Sarah S Brayton Center

Inspectors wroteBased on review of Resident Council Minutes, a resident group meeting, interviews, and record reviews, the facility failed to ensure grievances brought forward from the Resident Council were addressed and promptly resolved to ensure the residents felt their concerns were acted upon timely and included the facility response to the group.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services consistent with professional standards for five Residents (#81, #108, #12, #136 and #132), out of a total sample of 33 residents. Specifically, the facility failed:1. For Residents #81 and #108, to implement physician's orders for air mattress settings;2. For Residents #12 and #136, to implement physician's orders for oxygen; and 3. For Resident #132, to ensure physician's orders were in place upon admission for a continuous positive airway pressure (CPAP) machine (uses air pressure to hold the airway open while sleeping).

Inspectors wroteBased on observations, interviews, and record review, the facility failed to implement nutritional interventions to maintain acceptable parameters of nutritional status for two Residents (#12, #50), with unplanned gradual weight loss, and one Resident with significant weight gain (#95), in a total sample of 33 residents. Specifically, the facility failed:1. For Resident #12, to identify and develop interventions to prevent and address a 12.4% significant weight loss between 8/1/25 and 2/2/26;2. For Resident #50, to identify and develop interventions to prevent and address a 17.57% significant weight loss between 11/4/25 and 2/12/26; and3. For Resident (#95), to implement dietitian recommendations to address a weight gain and ensure the Resident's preference to lose weight was met.

Inspectors wroteBased on record review and interview, the facility failed to ensure physician visits were completed as required for three Residents (#6, #13 and #7), out of a total of 33 sampled residents.

Inspectors wroteBased on observations, test tray results, and interviews, the facility failed to serve food that was palatable, and at a safe and appetizing temperature, for two of two test trays on two different units.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one Resident (#185), out of a total sample of 33 residents, was treated with respect and dignity. Specifically, the facility failed for Resident #185, to ensure a cholecystostomy tube drainage system (a drainage bag connected to a catheter inserted through the skin into the gallbladder to drain bile, or infected fluid) was consistently covered with a privacy cover. Findings Include:Review of the facility's policy titled Dignity, dated February 2021, indicated but was not limited to:-Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem-Residents are treated with dignity and respect at all times-Demeaning practices and standards of care that compromise dignity are prohibited. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop, implement, and individualize a comprehensive care plan for one Resident (#132), out of a total sample of 33 residents. Specifically, the facility failed to ensure a comprehensive care plan related to Resident #132's obstructive sleep apnea (where throat muscles relax and block the airway) with use of a continuous positive airway pressure (CPAP) machine (uses air pressure to hold the airway open) was developed and implemented.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to provide care and services consistent with professional standards of practice for one Resident (#50) who required renal dialysis (a life sustaining treatment that helps the body remove extra fluids and waste products from the blood when the kidneys are not able to), out of a total sample of 33 residents. Specifically, the facility failed to ensure emergency supplies were kept with the Resident in accordance with the plan of care and the physician's orders in case of emergency.

Inspectors wroteBased on record review and interview, the facility failed to maintain medical records in accordance with accepted professional standards and practices that are complete and readily accessible for facility staff for three Residents (#6, #13 and #16), out of a total sample of 33 residents. Specifically, for Residents #6, #13 and #16, the facility failed to ensure the Physician's progress notes were available in the Residents' medical record.

Inspectors wroteBased on record review and interview, the facility failed to ensure three Residents (#74, #117, and #155) were offered or provided a summary of their baseline care plans, out of a total sample of 33 residents.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to provide services to ensure that proper treatment to maintain hearing ability was provided for one Resident (#115), out of a total sample of 33 residents. Specifically, the facility failed to notify the consultant provider to address Resident #115's non-functioning hearing aids for more than two months, resulting in a delay in the process of repairing them.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff stored all drugs and biologicals used in the facility in accordance with currently accepted professional principles on four of four units. Specifically, the facility failed: 1. On the [NAME] Unit to date insulin pens with an open and discard date; 2. On the Sagamore Unit to date ophthalmic ointment with a discard date; 3. On the Pocasset Unit to maintain a medication cart free from loose pills; and 4. On the [NAME] Unit to date eye drops with an open and discard date.

