Inspection Reports for
Brandon Community Carew Center
355 Crossgate Boulevard, Brandon, MS, 39042
Back to Facility Profile114 Reports
Inspection Report — Jun 11, 2026
Complaint Investigation
Date: Jun 11, 2026
Visit Reason
The State Agency conducted two Complaint Investigations (CI MS #3003877 and CI MS #3002148) at the facility from 6/10/26 through 6/11/26. CI MS #3003877 was related to nursing services, quality of care and neglect, and CI MS #3002148 was regarding physical environment.
Complaint Details
CI MS #3003877 was investigated related to nursing services, quality of care and neglect. CI MS #3002148 was investigated regarding physical environment. The facility was found in compliance with no deficiencies cited.
Findings
During the survey, the State Agency determined the facility was in compliance with the requirements for participation in Medicare and Medicaid and there were no deficiencies cited.
Inspection Report — Jun 11, 2026
Complaint Investigation
Date: Jun 11, 2026
Visit Reason
The State Agency conducted two Complaint Investigations (CI MS #3003877 and CI MS #3002148) at the facility from 6/10/26 through 6/11/26. CI MS #3003877 was related to nursing services, quality of care and neglect, and CI MS #3002148 was regarding physical environment.
Complaint Details
Two complaint investigations were conducted: CI MS #3003877 concerning nursing services, quality of care and neglect, and CI MS #3002148 regarding physical environment. Both complaints were investigated and no deficiencies were cited.
Findings
During the survey, the State Agency determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.
Report Facts
Complaint investigations conducted: 2
Inspection Report — Feb 5, 2026
Complaint Investigation
Date: Feb 5, 2026
Visit Reason
The State Agency conducted three Complaint Investigations (CI MS #2730856, CI MS #2719821 and CI MS #2719826) at the facility from 2/04/26 through 2/05/26. The investigations concerned dental services, quality of care, misappropriation of property, infection control, and accidents/falls.
Complaint Details
Three complaint investigations were conducted: CI MS #2730856 related to dental services, quality of care, misappropriation of property and infection control; CI MS #2719821 and CI MS #2719826 regarding accidents/falls. The facility was found in compliance with no deficiencies cited.
Findings
During the survey, the State Agency determined the facility was in compliance with the requirements for participation in Medicare and Medicaid and there were no deficiencies cited.
Report Facts
Complaint Investigations conducted: 3
Inspection Report — Feb 4, 2026
Follow-Up
Date: Feb 4, 2026
Visit Reason
The State Agency conducted a follow-up revisit at the facility on 2/04/26 related to the complaint survey that was conducted on 1/12/26.
Findings
The State Agency found the facility to be in compliance with the requirements of the Mississippi Regulations for Minimum Standards for Institutions for the Aged or Infirm and recommends the facility be placed back in compliance effective 2/03/26.
Inspection Report — Jan 12, 2026
Complaint Investigation
Date: Jan 12, 2026
Visit Reason
The inspection was conducted following a complaint investigation related to a resident fall incident involving inadequate supervision and environmental safety hazards.
Complaint Details
The investigation was substantiated. Resident #1 fell on a wet floor that lacked wet floor signage, resulting in serious injuries including facial trauma and an orbital fracture. The housekeeper responsible was disciplined and terminated.
Findings
The facility failed to ensure a safe environment free from accident hazards and adequate supervision for residents, resulting in a resident sustaining multiple lacerations and an orbital fracture after slipping on a wet floor without wet floor signage. The housekeeper responsible was disciplined and terminated for noncompliance with facility policy.
Deficiencies (1)
F 0689: The facility failed to maintain a safe environment free from accident hazards and provide adequate supervision to prevent falls, resulting in a resident sustaining multiple lacerations and an orbital fracture after slipping on a wet floor without wet floor signage.
Report Facts
Residents Affected: 4
Residents Affected: 1
Laceration size: 2
Laceration size: 0.75
Laceration size: 0.25
Sutures received: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper #1 | Housekeeper | Responsible for mopping floor without placing wet floor signs, leading to resident fall |
| Director of Nursing | Director of Nursing | Provided interview confirming details of the fall and disciplinary actions |
| Environmental Services Supervisor | Environmental Services Supervisor | Notified of fall and responsible for reminding housekeeper about wet floor signage |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Witnessed resident after fall and assisted until EMS arrived |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Assessed resident after fall and notified resident representative and EMS |
| Licensed Nursing Home Administrator | Licensed Nursing Home Administrator | Confirmed incident details and disciplinary actions during interview |
Inspection Report — Jan 12, 2026
Complaint Investigation
Date: Jan 12, 2026
Visit Reason
The State Agency conducted two Complaint Investigations (CI MS #2706882 and CI MS #2712907) at the facility on 01/12/25. CI MS #2706882 was investigated for Accidents and Quality of Care. CI MS #2712907 was investigated for Resident/Patient Rights.
Complaint Details
Two complaint investigations were conducted: CI MS #2706882 for Accidents and Quality of Care, and CI MS #2712907 for Resident/Patient Rights. Deficiency F0689 was cited related to CI MS #2706882.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements due to failure to ensure a safe environment free of accident hazards. Specifically, the facility failed to prevent a fall resulting in serious injury to Resident #1 due to wet floors without proper signage and inadequate supervision.
Deficiencies (1)
F0689 - The facility failed to ensure the resident environment remained as free as possible from accident hazards and that each resident received adequate supervision and assistance to prevent accidents, resulting in Resident #1 sustaining multiple lacerations and an orbital fracture after a fall on a wet floor without wet floor signage.
Report Facts
Deficiencies cited: 1
Complaint investigations: 2
Licensed beds: 230
Inspection Report — Dec 19, 2025
Complaint Investigation
Date: Dec 19, 2025
Visit Reason
On 12/19/25 the State Agency conducted a desk review of the information provided related to the complaint survey completed on 11/18/25. The facility confirmed it had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements of participation.
Complaint Details
Complaint survey completed on 11/18/25; the facility was found to have corrected the deficient practice and was placed back in compliance.
Findings
The State Agency is recommending that the facility be placed back in compliance effective 12/17/25. No deficiencies were cited in this desk review.
Report Facts
Deficiencies cited: 0
Inspection Report — Dec 17, 2025
Complaint Investigation
Date: Dec 17, 2025
Visit Reason
The State Agency conducted a Complaint investigation (CI MS# 2683554) regarding Resident Rights, Admissions and Transfer, Neglect, Quality of Care and Personal Property.
Complaint Details
CI MS# 2683554 regarding Resident Rights, Admissions and Transfer, Neglect, Quality of Care and Personal Property was investigated and found to be unsubstantiated as no deficiencies were cited.
Findings
The facility was found in compliance with Medicare and Medicaid requirements and no deficiencies were cited during this investigation. However, the facility remains out of compliance due to deficiencies cited on the 11/18/25 survey.
Report Facts
Complaint investigations: 1
Inspection Report — Dec 17, 2025
Complaint Investigation
Date: Dec 17, 2025
Visit Reason
The State Agency conducted a Complaint investigation (CI), MS# 2683554, at the facility from 12/16/2025 through 12/17/2025 regarding Resident Rights, Admissions and Transfer, Neglect, Quality of Care and Personal Property.
Complaint Details
Complaint investigation CI MS# 2683554 regarding Resident Rights, Admissions and Transfer, Neglect, Quality of Care and Personal Property was conducted and found no deficiencies; the complaint was not substantiated.
Findings
The facility was found in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement and no deficiencies were cited during this complaint investigation.
Inspection Report — Nov 18, 2025
Complaint Investigation
Date: Nov 18, 2025
Visit Reason
The State Agency conducted a Complaint Investigation (CI) MS #2614966 and Facility Reported Incident #2615381 at the facility on 10/2/25 related to reporting abuse in a timely manner.
Complaint Details
CI MS #2614966 involved allegations of abuse reporting delays related to Resident #1. The complaint was substantiated with deficiencies cited.
Findings
The facility failed to report allegations of abuse for one of three residents reviewed, specifically Resident #1, resulting in a deficiency cited.
Deficiencies (1)
F0609 - Reporting of Alleged Violations. The facility failed to report allegations of abuse within the required timeframe for Resident #1, delaying notification to the State Agency until several days after the incident.
Report Facts
Deficiencies cited: 1
Inspection Report — Nov 18, 2025
Complaint Investigation
Date: Nov 18, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report suspected abuse involving Resident #1.
Complaint Details
The complaint investigation was substantiated. The facility failed to report an allegation of abuse involving Resident #1 within the required two-hour timeframe. The investigation was initiated after CNA #2 notified the Director of Nursing on 9/8/25, but the State Agency was not notified until 9/12/25.
Findings
The facility failed to report allegations of abuse for Resident #1 within the required two-hour timeframe. Interviews and record reviews revealed that CNA #1 hit the resident during care, and CNA #2 did not immediately report the incident to nursing staff. The facility delayed reporting to the State Agency until several days after the incident.
Deficiencies (1)
F 0609: The facility failed to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. The abuse allegation involving Resident #1 was not reported within two hours as required.
Report Facts
Residents affected: 3
Residents affected: 1
Inspection Report — Sep 9, 2025
Complaint Investigation
Date: Sep 9, 2025
Visit Reason
The State Agency conducted Complaint Investigations (CIs), MS #2581397 and MS #2582205, at the facility on 9/9/25. MS #2581397 was investigated for resident rights and discharge planning for an allegation that the facility required residents to forfeit two months of Social Security checks upon discharge. MS #2582205 was investigated regarding an allegation that anti-rejection medications were not administered to a resident.
Complaint Details
Complaint Investigations MS #2581397 and MS #2582205 were investigated; no deficiencies were cited and the facility was found in compliance during this survey.
Findings
The survey determined the facility was in compliance with Medicare and Medicaid requirements and no deficiencies were cited during this investigation. However, the facility remains out of compliance due to deficiencies cited on the July 31, 2025 survey.
Report Facts
Complaint Investigations: 2
Inspection Report — Sep 9, 2025
Complaint Investigation
Date: Sep 9, 2025
Visit Reason
The State Agency conducted Complaint Investigations (CIs), MS #2581397 and MS #2582205, at the facility on 9/9/25. MS #2581397 was investigated for resident rights and discharge planning regarding an allegation that the facility required residents to forfeit two months of Social Security checks upon discharge. MS #2582205 was investigated regarding an allegation that anti-rejection medications were not administered to a resident.
Complaint Details
Complaint Investigations MS #2581397 and MS #2582205 were investigated; the facility was found in compliance with no deficiencies cited.
Findings
The survey determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.
Inspection Report — Jul 31, 2025
Complaint Investigation
Date: Jul 31, 2025
Visit Reason
The inspection was conducted to investigate complaints regarding failure to honor resident preferences, unsafe resident transport, dietary preference issues, and improper food handling practices at Brandon Community Care Center.
Complaint Details
The investigation was complaint-driven, focusing on Resident #216's repeated complaints about not being returned to bed after therapy, Resident #11's unsafe transport, Resident #42's unmet dietary preferences, and unsanitary food handling practices. The complaints were substantiated with observations, interviews, and record reviews.
Findings
The facility failed to honor a resident's preference to be put back to bed after therapy, resulting in pain and emotional distress. Unsafe transport practices were observed, placing a resident at risk of falling. The facility also failed to accommodate dietary preferences for a resident and did not practice proper hand hygiene in food service, risking contamination.
Deficiencies (4)
F 0561: The facility failed to ensure staff honored Resident #216's preference to be put back to bed after therapy, causing pain and emotional distress. Some CNAs delayed assistance despite multiple requests.
