The Mansion at Brigham

Inspectors wroteBased on record review and interview, the facility failed to electronically submit direct care staffing data to the Centers for Medicare and Medicaid Services (CMS) for the entire reporting period, Fiscal Year (FY) Quarter 2, 2025 (January 1 - March 31), in accordance with the schedule specified by CMS.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure an intervention used to prevent and manage a pressure ulcer was effectively implemented for one Resident (#8), out of a total sample of 14 residents. Specifically, the facility failed to identify, intervene and ensure proper function when Resident #8's air mattress alert feature was illuminated and flashing, indicating a potential problem with the air mattress function.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the environment remained free of accidents and hazards and was safe for all residents and, one Resident (#1), out of a total sample of 14 residents. Specifically, the facility failed to ensure:1. Safe practices in preparing food in the facility kitchen, which has the potential to affect all residents, when [NAME] #1 left a large double pot boiling over two gas burners, with the back burner spewing large flames shooting upwards and left unattended and,2. For Resident #1, the facility failed to implement interventions in the Resident's care plan to keep in supervised area, common areas for increased supervision when out of bed.

Inspectors wroteBased on resident interviews and test tray results, the facility failed to ensure food provided to the residents was prepared by methods that conserve palatability and are at appetizing temperatures on two of two units.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure standards of quality of care were provided for one Resident (#8), out of a total sample of 14 residents. Specifically, the facility failed to ensure Resident #8 was provided care and treatment for a skin tear on the back of his/her right hand.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure professional standards of practice for the care of a suprapubic urinary catheter (a tube placed through the suprapubic region into the bladder to drain urine) for one Resident (#35) out of a total sample of 14 residents. Specifically, the facility failed to ensure nursing changed Resident #35's catheter drainage bag (a collection pouch that connects to a urinary catheter to collect urine from the bladder) in accordance with physician's orders.

Inspectors wroteBased on record review and interview, the facility failed to maintain acceptable parameters of nutritional status for one Resident (#33) out of a total sample of 14 residents. Specifically, the facility failed to obtain weekly weights to monitor the weight for Resident #33 as ordered by the physician resulting in the facility failing to identify a significant weight loss in a timely manner.

Inspectors wroteBased on interview and records reviewed, the facility failed to complete annual Certified Nurse Aide (CNA) performance reviews for two out of two eligible sampled CNAs.

Inspectors wroteBased on observation and interview, the facility failed to ensure a gap in the bed was filled to prevent possible entrapment for one Resident (#42) out of a total sample of 14 residents.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who during the overnight shift on 10/04/24 into 10/05/24 was found sitting on the floor by Nurse #1 and CNA #1 after an unwitnessed fall, the Facility failed to ensure nursing reported the incident to the Physician, his/her Health Care Agent, Administrative staff and to the oncoming shift Nurse (Nurse #2) as required, and per Facility policy.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who during the overnight shift (on 10/04/24 into 10/05/24) was found sitting on the floor by Nurse #1 and Certified Nurse Aide (CNA) #1 after an unwitnessed fall, the Facility failed to ensure he/she was provided with nursing care and treatment that met professional standards of quality care, when although Nurse #1 said she assessed Resident #1 prior to moving him/her off the floor, there was no documentation to support she adequately assessed Resident #1 after his/her fall for potential injury. The following day shift (7:00 A.M. to 3:00 P.M.) Resident #1 verbalized complaints of pain, reported he/she had fallen during the previous overnight shift, and was transferred to the Hospital Emergency Department (ED) for evaluation. [...]

Inspectors wroteBased on record review and interview the facility failed to annually conduct, review, and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies.

Inspectors wroteBased on observations and interviews, the facility failed to ensure residents on two of two units experienced a homelike dining experience.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure staff developed and implemented a comprehensive person-centered care plan for four Residents (#4, #23, #25 and #47), out of a total sample of 17 residents. Specifically: 1.) For Resident #4, the facility failed to implement a fall care plan intervention to keep a urinal within reach and failed to develop a fall care plan intervention for fall mats. 2.) For Resident #23, the facility failed to develop personalized mood, behavior, and substance abuse care plans. 3.) For Resident #25, the facility failed to develop a comprehensive care plan for dialysis and antidepressant medication. 4.) For Resident #47, the facility failed to develop a comprehensive care plan for post-traumatic stress disorder (PTSD) and the use of psychotropic medication.

