Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Royal Braintree Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Failure to implement QAPI for ongoing food temperature complaints. Residents on Windsor 2 repeatedly reported cold meals, inaccurate orders, and melted ice cream in Resident Council/Food Committee meetings, and surveyors validated cold food with test trays at lunch and breakfast. The FSM acknowledged the ongoing concerns and suspected tray distribution delays, but could not provide documentation of any QAPI project, and the Administrator said no QAPI project had been initiated to address the complaints.
The facility failed to maintain a QAPI committee with the required members present at meetings. Review of the QAPI policy showed the committee was to include the Medical Director or designee, DON, Administrator or corporate leadership, Infection Preventionist, and two additional staff members. Attendance sheets for three QAPI meetings showed the Infection Preventionist was absent from all three, and the IP stated she does not attend QAPI meetings. The Administrator reviewed the records and could not identify the IP's signature, stating it is hard to get everyone together for the meetings.
Resident Council complaints about cold food, incorrect meals, and melted ice cream were repeatedly raised but not consistently addressed or documented in the meeting minutes or grievance process. Residents reported that meals on the units were served cold, ice cream arrived melted, and they often did not receive what they ordered. The AD, FSM, and Administrator were aware of the ongoing concerns, but the records showed little follow-up and no documented resolution to the residents’ repeated complaints.
Failure to care plan for suicidal ideation and self-harm behaviors. A resident with bipolar disorder, schizoaffective disorder, and suicidal ideations had repeated episodes of self-harm behavior, including holding a knife to the wrist and later holding broken glass to the wrist while stating an intent to cut the wrist. Although the NP and psych NP adjusted meds and ordered safety measures such as 15-minute checks, no individualized comprehensive care plan was developed or updated to address the resident’s suicidal ideation, gestures, or attempts, and staff interviews confirmed the gap in communication and planning.
Food was repeatedly served at cold or lukewarm temperatures because tray passes were delayed on two units. Residents reported that meals were always cold, and council minutes documented cold eggs and melted ice cream. Surveyors observed meal carts remaining on the unit for extended periods, and test trays showed hot items such as chicken, vegetables, oatmeal, eggs, and toast were tepid, cold, or soggy. The Regional FSD said trays should be passed within 15 minutes, while a UM noted many residents needed eating assistance and staffing support was limited.
Unlabeled and undated food items were found in multiple unit kitchenettes, including opened thickened juices, bottled water, soda, soup, and a slice of cake-like product. The FSD stated personal food items should not be left unlabeled or undated and that thickened liquids should have opened-on and use-by dates, but surveyors observed several items that did not meet those standards.
A secured dementia unit failed to provide an ongoing program of meaningful group, individual, and self-directed activities. Residents were repeatedly observed seated in the dayroom with nothing to do, little or no staff interaction, and no materials for independent activity, while the AD and UM said activity staff only came up a few times a day and supplies for busy boxes were limited or not available to other staff.
A resident with COPD and nicotine dependence was identified as an independent smoker, but the record did not show a completed smoking assessment and the smoking care plan had been resolved. The resident reported keeping cigarettes and a lighter in a dresser drawer or sock in the drawer, while staff gave conflicting accounts about whether smoking supplies were kept in the room or locked by nursing staff.
A resident with COPD, emphysema, and weakness was approved for self-administration of an Albuterol rescue inhaler, but surveyors repeatedly found the inhaler unsecured on the bedside nightstand. Surveyors also found Trelegy and Combivent inhalers left unsecured in the room even though those medications were ordered for clinician administration. The resident said the rescue inhaler was usually left out and not locked away, and the nurse and DON gave differing explanations about bedside storage and security.
Two residents admitted with complex medical needs did not have baseline care plans developed or implemented within 48 hours, as required by facility policy. Staff interviews revealed that the admitting nurse was responsible for initiating these plans, but management was unaware that the plans were incomplete, resulting in a failure to address immediate care needs such as infection control, fall risk, and specialized treatments.
A resident with an indwelling urinary catheter was not provided with a voiding trial or timely assessment for catheter removal as instructed in the hospital discharge summary. The care plan lacked interventions for catheter removal, and there was no documentation of communication with urology or attempts to remove the device. Both the resident and nursing staff were unaware of the reason for the catheter's continued use.
The facility failed to ensure that the call system was accessible to seven residents on the Sunshine Unit. Observations revealed that call lights were out of reach, and no alternative devices were available for residents to contact caregivers. Staff interviews confirmed that residents should have access to call lights, but the deficiency persisted over several days.