F 0689: The facility failed to ensure safe transfer of Resident #11, who was transported in a wooden chair without wheels, posing a fall risk. Proper wheelchair use was not followed.
F 0800: The facility failed to accommodate Resident #42's dietary preferences, repeatedly serving unwanted meals and metal silverware despite requests for alternatives and plastic utensils.
F 0812: The facility failed to practice proper hand hygiene in food service as the District Dietary Manager handled food and plates with bare hands, risking contamination.
Report Facts
Residents sampled: 35
Residents reviewed for accident hazards: 3
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | CNA | Confirmed Resident #216's preference to be laid back after therapy and acknowledged staff refusal to honor it |
| Certified Nursing Assistant #2 | CNA | Acknowledged awareness of Resident #216's preference but delayed returning resident to bed |
| Director of Nursing | DON | Acknowledged responsibility of CNAs to honor resident preferences and confirmed risk in unsafe transport |
| Administrator | Facility Administrator | Acknowledged expectations for staff to follow resident preferences and infection prevention policies |
| Dietary Manager | Dietary Manager | Confirmed dietary preferences should be honored and acknowledged failure to provide requested meals and proper silverware |
| District Dietary Manager | DDM | Observed handling food with bare hands and acknowledged lack of glove use during food service |
| Licensed Practical Nurse #1 | LPN | Confirmed proper resident transport should use wheelchair or rolling chair, not wooden chair |
| Infection Preventionist Nurse | IP Nurse | Confirmed dietary staff should wear gloves during food plating and serving to prevent contamination |
Inspection Report — Jul 31, 2025
Annual Inspection
Date: Jul 31, 2025
Visit Reason
The State Agency conducted an annual recertification survey and a complaint investigation (CI) MS #490767 at the facility from 7/28/25 through 7/31/25. The SA investigated CI MS #490767 for resident rights and environment. There were no citations related to the complaint investigations. During the annual recertification survey, the SA determined the facility was not in compliance with the requirements of participation in Medicare and Medicaid and cited F561, F689, F800 and F812.
Complaint Details
CI MS #490767 investigated for resident rights and environment; no deficiencies were cited related to the complaint.
Findings
The facility was found not in compliance with federal requirements during the annual recertification survey. Deficiencies included failure to honor resident self-determination preferences, unsafe resident transfer practices, failure to meet dietary preferences, and unsanitary food handling practices.
Deficiencies (4)
F0561 - The facility failed to ensure staff honored a resident's preference to be put back to bed after therapy, resulting in pain and emotional distress for one resident.
F0689 - The facility failed to ensure residents were transferred safely, as evidenced by a resident being transported in a wooden chair without proper stabilization, risking injury.
F0800 - The facility failed to provide a diet that met the preferences of a resident, including failure to provide requested alternate meals and appropriate utensils.
F0812 - The facility failed to practice proper food handling and glove use, as the District Dietary Manager was observed touching food and plates with bare hands, risking contamination.
Report Facts
Deficiencies cited: 4
Inspection Report — Jul 31, 2025
Annual Inspection
Date: Jul 31, 2025
Visit Reason
The State Agency conducted an annual recertification survey and a complaint investigation (CI) MS #490767 at the facility from 7/28/25 through 7/31/25. The complaint investigation was for resident rights and environment, with no citations related to the complaint. During the annual recertification survey, the facility was found not in compliance with state licensure requirements and cited M640 and M815.
Complaint Details
CI MS #490767 investigated resident rights and environment; no deficiencies were cited related to the complaint.
Findings
Two deficiencies were cited related to resident safety and food handling. The facility failed to ensure safe resident transfers, placing a resident at risk during transport, and failed to follow proper food handling and glove use procedures in the dietary department.
Deficiencies (2)
M0640 - Accidents. The facility failed to ensure residents were transferred safely, as evidenced by a resident being transported in an unsafe wooden chair without wheels, posing a fall risk.
M0815 - Safe Food Handling Procedures. The facility failed to practice proper hand hygiene and glove use in food preparation and serving, as the District Dietary Manager was observed handling food without gloves.
Report Facts
Deficiencies cited: 2
Inspection Report — Jul 31, 2025
Life Safety
Date: Jul 31, 2025
Visit Reason
The facility was surveyed for compliance with the 2012 Edition of the Life Safety Code (LSC) and Emergency Preparedness requirements.
Findings
The facility was found to be in compliance with all applicable Life Safety Code and Emergency Preparedness requirements. No deficiencies were cited during this survey.
Inspection Report — Jun 9, 2025
Complaint Investigation
Date: Jun 9, 2025
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #29087, at the facility from 6/09/25 through 06/10/25 related to residents rights and quality of care.
Complaint Details
Complaint number CI MS#29087 was investigated related to residents rights and quality of care. The SA determined the facility was in compliance with no deficiencies cited.
Findings
The facility was found in compliance with the Mississippi Regulations for Minimum Standards for Institutions for the Aged or Infirm and there were no deficiencies cited.
Report Facts
Complaint investigations: 1
Inspection Report — Jun 9, 2025
Follow-Up
Date: Jun 9, 2025
Visit Reason
On 06/09/25 the State Agency (SA) conducted an onsite revisit related to the annual survey that was completed on 03/06/25.
Findings
The information reviewed confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm. The SA is recommending that your facility be placed back in compliance effective 06/07/25.
Inspection Report — Jun 9, 2025
Follow-Up
Date: Jun 9, 2025
Visit Reason
On 06/09/25 the State Agency (SA) conducted an onsite revisit related to the complaint survey that was completed on 04/22/25. The information reviewed confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements of participation.
Findings
The SA is recommending that your facility be placed back in compliance effective 06/07/25.
Report Facts
Deficiencies cited: 0
Inspection Report — Jun 9, 2025
Follow-Up
Date: Jun 9, 2025
Visit Reason
On 06/09/25 the State Agency (SA) conducted an onsite revisit related to the complaint survey that was completed on 04/01/25. The information reviewed confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm.
Findings
The State Agency is recommending that the facility be placed back in compliance effective 06/07/25.
Inspection Report — May 12, 2025
Follow-Up
Date: May 12, 2025
Visit Reason
The State Agency conducted a follow-up revisit at the facility on 5/12/25 related to the Complaint Investigation survey conducted from 3/31/25 through 4/1/25.
Complaint Details
Complaint Investigation (CI) survey conducted from 3/31/25 through 4/1/25. The facility was found out of compliance with F656 on Complaint Investigations conducted 4/23/25 and 5/12/25.
Findings
The facility remains out of compliance with F656 related to deficient practice cited on Complaint Investigations conducted 4/23/25 and 5/12/25. The State Agency determined the facility had taken measures to correct the deficient practice related to F698 effective 4/25/25.
Deficiencies (1)
F0656 - The facility failed to develop and implement a comprehensive person-centered care plan consistent with resident rights, including measurable objectives and timeframes. The deficiency was evidenced by failure to follow care plans and physician orders related to removal of dialysis pressure dressings, as confirmed during audits and observations.
Report Facts
Deficiencies cited: 1
Inspection Report — May 12, 2025
Complaint Investigation
Date: May 12, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding Resident #5's elopement from the facility unnoticed and unsupervised on 05/01/2025, and related allegations of neglect, inadequate supervision, failure to report, and failure to investigate.
Complaint Details
The complaint investigation was triggered by Resident #5's elopement on 05/01/25 when she exited the facility unnoticed and unsupervised and was found sitting in a staff member's car in the parking lot. The facility failed to supervise adequately, report the incident timely, investigate thoroughly, and update care plans. The investigation confirmed multiple failures in care and supervision.
Findings
The facility failed to prevent Resident #5 from exiting the facility unsupervised, failed to report the incident timely to appropriate authorities, failed to conduct a thorough investigation, failed to develop and implement a comprehensive care plan for residents with wandering and exit-seeking behaviors, failed to provide adequate supervision and a secure environment to prevent elopement, and failed to provide appropriate nephrostomy tube care for Resident #6.
Deficiencies (6)
F600: The facility failed to protect residents from neglect by not ensuring adequate supervision to prevent Resident #5's elopement on 05/01/25, placing residents at risk of serious injury or death.
F609: The facility failed to timely report the allegation of neglect and elopement of Resident #5 to the State Agency as required by law.
F610: The facility failed to initiate a thorough investigation of Resident #5's elopement and neglect incident on 05/01/25.
F656: The facility failed to develop and implement a comprehensive care plan addressing wandering and exit-seeking behaviors for Resident #5 and failed to develop a care plan for Resident #6's nephrostomy tube care.
F689: The facility failed to provide adequate supervision and a secure environment to prevent the elopement of Resident #5 on 05/01/25, exposing residents to risk of harm.
F691: The facility failed to provide appropriate nephrostomy tube care for Resident #6, including dressing changes and flushing, increasing risk of infection and complications.
Report Facts
Immediate Jeopardies: 5
Residents at risk for elopement: 18
Vehicles observed: 125
Temperature: 81
Wander guard supervision duration: 72
BIMS score: 14
Distance Resident #5 able to walk with supervision: 150
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #9 | Licensed Practical Nurse | Assigned to Resident #5 on 05/01/25, documented exit seeking behaviors but did not update care plan or complete incident report. |
| CNA #9 | Certified Nursing Assistant | Found Resident #5 sitting in his car on 05/01/25 and escorted her back into the facility. |
| LPN #7 | Unit Manager | Responsible for Resident #5's unit, confirmed no care plan update or elopement drills after incident. |
| Executive Director | Notified of Resident #5's elopement, confirmed no report to State Agency initially, and participated in corrective actions. | |
| Social Services Director | Notified of Resident #5's behaviors and elopement, updated elopement binders but did not update care plan. | |
| MDS Coordinator | Responsible for care plan updates, unaware of Resident #5's elopement until 05/09/25. | |
| Former Director of Nursing | DON | Aware of Resident #5's elopement but did not participate in investigation or report. |
| Director of Nursing | DON | Confirmed failure to update care plan for Resident #5 and lack of nephrostomy tube care plan for Resident #6. |
| Medical Director | Not contacted for nephrostomy tube care orders for Resident #6, confirmed standard care expectations. | |
| LPN #5 | Licensed Practical Nurse | Cared for Resident #6, unaware of nephrostomy tube care plan or orders. |
| RN | Registered Nurse | Responsible for Resident #6's unit, confirmed no nephrostomy tube care plan or documentation. |
| Receptionist | Manned front desk on 05/01/25, familiar with Resident #5's behaviors, notified Executive Director after elopement. |
Inspection Report — May 12, 2025
Complaint Investigation
Date: May 12, 2025
Visit Reason
The State Agency conducted six Complaint Investigations (CI MS #28816, CI MS #28798, CI MS #28762, CI MS #28763, CI MS #28882, and CI MS# 28878) at the facility from 05/06/2025 through 05/12/2025. The SA investigated CI MS #28763 for Quality of Care and cited F691 and F656. The SA investigated CI MS# 28878 for elopement and cited F600, F609, F610, F656 and F689. The other four complaints were investigated with no deficiencies cited.
Complaint Details
Six complaint investigations were conducted at the facility from 05/06/2025 through 05/12/2025. Deficiencies were cited for CI MS #28763 (Quality of Care) and CI MS #28878 (elopement). The facility failed to prevent Resident #5 from eloping, failed to report and investigate the incident timely, and failed to develop appropriate care plans. Immediate Jeopardy was identified and removed after corrective actions.