Inspectors wroteBased on observation, interview, and document review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to: 1. Ensure environmental cleaning was maintained in the laundry room including flooring and surfaces and properly store linens; 2. For Resident #154, who has chronic wounds, putting him/her at increased risk for infection, to ensure that staff implemented Enhanced Barrier Precautions (EBP-an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) that employs targeted gown and glove use during high contact resident care activities.

Inspectors wroteBased on record review, document review, and interview, the facility failed to ensure residents were screened for eligibility to receive the recommended influenza and/or pneumococcal vaccinations, residents/residents' representatives were educated on the benefits and potential side effects of the vaccine, and were offered and administered (if applicable) the vaccine in a timely manner for one Resident (#117), out of a total sample size of five residents reviewed for immunizations.

Inspectors wroteBased on record review and interview, the facility failed to provide education and/or offer the COVID-19 vaccination as required or appropriate per the Centers for Disease Control and Prevention (CDC) recommendations for two Residents (#153 and #117), out of a total sample size of five residents reviewed for immunizations.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure for one sampled Resident (#7) with an indwelling nephrostomy tube (a catheter inserted through the skin into the kidney draining urine into a collection bag outside of the body), out of a total sample of 33 residents, that the Resident's dignity was maintained. Specifically, the facility failed to consistently place the Resident's nephrostomy tube drainage bag in a privacy bag.

Inspectors wroteBased on record review and interview, the facility failed to notify the Physician/Nurse Practitioner when one Resident (#30), out of a total sample of 33 residents, did not keep medical appointments with his/her consultant cardiologist and urologist as scheduled.

Inspectors wroteBased on interview and record review, the facility failed to protect one Resident (#413) from misappropriation of resident property, out of a total sample of 33 residents, when fifty dollars and a store credit card were taken from his/her personal bag.

Inspectors wroteBased on interview and record review, the facility failed to implement policies and procedures for alleged misappropriation of resident property for one Resident (#413), out of a total sample of 33 residents. Specifically, the facility failed to investigate and report an allegation of misappropriation of Resident #413's fifty dollars and a store credit card.

Inspectors wroteBased on record review and interviews, the facility failed to ensure an allegation of misappropriation of resident property was reported timely to the state agency and to the police as required, for one Resident (#413), of 33 sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure that individualized, comprehensive care plans were developed and consistently implemented for two Residents (#30 and #72), out of 33 sampled residents. Specifically, the facility failed to: 1. For Resident #30, develop and implement an individualized plan of care for a pacemaker; and 2. For Resident #72, develop a person-centered, individualized care plan that was implemented for wandering and elopement risk.

Inspectors wroteBased on observation, interview, and record review, the facility failed to review and revise the care plan for one Resident (#115), out of a total sample of 33 residents. Specifically, the facility failed to ensure the care plan for communication was updated to reflect the Resident's non-functioning bilateral hearing aids.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow professional standards of practice for one Resident (#30), out of a total sample of 33 residents. Specifically, the facility failed to monitor for signs/symptoms for pacemaker complications and monitor the function of the pacemaker.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the proper care and treatment of a peripherally inserted central catheter (PICC) line device (inserted into a vein in the upper arm and is advanced until the internal tip of the catheter is in the superior vena cava to deliver medications and other treatments directly to the large central veins near your heart) was provided in accordance with professional standards of practice for one Resident (#66), out of a total sample of 33 residents. Specifically, the facility failed to ensure Resident #66's PICC line dressing was secured to prevent infection.

Inspectors wroteBased on resident and staff interviews, observation, and meal test tray results, on one of four units, the facility failed to prepare and serve meals in a manner conserving flavor, were palatable, and served at safe and appetizing temperatures for one out of one test tray conducted.