Inspectors wroteBased on interview and record review, the facility failed to develop a plan of care for dialysis and failed to ensure staff implemented dialysis care and services consistent with professional standards of practice for one Resident (#25), out of 17 sampled residents. Specifically, the facility failed to provide ongoing communication between the nursing facility and dialysis facility.

Inspectors wroteBased on record review and interview, the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility failed to meet the facility-determined minimum for certified nurse assistant (CNA) staff on the weekends. Findings Include: During the Resident Group interview on 9/10/24 at 1:00 P.M., the Resident Group expressed concern about certified nurse assistant (CNA) staffing. The Resident Group said they do not feel there is enough CNAs, and they often must wait too long for their call lights to be answered. On 9/11/24 at 1:50 P.M., the Chief Nursing Officer (CNO) said there was no facility assessment for the facility. The CNO gave the surveyor a list of current staffing needs for direct care staff. [...]

Inspectors wroteBased on interviews and record review, the facility failed to provide Substance Abuse Services for one Resident (#47) out of a sample of 17 Residents, and additionally failed to provide Substance Abuse Services for 6 additional Residents identified by the Social Worker.

Inspectors wroteBased on record review, policy review and interview, the facility failed to ensure recommendations from the Monthly Medication Reviews (MMRs) conducted by the consultant pharmacist were addressed and acknowledged by the physician in a timely manner for two Residents (#33 and #47) out of a total sample of 17 residents. Findings Include: Review of the facility policy titled Documentation and Communication of Consultant Pharmacist Recommendations dated 10/1/19, indicated that comments and recommendations concerning medication therapy are communicated in a timely fashion. Further review indicated that in the event that a problem requiring the immediate attention of the prescriber, the responsible prescriber is contacted by the consultant pharmacist or the facility, and the prescriber response is documented on the consultant pharmacist review record or elsewhere is the medical record. [...]

Inspectors wroteBased on observation, policy review and interview, the facility failed to ensure nursing staff stored all drugs and biologicals in accordance with accepted professional standards of practice. Specifically, the facility failed to properly secure the medication room on two of two units.

Inspectors wroteBased on record reviews and interviews the facility failed to ensure they provided laboratory services to meet the needs of its residents. Specifically, the facility failed to: 1.) Maintain a current Clinical Laboratory Improvement Amendment (CLIA) certificate appropriate for the level of testing performed within the facility, and 2.) For Resident #19 the facility failed to obtain an albumin level (a test that can help determine liver disease or kidney disease, or if the body is not absorbing enough protein).

Inspectors wroteBased on observations, interviews and facility assessment review, the facility failed to have sufficient number of staff to effectively carry out the function of food and nutrition services.

Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to ensure that staff accommodated food preferences for four Residents (#17, #14, #2, and #10), out of a total sample of 17 residents. Specifically, 1.) For Resident #17, the facility failed to honor the Resident's preferences and served the Resident foods that he/she disliked, including eggs. 2.) For Resident #14, the facility failed to honor the Resident's preferences and served the Resident foods that he/she disliked, including eggs. 3.) For Resident #2, the facility failed to honor the Resident's preferences and served the Resident foods that he/she disliked, including ham. 4.) For Resident #10, the facility failed to honor the Resident's preferences.

Inspectors wroteBased on observations, interviews, and review of the meal truck delivery schedule, the facility failed to offer a nourishing evening snack when there was greater than 14 hours between dinner and breakfast service.

Inspectors wroteBased on observations, interviews and policy review, the facility failed to store food in accordance with professional standards for food service safety. Specifically, the facility failed to label and date food in the refrigerator, store food in the freezer with dates opened and expiration dates and failed to store food directly off the floor.