Findings
The facility was found not in compliance due to failure to prevent elopement of Resident #5, failure to report and investigate the incident timely, failure to develop a comprehensive care plan for residents with wandering and exit seeking behaviors, and failure to provide appropriate nephrostomy tube care for Resident #6. Immediate Jeopardy was identified and removed after corrective actions were implemented.
Deficiencies (6)
F0600 - The facility failed to protect residents from neglect by not ensuring adequate supervision to prevent Resident #5 from exiting the facility unnoticed and unsupervised, placing residents at risk of serious injury or death.
F0609 - The facility failed to report allegations of neglect and elopement of Resident #5 to the appropriate agencies within required timeframes, and failed to complete a thorough investigation.
F0610 - The facility failed to initiate a thorough investigation of the elopement and neglect allegation involving Resident #5, and failed to prevent further potential harm during the investigation.
F0656 - The facility failed to develop and implement a comprehensive care plan for Resident #5 related to wandering and exit seeking behaviors, and failed to develop a care plan for Resident #6's nephrostomy tube management.
F0689 - The facility failed to provide adequate supervision and a secure environment to prevent the elopement of Resident #5, who exited the facility unnoticed and unsupervised, placing residents at risk of serious injury or death.
F0691 - The facility failed to provide appropriate care and services for Resident #6's nephrostomy tube, including failure to perform or document dressing changes or flushes, increasing risk of infection and complications.
Report Facts
Deficiencies cited: 6
Complaint investigations: 6
Beds licensed: 230
Residents at risk for elopement: 18
Inspection Report — May 12, 2025
Follow-Up
Date: May 12, 2025
Visit Reason
The State Agency (SA) conducted a follow-up revisit at the facility on 5/12/25 related to the Complaint Investigation (CI) survey that was conducted from 3/31/25 through 4/1/25.
Complaint Details
Complaint Investigation (CI) survey conducted from 3/31/25 through 4/1/25; the facility remains out of compliance related to deficient practices cited on CIs conducted 4/23/25 and 5/12/25.
Findings
The SA determined the facility had taken measures to correct the deficient practices, however, the facility remains out of compliance related to deficient practice cited on CIs conducted 4/23/25 and 5/12/25.
Inspection Report — Apr 23, 2025
Follow-Up
Date: Apr 23, 2025
Visit Reason
The State Agency conducted a revisit/follow-up survey from 4/22/25 through 4/23/25 at the facility for the Complaint Investigation Survey conducted on 3/06/25. The facility remains out of compliance due to deficiencies cited on the 4/01/25 and 4/22/25 surveys.
Complaint Details
Complaint Investigation (CI) Survey conducted on 3/06/25. The facility remains out of compliance due to deficiencies cited on the 4/01/25 and 4/22/25 surveys.
Findings
The facility was found to remain out of compliance with deficiencies related to developing and implementing comprehensive care plans and quality of care, specifically regarding care plans for residents with indwelling urinary catheters and showering preferences, and ensuring physician orders for Foley Catheter drainage bags.
Deficiencies (2)
F0656 - The facility failed to develop and implement comprehensive person-centered care plans that included measurable objectives and timeframes, as evidenced by inadequate care plans addressing indwelling urinary catheters and shower preferences for residents.
F0684 - The facility failed to ensure residents received treatment and care in accordance with professional standards and their comprehensive care plans, as evidenced by missing physician orders for Foley Catheter drainage bags and incomplete audits.
Report Facts
Deficiencies cited: 2
Inspection Report — Apr 23, 2025
Follow-Up
Date: Apr 23, 2025
Visit Reason
The State Agency (SA) conducted a revisit/follow-up survey, from 4/22/25 through 4/23/25, at the facility for the Complaint Investigation (CI) Survey conducted on 3/06/25.
Findings
The SA determined the facility took measures to correct these deficiencies as of 3/31/25, however, the facility remains out of compliance due to deficiencies cited on the 4/01/25 and 4/22/25 surveys.
Inspection Report — Apr 22, 2025
Complaint Investigation
Date: Apr 22, 2025
Visit Reason
The State Agency (SA) conducted a Complaint Investigation (CI), MS #28645, at the facility, from 4/21/25 through 4/22/25. MS #28645 was investigated related to assessing and monitoring a resident.
Complaint Details
CI MS#28645 was investigated related to assessing and monitoring a resident. The SA determined the facility was not in compliance and cited deficiencies.
Findings
The facility was found not in compliance and cited for failing to implement the resident's care plan interventions related to daily skin and foot assessments, resulting in untreated wounds for five days. The facility also failed to provide necessary care and respond appropriately to changes in the resident's condition, delaying treatment and placing the resident at risk for worsening wounds and infection.
Deficiencies (2)
F0656 - The facility failed to implement the care plan interventions for Resident #1 related to daily skin and foot assessments, resulting in wounds on the resident's foot remaining untreated for five days after being discovered and treated at the dialysis center.
F0684 - The facility failed to provide necessary care and respond appropriately to changes in Resident #1's condition when wounds identified and treated by the dialysis clinic on 4/16/25 were not assessed or treated by the facility until 4/21/25, causing a delay in care and risk of worsening wound condition and infection.
Report Facts
Deficiencies cited: 2
Inspection Report — Apr 22, 2025
Complaint Investigation
Date: Apr 22, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to implement a resident's care plan interventions related to daily skin and foot assessments, resulting in untreated wounds for Resident #1.
Complaint Details
The investigation was triggered by a complaint regarding failure to implement care plan interventions for Resident #1's foot wounds. The complaint was substantiated as the facility did not perform timely assessments or treatments despite notification from the dialysis center.
Findings
The facility failed to identify and address wounds on Resident #1's foot for five days after notification from the dialysis center. Staff did not complete required skin assessments or initiate timely treatment, resulting in delayed wound care and risk of worsening condition.
Deficiencies (2)
F 0656: The facility failed to implement Resident #1's care plan interventions for daily skin and foot assessments, resulting in untreated wounds for five days after discovery at the dialysis center.
F 0684: The facility failed to provide appropriate treatment and respond to changes in Resident #1's condition when wounds were identified and treated by the dialysis clinic, delaying care and risking worsening infection.
Report Facts
Wound measurement: 0.4
Wound measurement: 5
Brief Interview for Mental Status (BIMS) score: 6
Assessment Reference Date: Mar 12, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | Wound Care Nurse | Interviewed regarding failure to complete skin checks and audits on 04/16/25 |
| Wound Care Physician | Contracted Specialist | Reported first evaluation of Resident #1 on 04/22/25 |
| Director of Nursing | Director of Nursing (DON) | Acknowledged failure to implement wound care interventions and follow-up |
| Licensed Nursing Home Administrator | LNHA | Stated expectation for prompt reporting of resident condition changes |
| Registered Nurse #2 | Dialysis Nurse | Documented wounds and notified facility on 04/16/25 |
Inspection Report — Apr 1, 2025
Complaint Investigation
Date: Apr 1, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to implement a comprehensive care plan intervention related to the removal of a pressure dressing from a dialysis access site for Resident #4.
Complaint Details
The complaint investigation found substantiated failure to follow the care plan and physician orders regarding removal of pressure dressings for Resident #4. The issue was confirmed by multiple staff interviews and observations.
Findings
The facility failed to timely remove pressure dressings from a dialysis access site for Resident #4, despite physician orders and dialysis unit instructions. Multiple staff, including the Director of Nursing and Administrator, confirmed the failure to follow the care plan and physician orders, posing immediate jeopardy to resident health.
Deficiencies (2)
F 0656: The facility failed to develop and implement a complete care plan that meets all the resident's needs, including timely removal of a pressure dressing from a dialysis access site for Resident #4. Staff did not remove the dressing as ordered, resulting in immediate jeopardy to resident health.
F 0698: The facility failed to provide safe, appropriate dialysis care by not ensuring timely removal of a pressure dressing from a dialysis access site for Resident #4. This failure could lead to complications such as clotting or stenosis.
Report Facts
Resident BIMS score: 6
Resident admission date: Oct 4, 2017
Physician order date: Aug 1, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Confirmed staff failed to remove bandage and follow care plan |
| LPN #2 | Licensed Practical Nurse | Confirmed failure to follow care plan by not removing bandage |
| LPN #3 | Licensed Practical Nurse | Admitted failure to review care plan for Resident #4 |
| Administrator | Facility Administrator | Unaware of failure to remove bandages, expects staff to follow orders |
| Unit Manager | Unit Manager | Observed bandage still in place on Resident #4 |
| Dialysis Nurse | Dialysis Nurse | Educated facility staff on importance of timely bandage removal |
Inspection Report — Apr 1, 2025
Complaint Investigation
Date: Apr 1, 2025
Visit Reason
The State Agency conducted four complaint investigations (CI MS #28342, CI MS #28408, CI MS #28419 and CI MS #28455) from 03/31/2025 through 04/01/2025. The investigations included pressure sores, discharge rights, quality of care, resident left wet, food palatability, and dialysis. Deficiencies were cited related to dialysis (F656 and F698).
Complaint Details
Four complaint investigations (CI MS #28342, CI MS #28408, CI MS #28419 and CI MS #28455) were conducted. No citations were related to CI MS #28342, CI MS #28408, and CI MS #28419. Deficiencies were cited related to CI MS #28455 concerning dialysis.
Findings
The facility failed to implement a comprehensive care plan intervention related to the removal of a pressure dressing from a dialysis access site for one resident. The facility also failed to ensure timely removal of the pressure dressing from the dialysis access site, risking complications.
Deficiencies (2)
F0656 - The facility failed to implement a comprehensive care plan intervention related to the removal of a pressure dressing from a dialysis access site for one resident. Staff did not remove the dressing as ordered, despite physician orders and care plan instructions.
F0698 - The facility failed to ensure timely removal of a pressure dressing from a dialysis access site for one resident, risking complications such as clotting or stenosis. Staff were educated but failed to follow physician orders and dialysis instructions.
Report Facts
Deficiencies cited: 2
Complaint investigations: 4
Licensed beds: 230
Inspection Report — Mar 6, 2025
Routine
Date: Mar 6, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident dignity, care planning, hygiene, and physician orders at Brandon Community Care Center.
Findings
The facility failed to ensure residents were treated with dignity, specifically Resident #5's urinary catheter bag was left uncovered. Care plans were incomplete for Residents #5 and #6, resulting in missed showers and lack of catheter care. Resident #5 had no physician order for the indwelling catheter. These deficiencies indicated lapses in care planning, hygiene, and adherence to physician orders.
Deficiencies (4)
F 0550: The facility failed to honor the resident's right to dignity when Resident #5's urinary catheter bag was left uncovered with visible urine in a public area.
F 0656: The facility failed to develop and implement complete care plans for Residents #5 and #6, including lack of catheter care plan and missed showers.
F 0676: The facility failed to ensure residents did not lose the ability to perform activities of daily living by not providing necessary hygiene, bathing, and grooming care for Residents #4 and #6.
F 0684: The facility failed to provide appropriate treatment and care according to orders as Resident #5 had an indwelling catheter with no physician order.