The facility failed to maintain a clean and homelike environment on the K2 unit, with issues such as missing privacy curtains, holes in walls, stained blinds, and broken windows. Staff interviews revealed a lack of communication and reporting of maintenance needs, with the new Maintenance Director unaware of the issues. The Administrator acknowledged a backlog of work orders and suggested staff fatigue might have contributed to the lack of repairs.
The facility failed to follow food safety standards by not dating opened thickened beverages in three kitchenettes, as required by the FDA Food Code and facility policy. Observations showed undated opened containers of thickened juices and dairy beverages, contrary to manufacturer guidelines. The Food Service Director confirmed the expectation for staff to date opened beverages.
A resident with dementia and weight loss was not provided with fortified foods as ordered, despite being at high nutritional risk. Observations showed the resident's meals lacked fortified items, and interviews confirmed the facility's failure to include these in the resident's diet.
A facility failed to assess and document triggers for a resident with PTSD, risking re-traumatization. The resident, diagnosed with PTSD, had a history of sexual assault, but the Trauma Assessment and care plan lacked details on specific triggers. Staff interviews revealed that the Social Worker did not inquire about triggers, and the Assistant Director of Nurses acknowledged the insufficiency of the assessment and care plan.
The facility failed to ensure accurate MDS assessments for two residents, leading to discrepancies in documented care needs. One resident was inaccurately assessed regarding bed rail use, despite daily use being observed and ordered by a physician. Another resident's MDS failed to document an indwelling Foley catheter, which was observed and confirmed by medical records and staff.
Failure to Implement QAPI for Ongoing Food Temperature Complaints
Penalty
Summary
The facility failed to maintain a QAPI program with documentation of the development, implementation, and evaluation of corrective actions or performance improvement activities. The facility’s QAPI policy stated that QAPI data would be reviewed monthly, including complaints and resident/family input, and that the Administrator was responsible for developing, leading, and closely monitoring the program. The policy also stated that QAPI documentation would include committee activity, performance improvement projects, and materials used to evaluate whether improvement was sustained. Residents on the Windsor 2 unit repeatedly reported that food was cold, meals were inaccurate, and ice cream arrived melted. Resident Council and Food Committee minutes from March 2025 through December 2025 documented ongoing complaints about cold food, inaccurate meals, cold eggs at breakfast, and melted ice cream. During a group meeting, residents told surveyors that meals served on the units were cool or cold, ice cream was always melted, some residents only ordered ham sandwiches because other foods arrived cold, and they did not always receive what they ordered. Test trays conducted by the survey team at lunch and breakfast validated the residents’ concerns of cold food. The FSM acknowledged the ongoing complaints and believed the problem was related to the time it took staff to distribute trays, but she could not provide documentation of any projects initiated to address the complaints. The Administrator stated he was aware of the ongoing complaints from Resident Council and minutes, but had not initiated a QAPI project to address them.
QAPI Committee Missing Required Infection Preventionist Attendance
Penalty
Summary
The facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) Committee with the required members present at its meetings. Review of the facility policy stated that the QAA committee was to include the Medical Director or designee, the DON, the Administrator or corporate leadership in the Administrator's absence, the Infection Preventionist, and two additional staff members. Review of QAPI attendee sign-in sheets for September 2025, December 2025, and January 2026 showed that the Infection Preventionist did not attend any of the three meetings reviewed. During interview, the Infection Preventionist stated she does not attend QAPI meetings, and the Administrator reviewed the attendance sheets and could not identify the Infection Preventionist's signature, stating it is hard to get everyone together to attend the meetings.
Resident Council Food Complaints Not Addressed
Penalty
Summary
The facility failed to ensure grievances and complaints brought forward by the Resident Council were addressed and resolved in a timely manner, and the facility did not include its response to the group. Review of the facility’s Resident Council Meetings policy stated 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 Council. The Complaint/Grievance Policy and Procedure stated voiced grievances may include a resident’s verbalized complaint to facility staff and are not limited to a formal written process. Resident Council notes, Resident Council Department Response Forms, and Food Committee Meeting Minutes from multiple units showed repeated resident complaints about cold food, incorrect meals, cold lunches, cold eggs, and melted ice cream over several months. Several meeting records documented the complaints, but the minutes often failed to show any follow-up or response to the residents’ concerns. One response form noted cold food complaints and stated the issue had a lot to do with how fast meal trays were handed out, but later records still showed no follow-up to the same concerns. No September 2025 Resident Council or Food Committee minutes were provided for review. During a group meeting, 12 residents reported meals on the units were served cool or cold, ice cream was always melted, some residents only ordered ham sandwiches because other foods arrived cold, and they did not always receive what they ordered. The residents said they complained about cold food in Resident Council every month and no one ever followed up with them about how it would be improved. The AD stated she had documented concerns and given them to the FSM, but residents still complained about cold food and she was not aware of any changes made to address the issue. The FSM acknowledged awareness of the ongoing complaints and believed tray distribution time contributed to the problem, but she could not explain or provide documentation of any approaches developed and implemented to address the complaints. The Administrator also stated he was aware of the ongoing food concerns and had not put a performance improvement plan in place until the survey team identified food temperature issues from test trays.