Inspectors wroteBased on record review and interview the facility failed to ensure they maintained complete and accurate medical records for four Residents (#22, #2, #28, and #23) out of a total sample of 17 residents. Specifically: 1.) For Resident #22, the facility failed to document weights in the Electronic Health Record (EHR). 2.) For Resident #2, the facility nurses documented a broken BiPAP was being used, when it was not. 3.) For Resident #28, the facility failed to document services provided each shift by the Certified Nurse Aide (CNA). 4.) For Resident #23, the facility failed to document weights in the medical record.

Inspectors wroteBased on observation, record review, interview and policy review, the facility failed to ensure residents were treated with dignity for one Resident (#28) out of a total sample of 17 residents. Specifically, for Resident #28, the facility failed to provide assistance with removal of unwanted chin hair.

Inspectors wroteBased on record review and interviews, the facility failed to provide a notice of transfer and failed to send a copy of the notice to the Ombudsman for one Resident (#30) and the facility failed to send a copy of the transfer notice to the Ombudsman for one Resident (#22) out of a total sample of 17 residents who were transferred to the hospital.

Inspectors wroteBased on record review and interview, the facility failed to provide a bed hold policy for two Residents (#30 and #22) out of a sample of 17 residents. Specifically, the facility failed to provide a facility bed hold policies to the Residents or Resident Representatives before Resident #30 and Resident #22 were transferred to the hospital.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that its staff completed a Preadmission Screening and Resident Review (PASRR - a federal and state required process that is used to identify evidence of serious mental illness (SMI) and/or intellectual or developmental disabilities in all individuals seeking admission to a nursing facility), in a timely manner after the expected length of stay exceeded 30 days for one Resident (#14) with SMI, out of 17 sampled residents.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to ensure staff developed and implemented a baseline care plan within 48 hours of the resident's admission, which included the instructions needed to provide effective and person-centered care to the resident which meet professional standards of quality care for three Residents (#25, #47 and #49), in a total sample of 17 residents. Specifically, the facility failed to ensure: 1. For Resident #25, a baseline care plan was developed for the Resident's dialysis treatment. 2. For Resident #47, a baseline care plan was developed. 3. For Resident #49, a baseline care plan was developed.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team for two Residents (#14 and #47) out of a total sample of 17 residents. Specifically: 1.) For Resident #14, the facility failed to update the comprehensive care plan to indicate a new change in advanced directives from full code to do not resuscitate (DNR) and failed to ensure the entire comprehensive care plan was reviewed and revised by an interdisciplinary team following the completion of a comprehensive assessment. 2.) For Resident #47, the facility failed ensure the entire comprehensive care plan was reviewed and revised by an interdisciplinary team following the completion of a comprehensive assessment.

Inspectors wroteBased on record review and interviews, the facility failed to provide services that met professional standards of quality for one Resident (#19) out of a sample of 17 Residents. Specifically, for Resident #19 the facility failed the ensure nursing implemented an air mattress setting according to the physician's order.

Inspectors wroteBased on observation, record review, and interview, for one Resident (#34) out of a total sample of 17 residents, the facility failed provide services and treatment for a resident who was assessed to have a reduction in range of motion of his/her left hand.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure the size of an indwelling urinary catheter was documented in the physician's orders for one Resident #23 out of a sample of 17 Residents.

Inspectors wroteBased on observation, record review and interview for one Resident (#19) of 17 sampled residents the facility failed to ensure acceptable parameters of nutritional status were maintained. Specifically, for Resident #19, a resident with weight loss, the facility failed consistently provide fortified foods and nutritional supplements.

Inspectors wroteBased on observation, record review, and interview the facility failed to adhere to professional standards for the administration of enteral feeding (nutrition taken through a tube directly to the stomach) for one Resident (#34) out of a total sample of 17 residents. Specifically, for Resident #34 the facility failed to administer enteral feedings in accordance to manufactures guidelines (product exceeded the expiration date).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary respiratory care and services for two Residents (#2 and #22), out of a total sample of 17 residents. Specifically: 1.) For Resident #2, the facility failed to ensure a bilevel positive airway pressure (BiPAP) machine, which is a device which assists with breathing, was repaired after identifying it was unable to be utilized because it was broken. 2.) For Resident #22 the facility failed to ensure nursing consistently provided respiratory care in accordance with professional standards of practice.

