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🔎 Braintree Manor Healthcare

Inspection Results


Inspection Overview

Braintree Manor Healthcare has been cited for a total of 82 deficiencies since we began saving each survey.

In Massachusetts, the average facility has **46.34 deficiencies** in our database. This profile shows the longer-term view.

Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.



Understanding Deficiency Severity (A-L Scale)

The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**

Severity (Harm)Scope (Widespread?)Code Range
No Actual HarmIsolated to PatternA - C
No Actual HarmWidespreadD - F
**Actual Harm**IsolatedG
**Actual Harm**PatternH
**Actual Harm**WidespreadI
**Immediate Jeopardy**IsolatedJ
**Immediate Jeopardy**PatternK
**Immediate Jeopardy**WidespreadL


Detailed Deficiency List (Most Recent First)

Scope/Severity: J

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2024-10-22
Correction Date: 2024-10-15
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Survey Date: 2024-09-26
Correction Date: 2024-11-04
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Survey Date: 2024-09-26
Correction Date: 2024-11-04
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: B

Ensure each resident receives an accurate assessment.

Survey Date: 2024-09-26
Correction Date: 2024-11-04
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Ensure services provided by the nursing facility meet professional standards of quality.

Survey Date: 2024-09-26
Correction Date: 2024-11-04
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: F

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Survey Date: 2024-09-26
Correction Date: 2024-11-04
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Survey Date: 2024-09-26
Correction Date: 2024-11-04
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Survey Date: 2023-07-03
Correction Date: 2023-08-14
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Reasonably accommodate the needs and preferences of each resident.

Survey Date: 2023-07-03
Correction Date: 2023-08-14
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Survey Date: 2023-07-03
Correction Date: 2023-08-14
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: D

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Survey Date: 2023-07-03
Correction Date: 2023-08-14
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: D

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2023-07-03
Correction Date: 2023-08-14
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: D

Respond appropriately to all alleged violations.

Survey Date: 2023-07-03
Correction Date: 2023-08-14
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: B

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

Survey Date: 2023-07-03
Correction Date: 2023-08-14
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2023-07-03
Correction Date: 2023-08-14
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Ensure services provided by the nursing facility meet professional standards of quality.

Survey Date: 2023-07-03
Correction Date: 2023-08-14
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide activities to meet all resident's needs.

Survey Date: 2023-07-03
Correction Date: 2023-08-14
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Assist a resident in gaining access to vision and hearing services.

Survey Date: 2023-07-03
Correction Date: 2023-08-14
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2023-07-03
Correction Date: 2023-08-14
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Survey Date: 2023-07-03
Correction Date: 2023-08-14
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide safe and appropriate respiratory care for a resident when needed.

Survey Date: 2023-07-03
Correction Date: 2023-08-14
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Survey Date: 2023-07-03
Correction Date: 2023-08-14
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Survey Date: 2023-07-03
Correction Date: 2023-08-14
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Survey Date: 2023-07-03
Correction Date: 2023-08-14
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2023-07-03
Correction Date: 2023-08-14
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

Survey Date: 2023-07-03
Correction Date: 2023-08-14
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: D

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Survey Date: 2023-07-03
Correction Date: 2023-08-14
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2023-07-03
Correction Date: 2023-08-14
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: E

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Survey Date: 2023-07-03
Correction Date: 2023-08-14
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: E

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Survey Date: 2023-02-16
Correction Date: 2023-03-24
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure services provided by the nursing facility meet professional standards of quality.

Survey Date: 2023-02-16
Correction Date: 2023-03-24
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: G

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2023-02-16
Correction Date: 2023-03-24
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Survey Date: 2022-02-24
Correction Date: 2022-04-11
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: G

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Survey Date: 2022-02-24
Correction Date: 2022-04-11
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Survey Date: 2022-02-24
Correction Date: 2022-04-11
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: E

Provide bedrooms that don't allow residents to see each other when privacy is needed.

