Royal Braintree Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Royal Braintree Nursing and Rehabilitation Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF867Feb 11, 2026

  Based on observation, interview, and document review, the facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) program with documentation of the development, implementation, and evaluation of corrective actions or performance improvement activities. Specifically, the facility failed to develop and implement appropriate plans of action for resident concerns regarding food temperatures.Findings include:Review of the facility's policy titled Quality Assurance Performance Improvement Program, last reviewed in January 2025, indicated but was not limited to the following:-Quality Assurance and Performance Improvement (QAPI) principles will drive the decision making within our organization. […]

• No harm, potential for more than minimal, widespreadF868Feb 11, 2026

  Based on interview and document review, the facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) Committee which included the required members at their meetings. Specifically, the facility's Infection Preventionist failed to attend three of three QAPI meetings reviewed.Findings include:Review of the facility's policy titled Quality Assurance on (sic) Performance Improvement (QAPI) Program, dated as revised January 2025, indicated but was not limited to:-The facility Administrator is responsible and accountable for developing, leading and closely monitoring our QAPI program.-QAPI activities will be governed and monitored by the Quality Assurance and Assessment (QAA) committee which will include: -The Medical Director, or designee -The Director of Nursing… […]

• No harm, potential for more than minimal, widespreadF680Jun 3, 2021

  Based on interviews, documentation review, and personnel record review, the facility failed to ensure that the facility's activity program was directed by a qualified activities professional. Findings include: During an interview on 5/26/21 at 8:01 A.M., the Administrator said that the facility's Activity Director is also the Dementia Special Care Unit's (DSCU) Therapeutic Activity Director (TAD). Review of a staff listing document titled, Who's Who at Royal Braintree, indicated the facility's Activity Director was identified as the same staff member identified as the TAD for the DSCU. During an interview on 5/26/21 at 10:10 A.M., the DSCU Consultant said she comes to the facility two or three times a month. […]

• No harm, potential for more than minimal, patternF565Feb 11, 2026

  Based on review of Resident Council Minutes, a resident group meeting, and interviews, the facility failed to ensure grievances/complaints brought forward from the Resident Council were addressed and resolved in a timely manner to ensure the residents felt their concerns were acted upon and included the facility response to the group.Findings include:Review of the facility's policy titled Resident Council Meetings, last reviewed December 2024, indicated but was not limited to the following:- The facility shall act upon concerns and recommendations of the Council, make attempts to accommodate recommendations to the extent practicable, and communicate its decisions to the CouncilReview of the facility's policy titled Complaint/Grievance Policy and Procedure, dated September 2023, indicated… […]

• No harm, potential for more than minimal, patternF656Feb 11, 2026

  Based on interviews and record review, the facility failed to ensure that individualized, comprehensive care plans were developed and consistently implemented for one Resident (#5), out of a total sample of 34 residents. Specifically, the facility failed to ensure resident specific, individualized care plans were developed to address the medical, physical, mental and psychosocial needs of a residents identified with a history of suicidal ideation/attempt/gestures. Findings include:Review of the facility's policy titled Comprehensive Care Plans, last revised May 2025, indicated but was not limited to:-It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and… […]