Inspectors wroteBased on record review and interview the facility failed to ensure a plan of care was developed for Trauma-Informed Care for one Resident (#47), who was admitted to the facility with the diagnosis of Post-Traumatic Stress Disorder (PTSD), out of a total 17 sampled residents.

Inspectors wroteBased on record review and interviews, the facility failed to indicate the duration of a PRN (as needed) psychotropic medication for one Resident (#23) out of a sample of 17 residents. Specifically, the facility failed to indicate the duration of a PRN (as needed) antipsychotic medication.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that the physician ordered therapeutic diet was followed for one Resident (#34), in a total sample of 17 residents.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to provide adaptive equipment for one Resident (#19) of 17 sampled residents. Specifically, the facility failed to ensure Resident #19 was consistently provided with a lip plate for use during his/her meals.

Inspectors wroteBased on interviews and review of the Health Care Facility Reporting System (HCFRS-State agency reporting system), the facility failed to provide written notice to the State Agency when a change in the facility's Administrator occurred.

Inspectors wroteBased on record review and interview, the facility failed to provide an accurate estimated cost of services to resident's or their representatives, for two out of two resident records reviewed, to ensure they were informed of their potential financial liabilities of the cost of items and services provided in addition to the daily per diem room rate.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a Minimum Data Set (MDS) discharge assessment was encoded and transmitted timely for one Resident (#40) out of 17 total sampled residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately code in the Minimum Data Set (MDS) for two Residents (#10 and #49) of 17 total sampled residents. Specifically: 1.) For Resident #10, the use of anticoagulant and antiplatelet medications were inaccurately coded in the MDS. 2.) For Resident #49, the discharge location was incorrectly coded in the MDS.

Inspectors wroteBased on observations and interviews, the facility failed to post nurse staffing information, which included the date, facility name, total number of hours worked for licensed and unlicensed staff, and the resident census number, on a daily basis in a prominent place readily accessible to residents and visitors.

Inspectors wroteBased on records reviewed, interviews and observations, the Facility failed to ensure the Dietary/Kitchen Department staff consistently prepared and followed the established, as posted, weekly menu for the resident meals.

Inspectors wroteBased on records reviewed, interviews and observations, for one of two sampled resident care units (Unit 1), the Facility failed to ensure food and beverages provided to the residents were served at safe and appetizing temperatures, when food temperatures were not consistently measured and recorded, and the results of a test tray observation indicated that the food items were not served at appetizing temperatures and food items were not palatable.

Inspectors wroteBased on records reviewed and interviews, for two of three sampled residents (Resident #1 and Resident #3), the Facility failed to ensure they maintained complete and accurate medical records, when documentation by nursing related to the conduction of weekly skin assessments was not consistently completed.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who had an activated Health Care Proxy (HCP) and had been admitted on to Hospice Services, the Facility failed to ensure nursing notified his/her Health Care Agent(s) (HCA) and the Hospice Agency in a timely manner that he/she had died. On [DATE] Resident #1 died shortly after midnight, however the HCA(s) and Hospice Agency were not made aware until the following morning when, Resident #1's Family Member arrived to the Facility expecting to visit with him/her.

Inspectors wroteBased on records reviewed, interviews and observations for one of three sampled residents (Resident #1), the Facility failed to ensure they maintained Resident #1's dignity when he/she was observed with stains and what appeared to be dried food on the front of both of his/her sneakers. Findings Include: The Facility Policy titled Resident Rights, dated as revised 12/06/21, indicated a Facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The Policy indicated that the facility would make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity. [...]

Inspectors wroteBased on records reviewed, interviews and observations, for one of three sampled residents (Resident #1), the Facility failed to ensure that staff provided a clean homelike environment when his/her wheelchair was observed to be dirty with dried food stuck to the seatbelt of Resident #1's wheelchair, with dried food also noted to be stuck to each side of his/her wheelchair. Findings Include: The Facility Policy titled Resident Rights, dated as revised 12/06/21, indicated a Facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The Policy indicated that each resident's rights included the resident has a right to a safe, clean, comfortable, and homelike environment. [...]