Inspectors wroteBased on observation, record review, and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to maintain safe and clean equipment, in two of four kitchenettes.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure that medical records were complete and accurately documented in accordance with professional standards of practice for one Resident (#30), out of a total sample of 33 residents. Specifically, the facility failed to ensure Resident #30's medical record included information about his/her cardiac pacemaker.

Inspectors wroteBased on interview and observations, the facility failed to post a notice of availability of survey results and prominently post the Department of Public Health (DPH) Survey inspection results binder.

Inspectors wroteBased on record review and interview, the facility failed to complete a discharge assessment to ensure timely coding and transmitting of a Minimum Data Set (MDS) assessment for one Resident (#60), out of one resident assessment reviewed, resulting in a 129-day delay in the encoding and transmission of a MDS post-discharge from the facility.

Inspectors wroteBased on records reviewed and interviews for two of three sampled residents (Resident #1 and Resident #3), the Facility failed to ensure the residents and/or their family members or legal representatives participated in the development and implementation of each of their person-centered care plans, which included conducting and inviting residents and/or their representatives to an interdisciplinary care plan meeting following the completion of their comprehensive admission Minimum Data Set (MDS) assessments.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), the Facility failed to ensure that nursing notified his/her Health Care Agent (HCA) of significant changes in his/her status, which included the development of additional pressure areas, testing positive for Covid-19 (a contagious respiratory infection caused by a particular virus), as well as the need to be transferred to the Hospital Emergency Department (ED) on multiple occasions, and the need for him/her to be admitted to the Hospital for treatment.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who was admitted with multiple pressure injuries and significantly impaired skin, the Facility failed to ensure they provided care and services consistent with professional standards of practice, when upon admission nursing failed to adequately assess his/her skin condition, which included assessment and documentation related to pressure injuries and other skin conditions, and the need to be evaluated by a wound physician.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to provide adequate supervision and accident prevention interventions to maintain the safety of one Resident (#76), out of a total sample of 32 residents. Specifically, the facility failed to provide adequate supervision to maintain the Resident's safety and prevent falls, and/or injury, resulting in Resident #76 sustaining a total of 14 falls from the time of their admission [DATE]) to 8/27/23; 12 of which were unwitnessed, and one resulted in the Resident being transported to the emergency room for a head laceration that required three staples.

Inspectors wroteBased on observation and interview, the facility failed to ensure the residents' environment was clean, comfortable, and homelike. Specifically, the facility failed to ensure: 1. Residents in 2 of 5 dining areas had a comfortable and homelike dining experience, 2. The resident's main dining area was not used as an overflow storage area, and the carpet was clean and well maintained, and 3. Residents' rooms were maintained in good repair, and homelike, on 2 of 4 resident care units.

Inspectors wroteBased on observation, documentation review, policy review, and interview, the facility failed to implement resident-centered, meaningful, and engaging activity programming for all residents on one unit and failed to provide for two Residents (#127 and #623), out of 32 sampled residents, an activity program which engaged the residents and supported their physical, mental, and psychosocial well-being. Specifically, the facility failed: 1. To provide resident-centered, meaningful, and engaging activities to residents on the Sagamore Unit; and 2. To ensure facility sponsored individualized and group activities were offered to support the psychosocial well-being of the residents, including Resident #127 and Resident #623.

Inspectors wroteBased on observation, interviews, and policy review, the facility failed to label medications in accordance with currently accepted professional principles to include the expiration dates when applicable, and ensure all drugs were stored in locked compartments to prevent unauthorized access. Specifically, the facility failed to: 1. Ensure multi-dose containers of medication were appropriately labeled for 2 of 5 medication carts observed, on 2 of 3 units; and 2. Ensure all drugs and biologicals were stored in locked compartments and permitted only authorized personnel access.