Failure to Care Plan for Suicidal Ideation and Self-Harm Behaviors
Penalty
Summary
The facility failed to develop and implement individualized, comprehensive care plans for a resident with diagnoses including bipolar disorder, schizoaffective disorder, and suicidal ideations. The facility’s policy required care plans to include measurable objectives and timeframes to meet each resident’s medical, nursing, mental, and psychosocial needs, and to be reviewed and revised by the interdisciplinary team after comprehensive and quarterly MDS assessments. Review of the resident’s comprehensive care plans showed no care plan addressing the resident’s history of suicidal ideation. The resident had multiple documented episodes of suicidal ideation and self-harm behavior. A NP note documented an episode in which the resident threw a food tray at staff, then held a butter knife to the wrist while stating that people on the television wanted to hurt and kill him/her; the NP and psychiatric NP adjusted psychotropic medications and initiated 15-minute safety checks when the resident was alone in the room, along with keeping the television off and removing sharp objects. Despite these events and interventions, the comprehensive care plan did not reflect suicidal ideation, gestures, or attempts. Later, a behavior note documented that the resident held broken glass to the wrist and stated an intent to cut the wrist, prompting 1:1 supervision and transfer to the hospital for psychiatric evaluation. Hospital records showed admission to a geriatric psychiatry unit for paranoid ideation and self-injurious behaviors, with a history of prior psychiatric hospitalizations, cutting, and a suicide attempt 30 years earlier. After return to the facility, the comprehensive care plan still did not include a plan for suicidal ideation, gestures, or attempts. Staff interviews confirmed that CNA staff were not informed through the CNA care card, and the UM and DON acknowledged that no individualized care plan had been developed for the resident’s suicidal behaviors.
Food Served at Cold Temperatures Due to Delayed Tray Passes
Penalty
Summary
The facility failed to ensure residents received food at appetizing temperatures, as shown by repeated observations and resident complaints about cold meals. During initial screening, residents on the Windsor 2 unit reported that food was always cold, including cold eggs at breakfast and melted ice cream for dessert. Resident Council Minutes from October 2025 through December 2025 also documented ongoing concerns about cold eggs, melted ice cream, and food arriving melted on meal carts, while Food Council notes from 10/15/25 and 11/20/25 did not include those temperature concerns. Surveyors observed delayed tray passes on both the Kensington 2 and Windsor 2 units. On Kensington 2, breakfast trays remained on the food truck for extended periods, with trays still not passed 45 minutes after arrival on one observation and the last tray not delivered until 9:05 A.M. on another. On Windsor 2, a test tray was delivered after the truck had been on the unit for more than 20 minutes, and the surveyor and Regional FSD found the hot items were only tepid or lukewarm, with chicken thigh at 112F, mixed vegetables at 118F, and parmesan noodles at 110F. A second test tray on Kensington 2 was also delayed, with the last tray delivered 44 minutes after arrival; the tray items were measured at 122F for oatmeal, 96F for scrambled eggs with cheese, and 90F for toast, which was described as cold and soggy. The Regional FSD stated trays should be passed within 15 minutes of the truck arriving to the unit, and a Unit Manager said the unit had many residents needing eating assistance and that more help had been requested but not received.