Report Facts
Residents reviewed: 8
Urine volume in catheter bag: 80
BIMS score: 3
Shower frequency: 3
Weight limit: 500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) #1 | Unit 2 Manager | Confirmed Resident #5 had an indwelling urinary catheter upon arrival and no physician order for catheter |
| Licensed Practical Nurse (LPN) #4 | Licensed Practical Nurse | Confirmed Resident #5 did not have a cover on urine collection bag and was new to facility |
| Certified Nurse Aide (CNA) #5 | Certified Nurse Aide | Reported Resident #6 missed showers due to scheduling and staffing issues |
| Director of Nurses (DON) | Director of Nurses | Confirmed lack of catheter care plan for Resident #5 and care discrepancies for Resident #6 |
| Administrator | Facility Administrator | Confirmed expectations for resident assessment, care planning, and physician order reconciliation |
| Minimum Data Set (MDS) Nurse | MDS Nurse | Confirmed Resident #5 had an indwelling catheter and lack of care plan and physician orders |
Inspection Report — Mar 6, 2025
Complaint Investigation
Date: Mar 6, 2025
Visit Reason
On 3/04/25 through 3/06/25 the State Agency (SA) conducted Complaint Investigations (CIs) at the facility for multiple complaints including Quality of Care, Physical Environment, Misappropriation, Resident Neglect, Dietary Services, and staffing issues.
Complaint Details
Complaint Investigations CI MS#27867, CI MS#27938, CI MS#27980, and CI MS#28004 were investigated for issues including Quality of Care, Physical Environment, Misappropriation, Resident Neglect, Dietary Services, and staffing. Deficiencies were cited related to residents' rights and activities of daily living.
Findings
The facility was found not in compliance with state licensure requirements and cited for deficiencies related to residents' rights and activities of daily living. The facility failed to ensure residents were treated with dignity and provided necessary hygiene and grooming care.
Deficiencies (2)
M500 - Residents' rights were not fully protected as evidenced by Resident #5's urinary catheter bag being left uncovered with urine visible in a public area, compromising dignity.
M610 - The facility failed to provide necessary care for hygiene, bathing, and grooming for two residents, including failure to trim Resident #4's mustache and failure to provide Resident #6 scheduled showers.
Report Facts
Deficiencies cited: 2
Inspection Report — Mar 6, 2025
Complaint Investigation
Date: Mar 6, 2025
Visit Reason
On 3/04/25 through 3/06/25 the State Agency conducted four Complaint Investigations (CI MS #27867, CI MS #27938, CI MS #27980, CI MS #28004) at the facility related to Quality of Care, Physical Environment, Misappropriation, Resident Neglect, Dietary Services, and staffing.
Complaint Details
Four complaint investigations (CI MS #27867, CI MS #27938, CI MS #27980, CI MS #28004) were conducted related to Quality of Care, Physical Environment, Misappropriation, Resident Neglect, Dietary Services, and staffing. Deficiencies were cited related to these complaints and other issues.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements and cited for deficiencies related to resident rights, comprehensive care planning, activities of daily living, and quality of care.
Deficiencies (4)
F0550 - Resident Rights/Exercise of Rights. The facility failed to ensure residents were treated in a dignified manner when Resident #5's urinary catheter bag was left uncovered with urine visible in a public area.
F0656 - Develop/Implement Comprehensive Care Plan. The facility failed to develop and implement care plans for two residents, including Resident #5 who lacked a care plan addressing catheter care and Resident #6 whose shower schedule and care plan were inconsistent.
F0676 - Activities Daily Living (ADLs)/Maintain Abilities. The facility failed to provide necessary care for hygiene, bathing, and grooming for two residents, including Resident #4 whose mustache was untrimmed and Resident #6 who missed scheduled showers.
F0684 - Quality of Care. The facility failed to meet professional standards of care by not having a physician's order for Resident #5's indwelling Foley catheter.
Report Facts
Deficiencies cited: 4
Inspection Report — Jan 31, 2025
Routine
Date: Jan 31, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, housekeeping, staffing, and feeding tube management at Brandon Community Care Center.
Findings
The facility failed to maintain a safe, clean, and sanitary environment, ensure timely incontinence care for a resident, provide appropriate feeding tube care, and maintain adequate nursing staffing levels on multiple days in December 2024.
Deficiencies (4)
F 0584: The facility failed to provide a safe, functional, sanitary environment for residents, with observations of clutter, trash, pest presence, and unclean surfaces in multiple resident rooms and common areas.
F 0690: The facility failed to ensure that Resident #6 received timely assistance with toilet use and hygiene, with a monitoring gap of approximately three and a half hours.
F 0693: The facility failed to provide care consistent with physician orders for Resident #7 reliant on enteral feeding, with feeding held for over four hours instead of the ordered 30 minutes prior to meals.
F 0725: The facility failed to provide sufficient nursing staff to meet resident needs on eight days in December 2024, including late arrivals, call-ins, and pulling CNAs from resident care to laundry duties.
Report Facts
Number of resident rooms: 129
Number of housekeeping staff: 2
Number of floor technicians: 6
Number of laundry aides: 4
Number of new housekeepers hired: 6
Number of CNAs needed per day: 54
Number of licensed nurses needed per day: 26
Number of CNAs on 12/16/24: 53
Number of CNAs on 12/23/24: 51
Number of CNAs on 12/25/24: 50
Number of CNAs on 12/26/24: 53
Number of CNAs on 12/27/24: 49
Number of CNAs on 12/28/24: 50
Number of CNAs on 12/31/24: 50
Number of licensed nurses on 12/24/24: 24
Duration feeding held: 4
Number of spots observed: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #6 | Licensed Practical Nurse | Confirmed enteral feeding for Resident #7 had been turned off since 3:00 PM |
| Administrator | Interviewed regarding housekeeping, staffing, and feeding tube care expectations | |
| Assistant Administrator | Interviewed about cleanliness and pest control observations | |
| DON | Director of Nurses | Interviewed about incontinence care expectations and staffing issues |
| Housekeeping Director | Interviewed about housekeeping procedures and staffing | |
| Maintenance Director | Interviewed about air conditioner maintenance and pest control | |
| CNA #1 | Certified Nursing Assistant | Reported not providing incontinence care to Resident #6 between 1:30 PM and 4:00 PM |
| CNA #2 | Certified Nursing Assistant | Provided incontinence care to Resident #6 at approximately 4:00 PM |
| CNA #3 | Certified Nursing Assistant | Assigned to Resident #6 until 1:30 PM, left for the day then care was missed |
| LPN #8 | Licensed Practical Nurse | Confirmed CNA #3's assignment and lack of monitoring for Resident #6 |
| Primary Healthcare Provider | Medical Director | Confirmed enteral feeding orders for Resident #7 |
| Staff Development Director | Interviewed about staffing challenges and use of Facility Assessment Tool | |
| Housekeeping Supervisor | Reported CNAs pulled from resident care to work in laundry due to staffing |
Inspection Report — Jan 31, 2025
Complaint Investigation
Date: Jan 31, 2025
Visit Reason
The State Agency conducted Complaint Investigations at the facility from 01/28/2025 through 01/31/2025 for multiple complaints including residents not groomed, roaches in facility, facility not clean, offensive odors, admission/transfer/discharge rights, quality of care, staffing, resident safety, neglect, no hot water, cold food, medications, and inappropriate feeding assistance.
Complaint Details
Complaint investigations CI MS #27305, #27401, #27428, #27463, and #27815 were substantiated with deficiencies cited for issues including grooming, cleanliness, odors, staffing, resident safety, neglect, hot water, food temperature, medications, and feeding assistance. CI MS #27400 was investigated with no deficiencies cited.
Findings
The facility was found not in compliance with Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements. Deficiencies were cited related to staffing shortages, inadequate incontinence care, improper feeding tube management, pest infestation, and poor housekeeping.
Deficiencies (5)
M225 - Staffing. The facility failed to ensure sufficient nursing staff to meet resident needs on eight of sixteen days reviewed in December 2024, resulting in inadequate care such as residents not being assisted with incontinence or showers.
M620 - Urinary incontinence. The facility failed to provide timely incontinence care to Resident #6, who was left wet for over three and a half hours without monitoring or assistance.
M655 - Special needs. The facility failed to provide enteral feeding according to physician orders for Resident #7, with the feeding pump turned off for over four hours, potentially affecting nutrition and hydration.
M970 - Control of insects, rodents, etc. The facility failed to maintain a pest-free environment, with roaches observed in Resident #8's room and no pest control policy in place.
M1010 - Housekeeping Facilities and Services. The facility failed to maintain a safe, functional, and sanitary environment for multiple residents, with dirty rooms, pest infestation, clutter, and poor housekeeping practices observed.
Report Facts
Deficiencies cited: 5
Inspection Report — Dec 5, 2024
Complaint Investigation
Date: Dec 5, 2024
Visit Reason
The State Agency conducted a Complaint Investigation (CI MS #27006) related to neglect and quality of care related to medications.
Complaint Details
Complaint number CI MS #27006 was investigated related to neglect and quality of care related to medications. The facility was found in compliance and no deficiencies were cited.
Findings
The facility was found in compliance with Medicare and Medicaid requirements and no deficiencies were cited.
Report Facts
Complaint investigations: 1
Inspection Report — Dec 5, 2024
Complaint Investigation
Date: Dec 5, 2024
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #27006 at the facility on 12/05/24 related to neglect and quality of care related to medications.
Complaint Details
CI MS#27006 was investigated related to neglect and quality of care related to medications. The SA determined the facility was in compliance with no deficiencies cited.
Findings
The facility was found in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.
Inspection Report — Oct 17, 2024
Complaint Investigation
Date: Oct 17, 2024
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #26479, related to neglect and quality of care/treatment for a resident left soiled for an extended period.
Complaint Details
CI MS#26479 was investigated related to neglect and quality of care/treatment for a resident left soiled for an extended period. The complaint was not substantiated as no deficiencies were cited.
Findings
The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm, and no deficiencies were cited.
Inspection Report — Oct 17, 2024
Complaint Investigation
Date: Oct 17, 2024
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #26479, related to neglect and quality of care/treatment for a resident left soiled for an extended period.
Complaint Details
CI MS#26479 was investigated related to neglect and quality of care/treatment for a resident left soiled for an extended period. The complaint was not substantiated as no deficiencies were cited.
Findings
The survey determined the facility was in compliance with Medicare and Medicaid requirements and no deficiencies were cited.
Report Facts
Complaint investigations: 1
Inspection Report — Aug 28, 2024
Complaint Investigation
Date: Aug 28, 2024
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #26047, CI MS#26130, CI MS#26158, and CI MS#26201 at the facility from 8/26/24 through 8/28/24. The investigations covered Resident Neglect related to medications, Quality of Care/Treatment related to resident over sedation, injury of unknown origin, inappropriate feeding assistance/weight loss, water not offered, physical environment issues related to facility cleanliness, resident rights violations including verbal abuse, and quality of care related to client services not performed per care plan or physician's instructions.
Complaint Details
Complaint Investigation MS #26047, MS#26130, MS#26158, and MS#26201 were conducted for allegations including Resident Neglect, Quality of Care/Treatment issues, Injury of Unknown Origin, Physical Environment concerns, Resident Rights violations, and Verbal Abuse. The facility was found in compliance with no deficiencies cited.
Findings
During the survey, the State Agency determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.
Inspection Report — Jul 30, 2024
Date: Jul 30, 2024
Visit Reason
On 07/30/24 the State Agency conducted a desk review of information related to the complaint survey completed on 06/12/24.
Complaint Details
Complaint survey completed on 06/12/24; the facility was found in compliance and no deficiencies were cited.
Findings
The facility was found to be in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm. The State Agency recommended the facility be placed back in compliance effective 07/25/24.
Inspection Report — Jul 30, 2024
Complaint Investigation
Date: Jul 30, 2024
Visit Reason
On 07/30/24 the State Agency conducted a desk review of the information provided related to the complaint survey completed on 06/12/24. The facility confirmed measures were put in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements.
Complaint Details
Complaint CI MS#26995 was reviewed via desk review; the facility was found in compliance with no deficiencies cited.
