. The DON later stated she was unaware of the medication error until questioned by the surveyor and identified that a transcription error had occurred on readmission.
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Compliance trends in Massachusetts
Data through Apr 2026Comparisons below measure the most recent period May 2025 – Apr 2026 against the prior period May 2024 – Apr 2025 (two equal 12-month windows). The most recent 3 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 3-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): May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: May 2025 – Apr 2026 vs the prior period May 2024 – Apr 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: May 2025 – Apr 2026 vs the prior period May 2024 – Apr 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 May 2025 – Apr 2026 vs the prior period May 2024 – Apr 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 3 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025; the most recent 3 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 3 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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