Inspectors wroteBased on resident and staff interviews, observation, and meal test trays on 2 of 4 units, the facility failed to provide residents with meals that were prepared and served in a manner that conserved flavor, were palatable, and served at safe and appetizing temperatures.

Inspectors wroteBased on observations, interviews, policy review, and records reviewed, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of infections. Specifically, the facility failed to ensure transmission-based precautions were maintained for four Residents (#17, #601, #129, and #15).

Inspectors wroteBased on observation and interview, the facility failed to maintain essential gas and electrical equipment, located in the main kitchen, in safe operating condition.

Inspectors wroteBased on observations, interviews, and records reviewed, the facility failed to ensure that individualized, comprehensive care plans were developed for one Resident (#74), of 32 sampled residents. Specifically, the facility failed for Resident #74, to develop a communication care plan.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to meet professional standards of care for one Resident (#114), out of a total sample of 32 residents. Specifically, the facility failed to ensure the Resident was weighed according to the physician's order, and if treatment refused, to notify the physician.

Inspectors wroteBased on record review, observation, policy review, and interview, the facility failed to provide the necessary services to ensure one Resident (#143), out of a total sample of 32 residents, was able to effectively communicate his/her needs.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure the proper care and management related to urinary catheter bags for three Residents (#52, #129, and #145), out of a total sample of 32 residents. Specifically, the facility failed to ensure: 1. For Resident #52, the drainage bag and tubing were positioned to lessen the likelihood of complications and maintained to prevent the possibility of infection, 2. For Resident #129, the catheter was maintained in a manner to prevent the possibility of infection, and 3. For Resident #145, the catheter was maintained in a manner to prevent the possibility of infection.

Inspectors wroteBased on record review and interviews, the facility failed to ensure there was ongoing communication and collaboration with the dialysis facility regarding dialysis care and services for one Resident (#86), of seven receiving dialysis services, out of a total sample of 32 residents. Specifically, the facility failed to consistently document weights and vitals in a dialysis communication book pre-dialysis and failed to receive communication from the dialysis center with weights and vitals post-dialysis.

Inspectors wroteBased on record review, interviews, and policy review, the facility failed to develop a person-centered plan of care which included trauma informed approaches and identified triggers to avoid potential re-traumatization for one Resident (#27) with a history of trauma, out of a total sample of 32 residents.

Inspectors wroteBased on observations, records reviewed, policy review, and interviews, the facility failed to ensure it remained free from a medication error rate of 5 percent (%) or greater. Specifically, two medication errors were observed, out of 30 total opportunities for error, which resulted in a medication error rate of 6.67% and affected one Resident (#601), out of seven total residents observed.

Inspectors wroteBased on observations, interviews, and records reviewed, for two Residents (#624 and #703) of 32 sampled residents and one Resident (#704), out of 11 randomly selected individual controlled substance records selected for inspection during medication storage review, the facility failed to maintain medical records that were complete, accurate, and systemically organized within accepted professional standards of practice. Specifically, the facility failed: 1. For Resident #624, to document the administration of parental nutrition; 2. For Resident #703, to document the accurate dosage of a narcotic administered on two identified occasions; and 3. For Resident #704, to document the accurate dosage of a narcotic administered on one identified occasion. Review of the facility's policy titled Charting and Documentation, dated as revised July 2017, indicated but was not limited to: [...]

Inspectors wroteBased on record review, policy review, and interview, the facility failed to ensure written notice for transfer or discharge was provided to Residents and/or Resident Representatives prior to hospital transfers for one Resident (#66), out of a total sample of 32 residents.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to provide written notification of the bed hold policy to the Resident or Resident Representative prior to discharge to the hospital for four Residents (#66, #83, #114, and #127), in a total sample of 32 residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the resident's status for three Residents (#145, #27, and #74), out of a total sample of 32 residents. Specifically, the facility failed: 1. For Resident #145, to accurately reflect the use of opioid medication; 2. For Resident #27, to accurately reflect the election of hospice services; and 3. For Resident #74, to accurately reflect a fall resulting in injury.