Inspectors wroteBased on observations, records reviewed and interviews, the facility failed to ensure they stored and prepared food in accordance with professional standards for food service safety, when on 1/31/24, during a tour of the kitchen, the surveyor observed food items stored or placed in unsanitary conditions, expired food items, kitchen equipment used to prepare and/or store food items that were in need of cleaning, and a kitchen sink and dishwasher not functioning properly, all of which placed residents at risk for contracting food bourne illnesses.

Inspectors wroteBased on record review and interview, the facility failed to protect one Resident (#53) from neglect when the Resident was reported to have a significant change in condition out of a total sample of 29 residents. Specifically, on [DATE] Nurse #1 failed to assess the medical emergency timely and call 911 immediately when the Resident was found to have chest pain, was unable to sit up, had significantly elevated blood pressure (194/100), a high pulse rate (119) and lost the ability to open his/her left eye. Furthermore, the Nurse failed to provide ongoing monitoring and assessment of the resident's condition. Resident #53 was transferred to the hospital and admitted to the intensive care unit over two hours after the change in condition was noted, where he/she died of septic shock and pneumonia.

Inspectors wroteBased on record review and interview, the facility failed to ensure licensed nursing staff had the appropriate competencies and skill set to identify, assess, and respond to a significant change in condition, for one Resident (#53), out of a total sample of 29 Residents. Specifically, the facility failed to alert EMS of a significant change in condition for greater than two hours when Resident #53 was identified as complaining of chest pain, could not sit up independently, had elevated blood pressure (194/100), an elevated pulse (119) and the inability to open his/her left eye. When on [DATE] Resident #53 presented with a change in condition at approximately 6:40 P.M., with symptoms including chest pain, elevated blood pressure and pulse, weakness, and the inability to open his/her left eye. [...]

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure open medications were dated as required on two out of four sampled medication carts.

Inspectors wroteBased on record reviews and interviews, the facility failed to maintain accurate medical records for four Residents (#22, #45, #13 and #15) out of a total sample of 29 residents.

Inspectors wroteBased on observation, record review and interview the facility failed to implement practices for the prevention of potential infection on 2 out of 2 resident units. Specifically, nursing staff failed to 1. perform adequate hand hygiene during a dressing change, 2. failed to perform hand hygiene and disinfect equipment used for multiple residents during the medication pass.

Inspectors wroteBased on observation, record review and interview, the facility failed to review and revise the plan of care for one Residents (#20) out of a total of 29 sampled residents.

Inspectors wroteBased on observations, record reviews and interviews the facility failed to ensure professional standards of care were followed specifically related to physician's orders for two Resident's (#15 and #22) out of a total sample of 21 residents; Findings Include: 1. Resident admitted to the facility in February 2023 with diagnoses including diastolic congestive heart failure. Review of Resident #15's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident scored a 6 out of total 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The MDS further indicated the Resident requires total dependence of one-person physical assist for personal hygiene On 8/22/23 at 8:25 A.M., the surveyor observed Resident #15 sitting in his/her room. Resident #15 did not have tubi grips/ ted stocking on his/her legs. [...]

Inspectors wroteBased on record reviews, observations and interviews the facility failed to ensure two Residents (#26 and #15) were provided required care out of a total sample of 29 residents. Specifically; 1. For Resident #26 the facility failed to provide with supervision with meals, and 2. For Resident #15 the facility failed to provide nail care to a dependent resident.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide audiology services for one Resident (#2) out of a total sample of 29 residents.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure an air mattress was on the correct setting for one Resident (#45) who had actual skin breakdown out of a total sample of 29 Residents.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure nursing provided respiratory care consistent with professional standards of practice for two Residents (#1 and #13), out of a total sample of 29 residents. Specifically, the facility failed: 1. For Resident #1 to ensure nursing changed oxygen tubing as ordered; and 2. For Resident #13, to ensure nursing provided the correct concentration of Oxygen as ordered.

Inspectors wroteBased on observation and interview, the facility failed to follow proper sanitation and food handling practices during meal service to prevent the risk of foodborne illness.

Inspectors wroteBased on record review and interview, the facility failed to accurately code Minimum Data Set Assessment information correctly for two Residents (#53 and #50) out of a total of 29 sampled residents.