BRIGHAM HEALTH AND REHABILITATION CENTER

Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

Administration Deficiencies — Deficient, Provider has date of correction, corrected October 23, 2025

Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

Environmental Deficiencies — Deficient, Provider has date of correction, corrected October 23, 2025

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

Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected October 23, 2025

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected October 23, 2025

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 23, 2025

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

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 23, 2025

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

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 23, 2025

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

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 23, 2025

Provide enough food/fluids to maintain a resident's health.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 23, 2025

Provide timely, quality laboratory services/tests to meet the needs of residents.

Administration Deficiencies — Deficient, Provider has date of correction, corrected October 24, 2024

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.

Administration Deficiencies — Deficient, Provider has date of correction, corrected October 24, 2024

Follow rules about disclosure of ownership requirements and tell the state agency about changes in ownership and/or administrative personnel.

Administration Deficiencies — Deficient, Provider has date of correction, corrected October 24, 2024

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

Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected October 24, 2024

Post nurse staffing information every day.

Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected October 24, 2024

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected September 25, 2024

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected September 25, 2024

Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected October 24, 2024

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected October 24, 2024

Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected October 24, 2024

Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected October 24, 2024

Provide special eating equipment and utensils for residents who need them and appropriate assistance.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected October 24, 2024

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

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected October 24, 2024

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

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected October 24, 2024

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.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected October 24, 2024

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.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected October 24, 2024

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.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 24, 2024

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

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 24, 2024

Provide enough food/fluids to maintain a resident's health.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 24, 2024

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 24, 2024

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

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 24, 2024

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 24, 2024

Provide care or services that was trauma informed and/or culturally competent.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 24, 2024

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 24, 2024

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

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected November 29, 2024

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

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected September 25, 2024

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected October 24, 2024

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected October 24, 2024

PASARR screening for Mental disorders or Intellectual Disabilities

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected October 24, 2024

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

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected October 24, 2024

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

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected October 24, 2024

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected October 24, 2024

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

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected October 24, 2024

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

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected October 24, 2024

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected November 29, 2024

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected August 16, 2024

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

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected October 24, 2024

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected October 24, 2024

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.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected October 24, 2024

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

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected October 24, 2024

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected October 24, 2024

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

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected September 13, 2023

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected September 13, 2023

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected September 13, 2023

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

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected March 13, 2024

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

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected September 13, 2023

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.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected September 13, 2023

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

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected September 13, 2023

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

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected September 13, 2023

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

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected September 13, 2023

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

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected September 13, 2023

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected September 13, 2023

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected September 13, 2023

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

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected September 13, 2023

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

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected September 13, 2023

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected May 1, 2024

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.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected May 1, 2024