Unlabeled and Undated Food Items in Unit Kitchenettes
Penalty
Summary
The facility failed to follow professional standards of practice for food safety by not ensuring that food items in 3 of 7 kitchenette refrigerators were properly dated and stored. The report states that the facility’s policy required perishable foods to be stored in resealable containers with tightly fitting lids, labeled with the resident’s name, item, and use-by date, and that nursing staff were responsible for discarding perishable foods on or before the use-by date. The FDA Food Code also required ready-to-eat refrigerated time/temperature control for safety food to be clearly marked with the date by which it must be consumed, sold, or discarded. Surveyors observed multiple unlabeled or undated items in unit kitchenettes. In the [NAME] unit kitchenette, opened thickened orange juice, thickened apple juice, and thickened cranberry juice were in the refrigerator without the date opened or use-by date, even though the labels indicated discard times of 10 days or 7 days after opening. In the Windsor 2 unit kitchenette, surveyors found opened and unlabeled coconut water in the freezer, Core water in the refrigerator, a can of Vanilla Coca Cola in the refrigerator, and a plastic shopping bag containing a bowl of soup and a ladle in the refrigerator. In the Sunshine unit kitchenette, a disposable to-go container with a slice of cake-like product was observed unlabeled. The Food Service Director stated there should be no unlabeled or undated personal food items in the unit kitchenettes and that thickened liquids should be labeled with opened-on and use-by dates.
Lack of Meaningful Activities on Secured Dementia Unit
Penalty
Summary
The facility failed to provide an ongoing program of individual and group activities designed to meet the interests of residents and support their physical, mental, and psychosocial well-being on the Kensington 2 secured unit. The unit housed 25 of 25 residents with a diagnosis of dementia. The facility policy stated activities were to include group, individual, and independent activities, including self-directed activities, to promote well-being, cognition, emotional health, dignity, pleasure, and independence. During multiple observations, residents on the Kensington 2 unit were seated in the dayroom with nothing to do and little or no staff interaction. On one observation, seven residents were at tables while two residents wandered the unit; the television was on but low and inaudible, and the posted activity calendar indicated Family Feud Trivia, but residents were not engaged and were not provided materials for self-directed activity. On later observations, 10 residents, then nine residents, then 12 residents, and then 14 residents were seen seated in the dayroom with no staff in the immediate vicinity or no staff interaction, with some residents sleeping and others awake and idle. At times the television was on, off, or inaudible, and the residents still had nothing in front of them for self-directed activity. Staff interviews confirmed the lack of activity support and materials. The Unit Manager said the unit did not have materials or supplies for independent activity and that activities staff came to the unit only three times a day. The Activity Director said activity staff only went to the unit a few times a day for a short period, no one else did anything with the residents, and there were no supplies available to make busy boxes. Activity supplies were stored in a small closet outside the unit and included items such as magazines, books, board games, a beach ball, a rubber ball, pool noodles, silk flowers, a fidget sensory busy board, baby clothing items, and sensory blankets, but these items were for use by all seven units and were accessible only to activity staff.
Smoking materials not secured and smoking assessment missing
Penalty
Summary
The facility failed to maintain a safe environment free of accident hazards for Resident #74 by not securing smoking materials and by not completing a smoking assessment. The resident was admitted with diagnoses including COPD and nicotine dependence and was identified by the facility as an independent smoker. The facility’s smoking policy stated that residents who smoke are to be assessed on admission, with changes in status, and quarterly, and that independent smokers must keep lighting materials in a designated secure area. However, the resident’s record did not include an active comprehensive smoking care plan, and the prior smoking care plan had been resolved on 12/6/24. Resident #74 told surveyors that cigarettes and a lighter were kept in the top drawer of a dresser or in a sock in the dresser drawer, and declined to allow observation of the location. Nursing staff stated the resident was an independent smoker who signed out to smoke and that smoking supplies were kept in the resident’s room, while the DON stated the supplies were supposed to be locked up by nursing staff and returned when the resident went out to smoke. The DON also stated the resident’s smoking care plan had been accidentally resolved and needed to be reinstated. The medical record failed to indicate that a smoking assessment was completed.
Unsecured inhalers left at bedside
Penalty
Summary
The facility failed to ensure medications were stored in accordance with acceptable standards for one resident, who had diagnoses including COPD, emphysema, and weakness and was cognitively intact with a BIMS score of 15 out of 15. The resident had physician orders allowing bedside use of an Albuterol inhaler for unsupervised self-administration, while Trelegy Ellipta and Combivent Respimat were ordered to be administered by a clinician. The facility’s policies stated that self-administered medications must be stored in a safe and secure place not accessible by other residents, and bedside storage was permitted only when access by other residents was prevented. Survey observations showed the resident’s Albuterol inhaler and Combivent inhaler on top of the bedside nightstand, unsecured, and later the Albuterol inhaler remained unsecured on the nightstand during repeated observations. On another observation, the resident’s Albuterol inhaler was unsecured on the nightstand while the Trelegy inhaler and Combivent inhaler were on the overbed table in bags, also unsecured. The resident stated that the Albuterol inhaler was kept on the nightstand and was not locked away or secured. The resident said the Trelegy and Combivent inhalers were brought by the nurse for administration and were not supposed to be stored in the room, adding that the nurse must have forgotten to take them after administration. The self-administration assessment indicated the resident was fully capable of self-administration and approved for it, but it did not specify which medications the resident could administer independently. The nurse stated the resident could use the rescue inhaler at bedside and was unsure whether medications needed to be locked or safely secured, while the DON stated the rescue inhaler could be left at the bedside but did not expect the Trelegy or Combivent inhalers to be left unsecured there.