Findings
The State Agency found the facility in compliance and is recommending the facility be placed back in compliance effective 07/25/24. No deficiencies were cited in this document.
Report Facts
Deficiencies cited: 0
Inspection Report — Jul 18, 2024
Complaint Investigation
Date: Jul 18, 2024
Visit Reason
The State Agency conducted four complaint investigations (CI MS #25698, CI MS #25708, CI MS #25618 and CI MS #25742) at the facility from 7/15/24 through 7/18/24 regarding incontinent care, dignity, cleanliness, resident left wet, safety, assessment, offensive odors, tube feeding positioning, flies, nursing care and therapy.
Complaint Details
Four complaint investigations (CI MS #25698, CI MS #25708, CI MS #25618, CI MS #25742) were conducted regarding multiple care and environment issues. The facility was found in compliance with no deficiencies cited during this survey.
Findings
During the survey, the State Agency determined the facility was in compliance with Medicare and Medicaid requirements and no deficiencies were cited. However, the facility remains out of compliance due to deficiencies cited on the 6/12/2024 survey.
Report Facts
Complaint investigations conducted: 4
Inspection Report — Jul 18, 2024
Complaint Investigation
Date: Jul 18, 2024
Visit Reason
The State Agency conducted four Complaint Investigations (CI MS #25698, CI MS #25708, CI MS #25618 and CI MS #25742) at the facility from 7/15/24 through 7/18/24. The investigations covered incontinent care, dignity, cleanliness, resident left wet, safety related to falls, resident assessment, offensive odors, tube feeding positioning, physical environment related to flies, nursing care and therapy.
Complaint Details
Four complaint investigations were conducted: CI MS #25698 (incontinent care, dignity, cleanliness), CI MS #25708 (resident left wet, falls safety, assessment), CI MS #25618 (offensive odors, tube feeding positioning, flies), and CI MS #25742 (nursing care and therapy). The facility was found in compliance with no deficiencies cited.
Findings
The State Agency determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited during this survey.
Report Facts
Complaint Investigations conducted: 4
Inspection Report — Jun 12, 2024
Complaint Investigation
Date: Jun 12, 2024
Visit Reason
The State Agency conducted Complaint Investigations (CIs), MS #25033, CI MS #25409, and CI MS #25439 at the facility from 6/11/24 through 6/12/24. CI MS #25033 was investigated related to resident neglect concerning pressure ulcers, quality of care/treatment concerning call bells not answered in a timely manner, resident left soiled for extended periods, and physical environment. CI MS #25409 was investigated related to resident neglect and quality of care/treatment concerning staffing. CI MS #25439 was investigated related to discharge planning.
Complaint Details
Complaint Investigations MS #25033, #25409, and #25439 were conducted. Deficiencies were cited only for CI MS #25033 related to resident neglect concerning pressure ulcers, call bells not answered timely, residents left soiled, and physical environment. No citations were issued for CI MS #25409 and CI MS #25439.
Findings
The facility was found not in compliance with Minimum Standards for Institutions for the Aged or Infirm related to CI MS #25033. Deficiencies were cited for failure to maintain a safe, clean, homelike environment in shower rooms and resident bedrooms, and failure to address malodorous conditions in resident rooms. No citations were related to CI MS #25409 and CI MS #25439.
Deficiencies (2)
M1015 - The facility failed to ensure a safe, clean homelike environment for one of three shower rooms observed, specifically the Back Hall Shower Room floor was dirty with brown stains that had not been cleaned.
M1020 - The facility failed to ensure a safe, clean homelike environment for two of six residents' rooms (Resident #3 and Resident #4). Resident #3's room was dirty with trash, dust, and stained floors and windows. Resident #4's room had a strong urine odor and the mattress was replaced during the survey.
Report Facts
Deficiencies cited: 2
Inspection Report — Jun 12, 2024
Complaint Investigation
Date: Jun 12, 2024
Visit Reason
The State Agency conducted Complaint Investigations (CIs), MS #25033, CI MS #25409, and CI MS #25439 at the facility from 6/11/24 through 6/12/24. CI MS #25033 was investigated related to resident neglect concerning pressure ulcers, quality of care/treatment concerning call bells not answered in a timely manner, resident left soiled for extended periods, and physical environment and F584 was cited. CI MS #25409 was investigated related to resident neglect and quality of care/treatment concerning staffing. CI MS #25439 was investigated related to discharge planning. There were no citations related to CI MS #25409 or CI MS #25439.
Complaint Details
Complaint Investigations MS #25033, MS #25409, and MS #25439 were conducted. MS #25033 was substantiated with deficiencies cited including F0584 related to resident neglect and physical environment. MS #25409 and MS #25439 had no citations.
Findings
F0584 was cited for failure to ensure a safe, clean, homelike environment in two residents' rooms, one shower room, and one hallway. Observations included dirty floors, dusty windows and shoes, strong urine odor, unclean shower room floor, and dusty decorative items and hand sanitizer dispensers in the hallway.
Deficiencies (1)
F0584 - Safe/clean/homelike environment. The facility failed to ensure a safe, clean homelike environment for two residents' rooms, one shower room, and one hallway, with issues including dirty floors, dust accumulation, strong urine odor, and unclean shower room floors.
Report Facts
Deficiencies cited: 1
Inspection Report — Jun 12, 2024
Routine
Date: Jun 12, 2024
Visit Reason
The inspection was conducted to assess compliance with facility housekeeping policies and to ensure a safe, clean, and homelike environment for residents.
Findings
The facility failed to maintain cleanliness in residents' rooms, shower rooms, and hallways, including dirty floors, dusty windows and surfaces, strong urine odors, and unclean shower room floors. Staffing challenges in housekeeping were noted as contributing factors.
Deficiencies (1)
F 0584: The facility failed to ensure a safe, clean, and homelike environment in two residents' rooms, one shower room, and one hallway, with issues including dirty floors, dusty windowsills, trash, and strong urine odors.
Report Facts
Residents affected: 2
Shower rooms affected: 1
Hallways affected: 1
Housekeeper assigned rooms: 30
Quarter to half dollar brown stains: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeping Supervisor | Confirmed housekeeping duties and staffing challenges. | |
| Housekeeper | Reported not cleaning shower room floor on 6/11/24 and 6/12/24. | |
| Certified Nursing Assistant (CNA) #1 | Confirmed odor of urine in Resident #4's room. | |
| Registered Nurse (RN) #1 | Confirmed strong urine odor inside and outside Resident #4's room. | |
| Administrator | Confirmed strong urine odor and housekeeping staffing challenges. |
Inspection Report — May 3, 2024
Follow-Up
Date: May 3, 2024
Visit Reason
The State Agency conducted a follow-up revisit at the facility on 5/03/24 related to an annual survey with three complaint investigations (CI MS#24348, MS#24323 and MS#24300) that was conducted from 3/11/24 through 3/15/24.
Complaint Details
Three complaint investigations (CI MS#24348, MS#24323 and MS#24300) were reviewed during the follow-up revisit. The facility was found in compliance with no deficiencies cited.
Findings
The State Agency found the facility to be in compliance with the requirements of participation in Medicare and Medicaid and recommends the facility be placed back in compliance effective 4/29/24.
Report Facts
Complaint investigations reviewed: 3
Inspection Report — May 3, 2024
Follow-Up
Date: May 3, 2024
Visit Reason
The State Agency conducted a follow-up revisit at the facility on 5/03/24 related to an annual survey with three complaint investigations (CI MS#24348, MS#24323 and MS#24300) that was conducted from 3/11/24 through 3/15/24.
Complaint Details
The follow-up revisit was related to three complaint investigations (CI MS#24348, MS#24323 and MS#24300). The State Agency determined the facility was in compliance and no deficiencies were cited.
Findings
The State Agency determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement and recommends the facility be placed back in compliance effective 4/29/24.
Report Facts
Complaint investigations: 3
Inspection Report — May 2, 2024
Complaint Investigation
Date: May 2, 2024
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #24710 and MS #24867, at the facility from 5/01/24 through 5/02/24. MS #24710 was investigated related to Resident Rights. MS #24867 was investigated regarding Quality of Care related to No Pressure Sore Precautions Taken, Care/Services not received per Physician Instructions and Resident Not Groomed Adequately.
Complaint Details
Complaint Investigation MS #24710 and MS #24867 involved Resident Rights and Quality of Care issues including pressure sore precautions, care per physician instructions, and grooming. No deficiencies were cited during this investigation.
Findings
No deficiencies were cited during this survey. The facility remains out of compliance with the Minimum Standards for Institutions for the Aged or Infirm due to deficiencies cited on the 03/15/24 survey.
Inspection Report — May 2, 2024
Complaint Investigation
Date: May 2, 2024
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #24710 and MS #24867, at the facility from 5/01/24 through 5/02/24. MS #24710 was investigated related to Resident Rights. MS #24867 was investigated regarding Quality of Care related to No Pressure Sore Precautions Taken, Care/Services not received per Physician Instructions and Resident Not Groomed Adequately.
Complaint Details
Complaint Investigation MS #24710 related to Resident Rights and MS #24867 regarding Quality of Care involving no pressure sore precautions, care/services not received per physician instructions, and resident not groomed adequately. No deficiencies were cited during this survey.
Findings
No deficiencies were cited during this complaint investigation survey. The facility remains out of compliance due to deficiencies cited on the 03/15/24 survey.
Report Facts
Deficiencies cited: 0
Inspection Report — Mar 28, 2024
Complaint Investigation
Date: Mar 28, 2024
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #24574, at the facility on 3/28/24 related to Resident Abuse.
Complaint Details
Complaint Investigation CI MS#24574 was related to Resident Abuse and was investigated. The facility was found in compliance with no deficiencies cited.
Findings
The facility was found in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. No deficiencies were cited during this investigation.
Inspection Report — Mar 28, 2024
Complaint Investigation
Date: Mar 28, 2024
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #24574 at the facility on 3/28/24 related to Resident Abuse.
Complaint Details
CI MS#24574 was investigated related to Resident Abuse. The SA determined the facility was in compliance and no deficiencies were cited.
Findings
The facility was found in compliance with Medicare and Medicaid requirements and no deficiencies were cited during this complaint investigation. However, the facility remains out of compliance due to deficiencies cited on the 3/15/2024 survey.
Report Facts
Complaint investigations: 1
Inspection Report — Mar 15, 2024
Annual Inspection
Date: Mar 15, 2024
Visit Reason
The State Agency (SA) conducted an annual recertification survey and three (3) Complaint Investigations (CI MS #24348, CI MS #24323, and CI #24300) from 3/11/24 to 3/15/24. During the survey, the SA determined that the facility was not in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements.
Complaint Details
Three complaint investigations were conducted: CI MS #24348 for loss of personal items and incontinent care with deficiency cited (M620); CI MS #24323 related to resident assessment and CI #24300 related to staffing and following physician orders with no citations.
Findings
The facility was found not in compliance with state licensure requirements during the annual recertification survey and complaint investigations. Deficiencies were cited related to residents' rights, bedroom conditions, linen availability, safe food handling, and food preparation.
Deficiencies (4)
M500 - Residents' rights. The facility failed to ensure residents who smoke were allowed to exercise their right to smoke during designated smoking times for two of 38 residents who smoke.
M545 - Bedrooms. The facility failed to maintain a clean, homelike environment and ensure clean linen was available for two of 35 sampled residents, resulting in residents being forced to sit in soiled briefs or without clean sheets.
M815 - Safe food handling procedures. The facility failed to ensure foods were stored safely in the walk-in refrigerator and freezer, with unlabeled and undated food items and boxes stored on the floor.
