Inspection Reports for
Brigham House

Emergency call response/Food and dietary services: In January 2023 there were 31, in June 2023 there were 29, and in August 2024 there were 90 emergency call response times over the eight minutes required by the Residence policy. Menus lacked the required nutrition-standards statement.

Resident care plans: Inconsistent with documenting all requirements of Assessments and Service Plans.

Quality assurance program: Documentation of management evaluating the effectiveness of the Evidence Informed Falls Prevention Program was missing for 2023, and documentation of a set target date for follow-up action was missing for the first three quarters of 2023. One PCA staff left a Resident’s unit without observing the Resident take their 8AM dose of medication (repeat finding).

Incident reporting: The Residence filed 17 incident reports greater than 24 hours after the occurrence of the incident during the period reviewed. Documentation of a missing person drill for third shift was missing for 2023.

Staff health screening: Three personnel records were missing documentation to confirm receipt or declination of the seasonal influenza vaccine (repeat finding).

Staff training: Two personnel records were missing documentation of the required LGBTQ training. Documentation that a Disclosure of Rights and Services was received by the Resident or Representative at the first meeting was missing in five records (repeat finding).

Information given to residents: Missing Full Disclosure of Rights and Services.