Failure to Develop Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement baseline care plans addressing the immediate care needs of two newly admitted residents within 48 hours of admission, as required by facility policy. For one resident with a history of traumatic brain injury, seizure disorder, multiple falls, acute urinary retention with an indwelling catheter, and cirrhosis, there was no documentation that baseline care plans were created to address acute urinary retention, infection control precautions, fall risk, or medication titration needs. Similarly, another resident admitted with chronic obstructive pulmonary disease, pneumonia, normal pressure hydrocephalus, dysphagia requiring a gastrostomy tube, and a pressure injury did not have baseline care plans developed to address pneumonia management, gastrostomy tube care, infection control, anticoagulation therapy, or pressure injury care within the required timeframe. Interviews with facility staff, including the Unit Manager, Assistant Director of Nurses (ADON), and Director of Nurses (DON), revealed a lack of awareness that the baseline care plans for these residents had not been completed. Staff indicated that the admitting nurse is responsible for initiating the baseline care plan, with management expected to review new admission charts the following day to ensure completion. Despite these expectations, the required baseline care plans were not documented or implemented for the two residents within 48 hours of admission.
Failure to Follow Discharge Instructions for Catheter Removal
Penalty
Summary
A deficiency occurred when a resident with a history of traumatic brain injury, seizure disorder, multiple falls, acute urinary retention with an indwelling catheter, and cirrhosis was admitted to the facility. The hospital discharge summary for this resident included instructions to attempt a voiding trial and remove the indwelling catheter as able after discharge. However, the resident's care plan did not include interventions related to conducting voiding trials or attempting to remove the catheter. Medical record review showed no documentation that nursing staff communicated with urology, attempted a voiding trial, or removed the catheter as directed in the discharge summary. Interviews revealed that the resident was unaware of the reason for the continued presence of the catheter and questioned when it would be removed. Nursing staff interviewed were also unaware of the rationale for the catheter's continued use or why a removal attempt had not been made. The DON stated she was not aware of the discharge instructions regarding the voiding trial and catheter removal, and confirmed that it is facility policy for nursing to review discharge summaries and verify all orders upon admission.
Inaccessible Call System for Residents
Penalty
Summary
The facility failed to ensure that the call system was accessible to seven residents on the Sunshine Unit, which has a census of 35. Observations by the surveyor revealed that these residents did not have a means of directly contacting caregivers while in their rooms. Specifically, the call lights were either clipped to themselves and hanging against the wall or draped over a wall-mounted monitoring device, making them unreachable for the residents. No alternative hand-held devices were observed to be available for these residents to use to call for assistance. Interviews with facility staff, including CNAs, a nurse, the Assistant Director of Nurses, and a Regional Nurse, confirmed that residents should always have access to their call lights. The staff acknowledged that the call lights were not within reach for the residents observed, and they agreed that residents should have a means of contacting staff when in their rooms. The deficiency was identified through multiple observations over several days, indicating a systemic issue with the accessibility of the call system for residents in the facility.
Facility Fails to Maintain Homelike Environment on K2 Unit
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for residents on the K2 unit, as observed by the surveyor. Specific deficiencies included missing privacy curtains, holes in walls with cracking paint, stained blinds, ripped floor mats, and broken windows and footboards. These issues were noted during multiple visits by the surveyor, indicating a lack of timely maintenance and repair. The facility's policy on preventative maintenance was not effectively implemented, as evidenced by the unaddressed maintenance needs. Interviews with staff revealed a breakdown in communication and reporting of maintenance issues. The Maintenance Director, who had recently started, was unaware of the problems on the K2 unit, and the TELS log did not reflect the need for repairs. Staff members, including a CNA and a nurse, indicated that maintenance requests were logged but not effectively addressed. The Administrator acknowledged the backlog of unfinished work orders and suggested that staff fatigue and desensitization to the environment might have contributed to the lack of reporting and repair. The Regional Nurse and Administrator agreed that the environment should be sanitary and in good repair for residents.