M855 - Food preparation. The facility failed to serve food in a manner that was appealing and palatable for two of 35 sampled residents, with complaints of bland and unappetizing food.
Report Facts
Deficiencies cited: 4
Complaint investigations: 3
Inspection Report — Mar 15, 2024
Annual Inspection
Date: Mar 15, 2024
Visit Reason
The State Agency (SA) conducted an annual recertification survey and three (3) Complaint Investigations (CI MS #24348, CI MS #24323, and CI #24300) from 3/11/24 to 3/15/24. During the survey, the SA determined that the facility was not in compliance with the requirements of participation in Medicare and Medicaid.
Complaint Details
The SA investigated CI MS #24348 for loss of personal items and incontinent care and cited F585 and F690. The SA investigated CI MS #24323 related to resident assessment and CI MS #24300 related to staffing and following physician orders, with no citations related to these complaints.
Findings
The survey found deficiencies in resident self-determination, notification of changes, safe/clean environment, grievance resolution, incontinent care, medication error rates, food palatability, and food safety. The facility failed to ensure timely incontinent care, proper medication administration, and adequate food storage and labeling.
Deficiencies (8)
F0561 - The facility failed to ensure residents who smoke were allowed to exercise their right to smoke during designated smoking times for two residents.
F0580 - The facility failed to notify the attending physician of repeated medication refusals for one resident.
F0584 - The facility failed to maintain a clean, homelike environment by not ensuring clean linen was available for two residents.
F0585 - The facility failed to resolve a resident's grievance related to activities of daily living care and showers for one resident.
F0690 - The facility failed to ensure timely incontinent care and prevent residents from being left soiled for extended periods for one resident.
F0759 - The facility failed to maintain less than a 5% medication error rate, with four medication errors out of 33 administered.
F0804 - The facility failed to serve food in a manner that was appealing and palatable for two residents.
F0812 - The facility failed to ensure foods were stored safely in the walk-in refrigerator and freezer, with unlabeled food and food stored on the floor.
Report Facts
Deficiencies cited: 9
Inspection Report — Mar 15, 2024
Routine
Date: Mar 15, 2024
Visit Reason
Routine inspection of Brandon Community Care Center to assess compliance with resident rights, medication administration, environment cleanliness, grievance resolution, incontinent care, medication error rates, food quality, and food safety.
Findings
The facility failed to ensure residents' rights to smoke breaks, timely medication administration, clean linens, grievance resolution, timely incontinent care, and medication error rates below 5%. Food served was bland and unappealing, and food storage practices did not meet safety standards.
Deficiencies (8)
F 0561: Facility failed to ensure residents who smoke were allowed to exercise their right to smoke during designated times for 2 of 38 residents.
F 0580: Facility failed to notify attending physician of repeated medication refusals for 1 of 5 residents reviewed for medications.
F 0584: Facility failed to maintain a clean, homelike environment by not ensuring clean linen was available for 2 of 35 residents.
F 0585: Facility failed to resolve a resident's grievance related to ADL care and showers for 1 of 35 residents.
F 0690: Facility failed to ensure residents were not left soiled for extended periods and received timely incontinent care for 1 of 4 dependent residents.
F 0759: Facility failed to maintain medication error rates below 5%, with 4 of 33 medications administered incorrectly.
F 0804: Facility failed to serve food in a manner that was appealing and palatable for 2 of 35 residents.
F 0812: Facility failed to ensure foods were stored safely in the walk-in refrigerator and freezer, with unlabeled foods and food stored on the floor.
Report Facts
Medication error rate: 12.12
Medication refusals: 8
Medication refusals: 10
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Practitioner #2 | Nurse Practitioner | Interviewed regarding medication refusals of Resident #159 |
| Director of Nursing | Director of Nursing | Interviewed regarding smoking breaks, medication refusals, and medication administration |
| Administrator | Administrator | Interviewed regarding facility acclimation and staff expectations |
| Pharmacy Consultant | Pharmacy Consultant | Interviewed regarding medication administration and review |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding grievance resolution and resident care |
| Registered Nurse #2 | Registered Nurse | Interviewed regarding linen availability and resident showers |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Observed administering medications via PEG tube |
| Registered Dietician #2 | Registered Dietician | Interviewed regarding food quality and kitchen observations |
Inspection Report — Mar 15, 2024
Complaint Investigation
Date: Mar 15, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding resident rights to smoke during scheduled breaks, unresolved grievances related to activities of daily living and shower care, and appropriate incontinent care for dependent residents.
Complaint Details
The investigation was complaint-driven based on reports from residents and family members about smoking rights violations, unresolved grievances regarding shower care, and inadequate incontinent care. Substantiation status is not explicitly stated.
Findings
The facility failed to ensure residents who smoke were allowed to exercise their right to smoke during designated times, failed to resolve a resident's grievance about inconsistent shower care, and failed to provide timely incontinent care resulting in residents being left soiled for extended periods.
Deficiencies (3)
F 0561: The facility failed to ensure residents who smoke were allowed to exercise their right to smoke during designated smoking times for two of 38 residents who smoke.
F 0585: The facility failed to resolve a resident's grievance related to activities of daily living and shower care for one of 35 sampled residents reviewed for ADLs.
F 0690: The facility failed to ensure residents were not left soiled for extended periods and received incontinent care timely for one of four dependent residents reviewed.
Report Facts
Residents who smoke: 38
Residents affected by smoking rights deficiency: 2
Residents sampled for ADLs: 35
Residents affected by grievance deficiency: 1
Dependent residents reviewed for incontinent care: 4
Residents affected by incontinent care deficiency: 1
BIMS score: 15
BIMS score: 13
BIMS score: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding responsibility for assigning CNAs for smoke breaks and awareness of negative impact on residents | |
| Administrator | Interviewed about staff expectations to provide residents' preferences; new to facility | |
| Certified Nurse Aide (CNA) #1 | Interviewed about residents ready for smoke breaks and agency work with Resident #167 | |
| Certified Nurse Aide (CNA) #3 | Interviewed about shower schedules and resident complaints | |
| Social Service (SS) #1 | Interviewed about grievance filing and resident care complaints | |
| Assistant Director of Nursing (ADON) | Interviewed about follow-up with resident's daughter and awareness of care issues | |
| Registered Nurse (RN) #2 | Interviewed about shower refusals and nurse notification procedures | |
| Licensed Practical Nurse (LPN) #8 | Interviewed about rounds and expectations for CNA care |
Inspection Report — Mar 12, 2024
Life Safety
Date: Mar 12, 2024
Visit Reason
The facility was surveyed for compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
The facility was found to meet the applicable provisions of the 2012 Edition of the Life Safety Code. There were no Life Safety Code deficiencies cited during this survey.
Inspection Report — Feb 23, 2024
Complaint Investigation
Date: Feb 23, 2024
Visit Reason
The State Agency conducted a desk review of information related to the complaint survey completed on 01/18/24 to confirm corrective measures and compliance.
Complaint Details
CI MS#26995 - The complaint survey was investigated and the facility was found to be in compliance with no deficiencies cited.
Findings
The facility was found to have implemented corrective measures and was placed back in compliance effective 02/22/24.
Report Facts
Deficiencies cited: 0
Inspection Report — Feb 14, 2024
Complaint Investigation
Date: Feb 14, 2024
Visit Reason
The State Agency conducted three Complaint Investigations (CI MS #24073, CI MS #24009 and CI MS #24044) at the facility from 2/13/24 through 2/14/24. CI MS #24073 was investigated for Quality of Care/Treatment related to resident not turned/repositioned adequately and other. CI MS #24009 and CI MS #24044 were investigated for Resident Neglect.
Complaint Details
Three complaint investigations were conducted: CI MS #24073 for Quality of Care/Treatment and CI MS #24009 and CI MS #24044 for Resident Neglect. The complaints were investigated and no deficiencies were cited; the facility was found in compliance.
Findings
During the survey, the State Agency determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.
Report Facts
Complaint Investigations conducted: 3
Inspection Report — Feb 14, 2024
Complaint Investigation
Date: Feb 14, 2024
Visit Reason
The State Agency conducted three Complaint Investigations (CI MS #24073, CI MS #24009 and CI MS #24044) at the facility from 2/13/24 through 2/14/24. CI MS #24073 was investigated for Quality of Care/Treatment related to resident not turned/repositioned adequately and other. CI MS #24009 and CI MS #24044 were investigated for Resident Neglect.
Complaint Details
Three complaint investigations (CI MS #24073, CI MS #24009, and CI MS #24044) were conducted. The facility was found in compliance with no deficiencies cited for these complaints.
Findings
The survey determined the facility was in compliance with Medicare and Medicaid requirements and no deficiencies were cited during this investigation. However, the facility remains out of compliance due to deficiencies cited on the 1/18/2024 survey.
Report Facts
Complaint Investigations: 3
Inspection Report — Jan 18, 2024
Complaint Investigation
Date: Jan 18, 2024
Visit Reason
The inspection was conducted following complaints regarding the facility's failure to properly empty and care for urinary drainage bags for Resident #2, specifically concerns about nephrostomy and catheter bag care.
Complaint Details
The complaint was substantiated. Resident #2 and her family reported multiple occasions where the nephrostomy drainage bag was not emptied as required, leading to overfilling and potential health risks. The facility acknowledged the issue and discussed corrective strategies during meetings.
Findings
The facility failed to ensure appropriate care and timely emptying of Resident #2's nephrostomy drainage bag, which was found overfilled multiple times, risking urinary tract infections. Interviews and observations confirmed lapses in monitoring and emptying the bags according to physician instructions.
Deficiencies (1)
F 0690: The facility failed to provide appropriate care for residents with urinary drainage tubes, as Resident #2's nephrostomy drainage bag was repeatedly left overfilled, contrary to physician and facility policy instructions.
Report Facts
Urine volume measured: 700
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Emptied Resident #2's nephrostomy drainage bag and confirmed last emptying time. | |
| Resident #2's Nurse Practitioner (NP) | Reported concerns about nursing staff not emptying urine collection bags according to physician instructions. | |
| Resident #2's Urologist | Provided medical instructions for nephrostomy care and urine bag emptying frequency. | |
| Resident #2's Unit Manager | Reported that urine monitoring and bag emptying was assigned to the nurse each shift. | |
| Administrator, Director of Nurses (DON), and Vice President (VP) of Operations | Acknowledged the facility lacked a separate policy for nephrostomy care and drainage bag emptying. |
Inspection Report — Jan 18, 2024
Complaint Investigation
Date: Jan 18, 2024
Visit Reason
The State Agency conducted five complaint investigations (CI MS #23896, CI MS #23828, CI MS #23714, CI MS #23872, and CI MS #23874) from 1/11/24 through 1/18/24. CI MS #23896, #23828, and #23714 had no deficiencies cited. Deficiencies were cited related to CI MS #23874 for Quality of Care for care/services not received per physician instructions and CI MS #23872 for Resident Neglect related to resident assessment and monitoring.
Complaint Details
Five complaint investigations were conducted (CI MS #23896, #23828, #23714, #23872, and #23874). No deficiencies were cited for CI MS #23896, #23828, and #23714. Deficiencies were cited related to CI MS #23874 for Quality of Care and CI MS #23872 for Resident Neglect. The facility was found not in compliance related to these complaints.
Findings
The facility was found not in compliance due to failure to ensure appropriate care and services for residents with indwelling urinary drainage tubes, specifically Resident #2's nephrostomy and catheter bags were not emptied as ordered, risking urinary tract infections and other complications.