Survey Date: 2022-02-24
Correction Date: 2022-04-11
Category: Environmental Deficiencies
From Complaint: Y

Scope/Severity: D

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Survey Date: 2021-03-16
Correction Date: 2021-04-22
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: G

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2020-11-24
Correction Date: 2020-11-18
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2020-09-23
Correction Date: 2020-11-20
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2020-09-23
Correction Date: 2020-11-20
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Survey Date: 2020-09-23
Correction Date: 2020-11-20
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Give the resident's representative the ability to exercise the resident's rights.

Survey Date: 2020-02-20
Correction Date: 2020-11-11
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: F

Honor the resident's right to organize and participate in resident/family groups in the facility.

Survey Date: 2020-02-20
Correction Date: 2020-11-11
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Survey Date: 2020-02-20
Correction Date: 2020-11-11
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Keep residents' personal and medical records private and confidential.

Survey Date: 2020-02-20
Correction Date: 2020-11-11
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: F

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Survey Date: 2020-02-20
Correction Date: 2020-11-11
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Survey Date: 2020-02-20
Correction Date: 2020-11-11
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: F

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Survey Date: 2020-02-20
Correction Date: 2021-02-15
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: D

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Survey Date: 2020-02-20
Correction Date: 2021-02-15
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: D

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Survey Date: 2020-02-20
Correction Date: 2020-11-11
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: B

Ensure each resident receives an accurate assessment.

Survey Date: 2020-02-20
Correction Date: 2020-11-11
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Survey Date: 2020-02-20
Correction Date: 2020-11-11
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2020-02-20
Correction Date: 2020-11-11
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Ensure services provided by the nursing facility meet professional standards of quality.

Survey Date: 2020-02-20
Correction Date: 2021-02-15
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey Date: 2020-02-20
Correction Date: 2020-11-11
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Survey Date: 2020-02-20
Correction Date: 2020-11-11
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Survey Date: 2020-02-20
Correction Date: 2020-11-11
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2020-02-20
Correction Date: 2020-11-11
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: F

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Survey Date: 2020-02-20
Correction Date: 2020-11-11
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: F

Observe each nurse aide's job performance and give regular training.

Survey Date: 2020-02-20
Correction Date: 2020-11-11
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: D

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Survey Date: 2020-02-20
Correction Date: 2020-11-11
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Survey Date: 2020-02-20
Correction Date: 2020-11-11
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Provide or obtain dental services for each resident.

Survey Date: 2020-02-20
Correction Date: 2020-11-11
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2020-02-20
Correction Date: 2020-11-11
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: F

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Survey Date: 2020-02-20
Correction Date: 2020-11-11
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: F

Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.

Survey Date: 2020-02-20
Correction Date: 2020-11-11
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: F

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies.

Survey Date: 2020-02-20
Correction Date: 2020-11-11
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: D

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Survey Date: 2020-02-20
Correction Date: 2020-11-11
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: F

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Survey Date: 2020-02-20
Correction Date: 2021-02-15
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2020-02-20
Correction Date: 2021-02-15
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: E

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Survey Date: 2020-02-20
Correction Date: 2021-02-15
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: F

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Survey Date: 2020-02-20
Correction Date: 2020-11-11
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: D

Honor the resident's right to organize and participate in resident/family groups in the facility.

Survey Date: 2019-03-19
Correction Date: 2019-05-14
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Survey Date: 2019-03-19
Correction Date: 2019-05-14
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Assist a resident in gaining access to vision and hearing services.

Survey Date: 2019-03-19
Correction Date: 2019-05-14
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide or obtain dental services for each resident.

Survey Date: 2019-03-19
Correction Date: 2019-05-14
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2019-03-19
Correction Date: 2019-05-14
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Survey Date: 2019-03-19
Correction Date: 2019-05-14
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: E

Give notice to the resident before a room or roommate change.

Survey Date: 2017-11-24
Correction Date: 2018-01-04
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.

Survey Date: 2017-11-24
Correction Date: 2018-01-04
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: F

Store, cook, and serve food in a safe and clean way.

Survey Date: 2017-11-24
Correction Date: 2018-01-04
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Keep accurate, complete and organized clinical records on each resident that meet professional standards.

Survey Date: 2017-11-24
Correction Date: 2018-01-04
Category: Administration Deficiencies
From Complaint: N


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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**