Failure to Date and Store Thickened Beverages Properly
Penalty
Summary
The facility failed to adhere to professional standards of practice for food safety and sanitation, specifically in the handling and storage of thickened beverage items. Observations revealed that thickened beverages in three of seven kitchenettes were not properly dated after being opened, which is a requirement according to both the FDA's 2022 Food Code and the facility's own policy. The FDA Food Code mandates that ready-to-eat, time/temperature control for safety food must be clearly marked with the date it was opened if it is held for more than 24 hours. The facility's policy also requires that beverages be dated when opened and discarded after 24 hours. During the survey, multiple instances were noted where thickened beverages, such as cranberry juice and dairy beverages, were found opened and undated across different units. The manufacturer's labels on these beverages provided specific guidelines for storage duration after opening, which were not followed. The Food Service Director acknowledged the expectation that staff should date opened beverages and adhere to the manufacturer's storage recommendations. This oversight in food safety practices poses a potential risk of foodborne illness to residents, who are considered high-risk individuals.
Failure to Provide Therapeutic Diet as Ordered
Penalty
Summary
The facility failed to provide a therapeutic diet as ordered for a resident with a history of dementia and failure to thrive, who was experiencing weight loss. The resident was admitted with a care plan that included the provision of fortified foods with all meals to address nutritional issues related to decreased appetite. Despite a physician's order for a regular texture house diet with fortified foods and a high-calorie supplement (Magic Cup) at lunch and dinner, the resident was observed not receiving these fortified foods during multiple meals. Observations by the surveyor revealed that the resident's meals did not include the fortified foods as indicated on the meal tickets. Interviews with the nursing staff and the registered dietitian confirmed that the facility's practice was to use oatmeal and mashed potatoes as fortified foods, but these were not provided to the resident. The dietitian acknowledged the resident's high nutritional risk and the necessity of fortified foods, while the nurse noted the absence of the Magic Cup and fortified items, indicating a failure in the kitchen's responsibility to include these on the meal trays.
Failure to Assess Trauma Triggers for Resident with PTSD
Penalty
Summary
The facility failed to adequately assess and document triggers for a resident with a history of trauma, potentially leading to re-traumatization. The resident, who was admitted in June 2015, was diagnosed with PTSD in December 2023. The facility's policy on Trauma Informed Care requires an assessment to identify past traumatic events and potential triggers, followed by the formulation of a specific care plan. However, the assessment for this resident did not include detailed information about the type of trauma or specific triggers, and the care plan lacked this critical information as well. Interviews with facility staff revealed that the Social Worker responsible for the Trauma Assessment did not inquire about specific triggers that might re-traumatize the resident. The Assistant Director of Nurses confirmed that the assessment and care plan were insufficient, as they did not provide necessary details to inform staff on how to prevent re-traumatization. The resident had reported a past sexual assault, and the lack of detailed assessment and care planning could have left staff unprepared to manage the resident's PTSD symptoms effectively.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for two residents, leading to discrepancies in their documented care needs. Resident #232, admitted in September 2024 with a history of a fall requiring rehabilitation, was inaccurately assessed regarding the use of bed rails. The MDS assessment dated 9/26/24 indicated that bed rails were not used, despite physician orders from 9/16/24 specifying daily use of bed rails. Observations during the survey from 11/12/24 to 11/14/24 confirmed that bed rails were in use daily, as corroborated by Nurse #4, who acknowledged the assessment error. Similarly, Resident #86, admitted in January 2022 with a cerebrovascular accident, was inaccurately assessed in the MDS dated 10/7/24, which failed to document the presence of an indwelling Foley catheter. On 11/12/24, the surveyor observed the resident with a Foley catheter, consistent with the resident's medical records and current physician orders for catheter care and monitoring. Unit Manager #3 confirmed the inaccuracy, noting that the resident had the catheter since April 2024 following a hospitalization for a Stage 2 coccyx pressure ulcer.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 992 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Braintree
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pope Nursing Home | 0.5 mi | ★★★★★ | 0 | 0 |
| John Scott House Nursing & Rehabilitation Center | 1 mi | ★★★★★ | 2 | 0 |
| Regalcare At Quincy | 1.9 mi | ★★★★★ | 0 | 0 |
| Alliance Health At Braintree | 2.2 mi | ★★★★★ | 0 | 0 |
| South Cove Manor Nursing & Rehabilitation Center | 2.2 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Royal Braintree Nursing And Rehabilitation Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.