Deficiencies (1)
F0690 - The facility failed to ensure a resident with indwelling urinary drainage tubes received appropriate care and services to prevent possible complications, as evidenced by Resident #2's nephrostomy drainage bag being left overfilled contrary to physician orders.
Report Facts
Deficiencies cited: 1
Inspection Report — Dec 27, 2023
Complaint Investigation
Date: Dec 27, 2023
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #23562 at the facility on 12/27/23. The complaint was related to resident abuse.
Complaint Details
Complaint MS #23562 related to resident abuse was investigated and found to be unsubstantiated; no deficiencies were cited.
Findings
The facility was found in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.
Report Facts
Complaint count: 1
Inspection Report — Dec 27, 2023
Complaint Investigation
Date: Dec 27, 2023
Visit Reason
The State Agency conducted a Complaint Investigation (CI MS #23562) at the facility on 12/27/2023 related to resident abuse.
Complaint Details
Complaint number CI MS #23562 related to resident abuse was investigated and found to be unsubstantiated with no deficiencies cited.
Findings
During the survey, the facility was found to be in compliance with the requirements of participation in Medicare and Medicaid, and there were no deficiencies cited.
Report Facts
Complaint count: 1
Inspection Report — Nov 28, 2023
Complaint Investigation
Date: Nov 28, 2023
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #22914 and MS #23076 at the facility from 11/27/23 through 11/28/23. MS #22914 was investigated for Physical Environment related to roaches/pests in the building and resident neglect. MS #23076 was investigated for Resident Neglect related to resident assessment.
Complaint Details
Complaint Investigation MS #22914 and MS #23076 were conducted regarding physical environment issues and resident neglect. The complaints were not substantiated as no deficiencies were cited.
Findings
The facility was found in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.
Inspection Report — Nov 28, 2023
Complaint Investigation
Date: Nov 28, 2023
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #22914 and MS #23076 at the facility from 11/27/23 through 11/28/23. MS #22914 was investigated for Physical Environment related to roaches/pests in the building and resident neglect. MS #23076 was investigated for Resident Neglect related to resident assessment.
Complaint Details
Complaint Investigation MS #22914 and MS #23076 were conducted for physical environment issues and resident neglect; the complaints were not substantiated as no deficiencies were cited.
Findings
The State Agency determined the facility was in compliance with the requirements for participation in Medicare and Medicaid and there were no deficiencies cited.
Report Facts
Complaints investigated: 2
Inspection Report — Sep 19, 2023
Complaint Investigation
Date: Sep 19, 2023
Visit Reason
The State Agency conducted a Complaint Investigation (CI MS #22740) related to pressure sores and responsible representative not being notified of changes.
Complaint Details
CI MS #22740 was investigated related to pressure sores and responsible representative not being notified of changes. The SA determined the facility was in compliance with no deficiencies cited.
Findings
The facility was found in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.
Inspection Report — Sep 19, 2023
Complaint Investigation
Date: Sep 19, 2023
Visit Reason
The State Agency conducted a Complaint Investigation (CI MS #22740) related to pressure sores and responsible representative not being notified of changes.
Complaint Details
CI MS #22740 was investigated related to pressure sores and responsible representative not being notified of changes. The SA determined the facility was in compliance with no deficiencies cited.
Findings
The facility was found in compliance with Medicare and Medicaid requirements and no deficiencies were cited.
Report Facts
Complaint investigations: 1
Inspection Report — Aug 15, 2023
Complaint Investigation
Date: Aug 15, 2023
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #22257, MS #22287, and MS #22312 at the facility from 8/14/23 through 8/15/23. The SA investigated MS #22257 for insufficient supplies, facility staffing, residents not turned or repositioned, and residents not changed timely, MS #22287 for resident assessment and infection control, and MS #22312 for resident elopement.
Complaint Details
Complaint Investigation MS #22257, MS #22287, and MS #22312 for insufficient supplies, staffing, resident care, infection control, and elopement; the facility was found in compliance with no deficiencies cited.
Findings
During the survey, the SA determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.
Inspection Report — Aug 15, 2023
Complaint Investigation
Date: Aug 15, 2023
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #22257, MS #22287, and MS #22312 at the facility from 8/14/23 through 8/15/23. The SA investigated MS #22257 for insufficient supplies, facility staffing, residents not turned or repositioned, and residents not changed timely, MS #22287 for resident assessment and infection control, and MS #22312 for resident elopement.
Complaint Details
Complaint Investigation MS #22257, MS #22287, and MS #22312 covering insufficient supplies, staffing, resident care, assessment, infection control, and elopement. The SA determined the facility was in compliance with no deficiencies cited.
Findings
During the survey, the SA determined the facility was in compliance with the requirements for participation in Medicare and Medicaid.
Report Facts
Complaints investigated: 3
Inspection Report — Aug 7, 2023
Routine
Date: Aug 7, 2023
Visit Reason
The facility was surveyed for compliance with COVID-19 reporting requirements as specified by CMS and CDC.
Findings
The facility failed to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day period. This failure had the potential to cause more than minimal harm to all residents.
Deficiencies (1)
F0884 - The facility failed to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a seven-day period as required by regulation.
Report Facts
Deficiencies cited: 1
Inspection Report — Jul 21, 2023
Complaint Investigation
Date: Jul 21, 2023
Visit Reason
The State Agency conducted a Complaint Investigation at the facility for three complaints, MS #21987, MS #21988, and MS #21989 from 7/20/23 through 7/21/23.
Complaint Details
The SA investigated MS #21987 for Dietary Services related to cold food, Resident Abuse, and Quality of Care related to staffing, following plan of care and physician's orders; MS #21988 for Quality of Care related to grooming and client assessments; and MS #21989 for Quality of Care related to assessment and following physician orders, Misappropriation of Resident Property and Physical Environment. No deficiencies were cited.
Findings
The facility was found in compliance with the Mississippi Regulations for Minimum Standards for Institutions for the Aged or Infirm. No deficiencies were cited.
Report Facts
Complaints investigated: 3
Inspection Report — Jul 21, 2023
Complaint Investigation
Date: Jul 21, 2023
Visit Reason
The State Agency conducted a Complaint Investigation (CI) at the facility for three complaints (CI MS #21987, CI MS #21988, and CI MS #21989) from 7/20/23 through 7/21/23.
Complaint Details
The SA investigated CI MS #21987 for Dietary Services related to cold food, Resident Abuse, and Quality of Care related to staffing, following plan of care and physician's orders; CI MS #21988 for Quality of Care related to grooming and client assessments; and CI MS #21989 for Quality of Care related to assessment and following physician orders, Misappropriation of Resident Property and Physical Environment. No deficiencies were cited.
Findings
The facility was found in compliance with Medicare and Medicaid requirements. No deficiencies were cited during the complaint investigation.
Report Facts
Complaints investigated: 3
Inspection Report — Jun 7, 2023
Complaint Investigation
Date: Jun 7, 2023
Visit Reason
On 6/06/23 through 6/07/23 the State Agency conducted a Complaint Investigation (CI) at the facility for two complaints, CI MS #21654 and CI MS #21701.
Complaint Details
The SA investigated CI MS #21654 for Quality of Care related to staffing, resident positioning and incontinent care and CI MS #21701 for Accidents related to falls and cited no deficiencies.
Findings
The State Agency determined the facility was in compliance with the Mississippi Regulations for Minimum Standards for Institutions for the Aged or Infirm and cited no deficiencies for these complaints. However, the facility remains out of compliance due to deficiencies cited on the 4/19/2023 survey.
Report Facts
Complaints investigated: 2
Inspection Report — Jun 7, 2023
Complaint Investigation
Date: Jun 7, 2023
Visit Reason
The State Agency conducted a Complaint Investigation at the facility for two complaints, CI MS #21654 and CI MS #21701, from 6/06/23 through 6/07/23.
Complaint Details
Complaint Investigation CI MS #21654 involved Quality of Care related to staffing, resident positioning, and incontinent care. Complaint Investigation CI MS #21701 involved Accidents related to falls. Both complaints were investigated and no deficiencies were cited.
Findings
The surveyor determined the facility was in compliance with Medicare and Medicaid requirements during this complaint investigation. No deficiencies were cited related to the complaints investigated.
Report Facts
Complaints investigated: 2
Inspection Report — Apr 19, 2023
Complaint Investigation
Date: Apr 19, 2023
Visit Reason
The State Agency conducted Complaint Investigations (CI) at the facility from 4/18/23 through 4/19/23. The investigations involved CI MS #21031 related to Resident Transfers, CI MS #20741 for Quality of Care related to assessment, CI MS #21030 for Quality of Care related to resident assessment and falls and Physical Environment cleanliness and pests, and CI MS #20742 for Physical Environment related to cleanliness, odor, pests, and grooming.
Complaint Details
Complaint Investigations (CI) were conducted for CI MS #21031 related to Resident Transfers, CI MS #20741 for Quality of Care related to assessment, CI MS #21030 for Quality of Care related to resident assessment and falls and Physical Environment cleanliness and pests, and CI MS #20742 for Physical Environment related to cleanliness, odor, pests, and grooming. Deficiencies were cited for CI MS #21030 and CI MS #20742. The facility was found in compliance with CI MS #21031 and CI MS #20741.
Findings
The facility was found in compliance with CI MS #21031 and CI MS #20741. Deficiencies were cited for CI MS #21030 and CI MS #20742, specifically related to inadequate ADL care for dependent residents and ineffective pest control.
Deficiencies (2)
F0677 - The facility failed to ensure that residents unable to carry out activities of daily living received necessary grooming and personal hygiene services, as evidenced by Resident #2 having long, dirty, and jagged fingernails with dark dried substance underneath and unclean feet with odor and skin issues.
F0925 - The facility failed to maintain an effective pest control program, as evidenced by the presence of roaches in Resident #3's room and bathroom despite a contract with a pest control company.
Report Facts
Deficiencies cited: 2
Inspection Report — Apr 19, 2023
Date: Apr 19, 2023
Visit Reason
The inspection was conducted to evaluate compliance with care standards related to activities of daily living assistance and pest control in the facility.
Findings
The facility failed to ensure proper grooming and personal hygiene care for one resident requiring assistance with activities of daily living. Additionally, the facility failed to maintain an effective pest control program, resulting in roach sightings in a resident's room.
Deficiencies (2)
F 0677: The facility failed to provide necessary grooming and personal hygiene care for Resident #2, who had long, dirty, and uneven fingernails with a dark substance underneath, and feet with dry skin and unpleasant odor. Licensed nurses confirmed the resident's fingernails were not cleaned or trimmed as required.
F 0925: The facility failed to maintain an effective pest control program, as evidenced by multiple observations of roaches in Resident #3's bathroom and room despite having a pest control contract.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Observed and confirmed Resident #2's fingernail and foot hygiene issues. | |
| Director of Nurses (DON) | Confirmed Resident #2's fingernail care deficiencies and pest control issues. | |
| Licensed Practical Nurse (LPN) #2 | Confirmed Resident #2's scheduled bath days and lack of proper hygiene on 4/18/23. | |
| Certified Nurse's Aide (CNA) #1 | Observed roach in Resident #3's bathroom and disposed of it. | |
| Housekeeping Supervisor | Observed and confirmed roach in Resident #3's room. | |
| Maintenance Assistant #1 | Reported pest control contract and procedures. | |
| Maintenance Assistant #2 | Accompanied pest control technician and reported pest control procedures. |
Inspection Report — Nov 3, 2022
Complaint Investigation
Date: Nov 3, 2022
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #19511 AND MS #19739 at the facility from 11/01/22 through 11/03/22.
