Cycle 1
Health 2024-11-15 · Fire 2024-11-15
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
14 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Braintree, MA
Royal Braintree Nursing And Rehabilitation Center
4-star overall rating with 3-star inspections with 8 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
95 Commercial Street, Braintree, MA
(781) 848-3678
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
204
Certified beds
Average residents
178
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Royal Health Group
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.62
Registered nurse staffing
LPN hours / resident day
0.94
Licensed practical nurse staffing
Aide hours / resident day
2.13
Nurse aide staffing
Weekend hours
3.37
Weekend nurse staffing
RN turnover
40%
Annual RN turnover
Total nurse turnover
29%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.9
0.6 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
1.5
0.8 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 87.5% |
92.2%
4.7 pts worse
|
93.4%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.9% |
94.8%
0.1 pts better
|
95.5%
0.6 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.9% |
3.5%
0.4 pts worse
|
3.3%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 7.8% |
12.0%
4.2 pts better
|
11.4%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 7.4% |
5.2%
2.2 pts worse
|
5.4%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.2% |
19.2%
4 pts better
|
19.6%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 27.9% |
22.5%
5.4 pts worse
|
16.7%
11.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 15.8% |
17.7%
1.9 pts better
|
16.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.1% |
17.6%
3.5 pts better
|
14.9%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
1.0%
0.7 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 1.6% |
2.0%
0.4 pts better
|
1.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.5% |
21.7%
2.2 pts better
|
19.8%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 2.3% |
4.6%
2.3 pts better
|
5.1%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 75.7% |
77.1%
1.4 pts worse
|
81.7%
6 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.6% |
11.8%
4.2 pts better
|
12.0%
4.4 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
1.3%
0.3 pts worse
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 78.5% |
77.7%
0.8 pts better
|
79.7%
1.2 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.3% |
25.8%
7.5 pts better
|
23.9%
5.6 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-03 · Fire 2023-08-03
13 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Cycle 3
Health 2021-06-03 · Fire 2021-06-03
19 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
3 fire-safety deficiencies
Top issue: Services (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-11-15
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-02-10
E · Potential for more than minimal harm
2024-11-15
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-01-17
E · Potential for more than minimal harm
2024-11-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-01-17
E · Potential for more than minimal harm
2024-11-15
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-01-17
E · Potential for more than minimal harm
2024-11-15
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-01-17
D · Potential for more than minimal harm
2024-11-15
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2025-01-17
D · Potential for more than minimal harm
2024-11-15
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2025-01-17
D · Potential for more than minimal harm
2024-11-15
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2025-01-17
D · Potential for more than minimal harm
2024-11-15
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2025-01-17
D · Potential for more than minimal harm
2024-11-15
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-01-17
D · Potential for more than minimal harm
2024-11-15
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-01-17
D · Potential for more than minimal harm
2024-11-15
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2025-01-17
D · Potential for more than minimal harm
2024-11-15
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-01-17
C · Minimal harm
2024-11-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-01-17
F · Potential for more than minimal harm
2023-08-03
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-08-25
C · Minimal harm
2023-08-03
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-08-25
D · Potential for more than minimal harm
2021-06-03
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2021-07-02
C · Minimal harm
2021-06-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-06-15
C · Minimal harm
2021-06-03
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2021-07-02
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-02
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2026-01-09
D · Potential for more than minimal harm
2025-12-02
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2026-01-09
E · Potential for more than minimal harm
2024-11-15
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-12-12
E · Potential for more than minimal harm
2024-11-15
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2024-12-12
E · Potential for more than minimal harm
2024-11-15
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-12-12
D · Potential for more than minimal harm
2024-11-15
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-12-12
D · Potential for more than minimal harm
2024-11-15
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-12-12
B · Minimal harm
2024-11-15
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-12-12
D · Potential for more than minimal harm
2023-11-20
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-12-29
D · Potential for more than minimal harm
2023-11-20
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2023-12-29
D · Potential for more than minimal harm
2023-11-20
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2023-12-29
E · Potential for more than minimal harm
2023-08-03
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-08-25
E · Potential for more than minimal harm
2023-08-03
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-08-25
E · Potential for more than minimal harm
2023-08-03
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-08-25
E · Potential for more than minimal harm
2023-08-03
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-08-25
D · Potential for more than minimal harm
2023-08-03
F585 · Resident Rights Deficiencies
Health
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.
Corrected 2023-08-25
D · Potential for more than minimal harm
2023-08-03
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-08-25
D · Potential for more than minimal harm
2023-08-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-25
D · Potential for more than minimal harm
2023-08-03
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2023-08-25
D · Potential for more than minimal harm
2023-08-03
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-08-25
D · Potential for more than minimal harm
2023-08-03
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2023-08-25
D · Potential for more than minimal harm
2023-08-03
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-08-25
D · Potential for more than minimal harm
2023-08-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-25
B · Minimal harm
2023-08-03
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-08-25
F · Potential for more than minimal harm
2021-06-03
F680 · Quality of Life and Care Deficiencies
Health
Ensure the activities program is directed by a qualified professional.
Corrected 2021-06-04
E · Potential for more than minimal harm
2021-06-03
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2021-09-03
E · Potential for more than minimal harm
2021-06-03
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2021-09-03
E · Potential for more than minimal harm
2021-06-03
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2021-06-14
E · Potential for more than minimal harm
2021-06-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-09-03
D · Potential for more than minimal harm
2021-06-03
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2021-06-04
D · Potential for more than minimal harm
2021-06-03
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2021-06-17
D · Potential for more than minimal harm
2021-06-03
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2021-09-03
D · Potential for more than minimal harm
2021-06-03
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2021-06-04
D · Potential for more than minimal harm
2021-06-03
F693 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2021-06-07
D · Potential for more than minimal harm
2021-06-03
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2021-06-07
D · Potential for more than minimal harm
2021-06-03
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2021-06-04
D · Potential for more than minimal harm
2021-06-03
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2021-06-04
D · Potential for more than minimal harm
2021-06-03
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2021-06-07
D · Potential for more than minimal harm
2021-06-03
F849 · Administration Deficiencies
Health
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.
Corrected 2021-09-03
D · Potential for more than minimal harm
2021-06-03
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2021-06-04
Penalties and ownership
What sits behind the stars
Ownership
Mamary, James
5% Or Greater Direct Ownership Interest · Individual
Reid, Paula
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
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Pope Nursing Home
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2-star overall rating with 2-star inspections with 14 recent health deficiencies with 22 fire-safety deficiencies in the latest cycle
#2
John Scott House Nursing & Rehabilitation Center
Braintree, MA
5-star overall rating with 4-star inspections with 8 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Regalcare At Quincy
Quincy, MA
2-star overall rating with 2-star inspections with $19,421 in total fines with 17 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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