The Mansion at Brigham

In the surveyor’s words

From the most serious findings on record at The Mansion at Brigham, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Sep 5, 2023

  Based 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 (,d+[DATE]), 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. […]

• Immediate jeopardy, isolatedF726Sep 5, 2023

  Based 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 (,d+[DATE]), an elevated pulse (119) and the inability to open his/her left eye. […]

• Actual harm, isolatedF689Jan 29, 2021

  Based on records reviewed and interviews, for one of four sampled residents (Resident #1), who was assessed as being at increased risk for falls and had a history of [REDACTED].#1's safety was maintained, when he/she was found sitting on a set of stairs past a closed alarmed safety gate, was sent to the Hospital Emergency Department for an evaluation and was diagnosed with [REDACTED]. Findings include: Review of Resident #1's medical record indicated his/her medical history included toxic [MEDICAL CONDITION], dementia with behavioral disturbance, adjustment disorder with mixed disturbance of emotions and conduct, and a history of falls. […]

• No harm, potential for more than minimal, widespreadF851Sep 17, 2025

  Based 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. Findings include: Review of the Payroll Based Journal (PBJ) Staffing Report, CASPER Report 1705D, FY Quarter 2 2025 (January 1 - March 31), indicated the facility triggered for:-Failed to Submit Data for the Quarter (No Data Submitted for Quarter)-One Star Staffing Rating (Staffing Rating Equals 1) During an interview on 9/16/25 at 8:55 A.M., the Director of Nurses said that while she is not responsible for the reporting of the PBJ data, she would expect the facility to submit it as… […]

• No harm, potential for more than minimal, widespreadF838Sep 12, 2024

  Based 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. Findings include: Review of the facility policy titled, Facility Assessment, dated as 3/4/24, indicated this facility conducts and documents a facility-wide assessment to determine what resources are necessary to care for our residents competently during both day-to-day operations (including nights and weekends) and emergencies. The purpose of this policy is to establish responsibilities and procedures for the facility assessment process. 4. […]