Complaint Details
Complaint Investigation MS #19511 for Resident Abuse and MS #19739 for Quality of Care/Treatment related to Resident Safety were not substantiated and no deficiencies were cited.
Findings
The facility was found in compliance with the Mississippi Regulations for Minimum Standards for Institutions for the Aged or Infirm. No deficiencies were cited.
Report Facts
Complaints investigated: 2
Inspection Report — Nov 3, 2022
Complaint Investigation
Date: Nov 3, 2022
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #19511 AND MS #19739 at the facility from 11/01/22 through 11/03/22.
Complaint Details
Complaint MS #19511 alleged Resident Abuse and MS #19739 alleged Quality of Care/Treatment related to Resident Safety; both complaints were not substantiated and no deficiencies were cited.
Findings
The facility was found in compliance with Medicare and Medicaid requirements. No deficiencies were cited.
Report Facts
Complaints investigated: 2
Inspection Report — Jul 27, 2022
Follow-Up
Date: Jul 27, 2022
Visit Reason
The State Agency conducted a follow-up revisit at the facility on 7/27/22 related to the annual survey conducted 5/23/22 through 5/26/22. The facility remains out of compliance due to deficiencies cited on a Compliance Investigation conducted on 7/12/22.
Findings
The State Agency found the corrective actions taken by the facility have put the deficiencies cited on the Annual Survey conducted on 5/26/22 in compliance effective 6/30/22; however, the facility remains out of compliance with the Minimum Standards due to deficiencies from the Compliance Investigation on 7/12/22.
Inspection Report — Jul 26, 2022
Complaint Investigation
Date: Jul 26, 2022
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #19392, MS #19396, and MS #19408, at the facility from 7/25/22 through 7/26/22.
Complaint Details
Complaint Investigation (CI), MS #19392, MS #19396, and MS #19408 were not substantiated for dietary services, abuse, nursing services, medications not given per physician orders, environment, sexual abuse, or misappropriation of property.
Findings
The SA did not substantiate complaints MS #19392, MS #19396, and MS #19408. The facility remains out of compliance due to deficiencies cited on the 5/26/2022 survey.
Inspection Report — Jul 26, 2022
Complaint Investigation
Date: Jul 26, 2022
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #19392, MS #19396, and MS #19408, at the facility from 7/25/22 through 7/26/22.
Complaint Details
Complaint Investigation (CI), MS #19392, MS #19396, and MS #19408 were not substantiated for the allegations investigated.
Findings
The SA did not substantiate MS #19392 for dietary services, MS #19396 for dietary services, abuse, nursing services, medications not given per physician orders, and environment, and MS #19408 for sexual abuse or misappropriation of property. The facility remains out of compliance due to deficiencies cited on the 5/26/2022 survey.
Inspection Report — Jul 12, 2022
Complaint Investigation
Date: Jul 12, 2022
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #19355 and MS #19360 at the facility from 7/11/22 through 7/12/22. The SA did not substantiate MS #19360 for neglect, administration, and care not received per Physician Orders. The SA substantiated MS #19355 for Physical Environment related to failure to maintain equipment and failure to ensure cleanliness of the facility.
Complaint Details
Complaint Investigation (CI), MS #19355 substantiated for Physical Environment related to failure to maintain equipment and failure to ensure cleanliness of the facility; MS #19360 not substantiated.
Findings
The facility was found not in compliance with Mississippi Regulations for Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements, due to failure to maintain a clean, homelike environment in eight of twenty resident rooms observed. Observations included dirty air conditioner filters, rusted overbed tables, spider webs, stained walls and baseboards, and tan discoloration on poles and equipment.
Deficiencies (1)
M1020 - Resident bedrooms were not cleaned and maintained to provide a clean, homelike environment as evidenced by dirty air conditioner filters, rusted overbed tables, spider webs, stained walls and baseboards, and tan discoloration on poles and equipment in multiple rooms.
Report Facts
Deficiencies cited: 1
Inspection Report — Jul 12, 2022
Complaint Investigation
Date: Jul 12, 2022
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #19355 and MS #19360 at the facility from 7/11/22 through 7/12/22. The SA did not substantiate MS #19360 for neglect, administration, and care not received per a Physician Orders. The SA substantiated MS #19355 for Physical Environment related to failure to maintain equipment and failure to ensure cleanliness of the facility.
Complaint Details
Complaint Investigation MS #19355 was substantiated for Physical Environment related to failure to maintain equipment and failure to ensure cleanliness of the facility. Complaint MS #19360 was not substantiated.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements due to failure to provide a clean, homelike environment in eight of twenty resident rooms observed. Observations, interviews, and record reviews confirmed dirty air conditioner filters, rusted overbed tables, spider webs, stained walls, and unclean baseboards in multiple rooms.
Deficiencies (1)
F0584 - Safe/clean/comfortable/homelike environment. The facility failed to provide a clean, homelike environment for eight of twenty resident rooms observed, including dirty air conditioner filters, rusted overbed tables, spider webs, stained walls, and unclean baseboards.
Report Facts
Deficiencies cited: 1
Inspection Report — May 26, 2022
Complaint Investigation
Date: May 26, 2022
Visit Reason
The inspection was conducted based on complaints and concerns regarding resident care, including participation in care planning, resident council grievances, financial management, care plan development and implementation, significant change assessments, ADL assistance, transfer safety, catheter care, and infection control.
Complaint Details
The visit was complaint-related, triggered by multiple resident and family concerns including lack of resident participation in care planning, unresolved resident council grievances about missing laundry, improper financial management of resident funds, failure to complete required assessments, incomplete and unimplemented care plans, inadequate assistance with activities of daily living, unsafe transfer practices, improper catheter care, and infection control breaches.
Findings
The facility failed to allow a resident to participate in care planning, respond to resident council grievances about missing laundry, allow a resident to manage her financial affairs, complete a significant change MDS assessment for hospice admission, develop and implement comprehensive care plans, provide scheduled shower assistance, secure residents properly during transfers, secure catheter tubing, and maintain infection control during wound care and linen handling.
Deficiencies (9)
F 0553: The facility failed to allow Resident #30 to participate in the development and implementation of her person-centered plan of care, as there was no documentation of her participation in care planning.
F 0565: The facility failed to respond and resolve group grievances regarding missing laundry items in resident council meetings for six months.
F 0567: The facility failed to allow Resident #30 to manage her monthly income allotment, wrongfully withholding $44 monthly without her permission.
F 0637: The facility failed to submit a Significant Change in Status MDS assessment for Resident #62 upon hospice admission.
F 0656: The facility failed to develop a comprehensive care plan for Resident #119 and failed to implement care plans related to ADLs for Residents #9 and #200.
F 0677: The facility failed to provide scheduled shower assistance for Residents #129 and #9 as care planned.
F 0689: The facility failed to properly secure Resident #18 with a waist belt during transfer using a sit-to-stand lift.
F 0690: The facility failed to secure Resident #18's suprapubic catheter with a leg strap to prevent trauma.
F 0880: The facility failed to prevent contamination during wound care for Resident #119 and failed to handle soiled linen properly for Resident #18.
Report Facts
Residents reviewed for care plans: 35
Resident council meetings reviewed: 6
Residents reviewed for personal funds: 3
Residents reviewed for ADL assistance: 12
Resident #30 monthly income allotment withheld: 44
Resident #119 admission date: Admitted on 3/25/22 (date not numeric)
Resident #18 admission date: Admitted on 1/22/19 (date not numeric)
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Failed to fasten waist belt during transfer and improperly handled soiled linen |
| LPN #1 | Licensed Practical Nurse | Failed to ensure waist belt was fastened during transfer and did not place leg strap on catheter |
| Social Worker | Failed to facilitate resident participation in care planning for Resident #30 | |
| Director of Nursing | Director of Nursing | Confirmed failures in care plan development, transfer safety, catheter care, and infection control |
| Business Office Manager | Business Office Manager | Confirmed wrongful withholding of Resident #30's income allotment |
| Interim Administrator | Interim Administrator | Confirmed wrongful withholding of Resident #30's income allotment and acknowledged ongoing laundry issues |
| LPN #4 | Licensed Practical Nurse | Provided information on shower schedules and resident care |
| CNA #3 | Certified Nursing Assistant | Involved in wound care contamination incident |
Inspection Report — May 26, 2022
Annual Inspection
Date: May 26, 2022
Visit Reason
The State Agency (SA) conducted an annual recertification survey and Complaint Investigations, (CI) MS #18656, MS #18654, and MS #18646, at the facility from 5/23/22 through 5/26/22.
Complaint Details
Complaint Investigations MS #18656, MS #18654, and MS #18646 were conducted. MS #18654 and MS #18656 were not substantiated. MS #18646 was substantiated related to resident not groomed and F0677 was cited.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements. Deficiencies were cited related to resident care planning, resident group grievances, personal funds management, significant change assessments, comprehensive care plans, ADL assistance, accident hazards, catheter care, and infection control.
Deficiencies (9)
F0553 - The facility failed to allow a resident to participate in the care planning process as evidenced by no documentation of resident participation for one of 35 residents reviewed.
F0565 - The facility failed to respond and resolve group grievances in resident council for six months of meetings reviewed.
F0567 - The facility failed to allow a resident to manage her monthly income allotment as evidenced by withholding $44 monthly income without resident's consent.
F0637 - The facility failed to submit a Significant Change in Status Minimum Data Set (MDS) Assessment for a resident admitted to hospice.
F0656 - The facility failed to develop a comprehensive care plan and failed to implement care plans related to ADLs and feeding assistance for three residents reviewed.
F0677 - The facility failed to ensure ADL assistance was provided for residents dependent for showering for two residents reviewed.
F0689 - The facility failed to properly secure a resident in a sit to stand lift while being transferred from wheelchair to bed.
F0690 - The facility failed to ensure a suprapubic catheter was secured by a leg strap for one resident observed with catheter.
F0880 - The facility failed to ensure soiled linen was discarded in a manner to prevent the spread of infection and ensure a contaminated object did not come in contact with a clean area for two residents.
Report Facts
Deficiencies cited: 9
Inspection Report — May 24, 2022
Routine
Date: May 24, 2022
Visit Reason
This facility was surveyed under the Centers for Medicare Medicaid Services (CMS) COVID-19 Emergency Declaration Blanket 1135 Waivers for Health Care Provider.
Findings
The facility meets the applicable provisions of the 2012 (existing) Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA). There were no LSC deficiencies cited during this survey.
Inspection Report — May 24, 2022
Life Safety
Date: May 24, 2022
Visit Reason
This facility was surveyed under the Centers for Medicare Medicaid Services (CMS) COVID-19 Emergency Declaration Blanket 1135 Waivers for Health Care Provider. The facility must meet the applicable provisions of the 2012 (existing) Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
The facility was found to have deficiencies related to life safety code violations including obstructed exit egress due to slide bolts above 48 inches on a required exit door, hazardous areas with unsealed holes and missing ceiling tiles, and improperly installed alcohol-based hand rub dispensers above electrical switches.
Deficiencies (3)
K0211 - The facility failed to properly maintain exit egress as evidenced by slide bolts above 48 inches on the Garden Cafe Area door, obstructing exit capability. This affected one of twelve required exits.
K0221 - The facility failed to protect hazardous areas as evidenced by an unsealed large hole in the ceiling of the biohazard room near room 402, a basement door incapable of positive latching, missing ceiling tiles in the janitor supply room, and damaged ceiling in the Unit 3 soiled utility room. These conditions affected 4 of 12 smoke compartments and 80 of 217 residents.
K0325 - The facility failed to provide alcohol-based hand rub dispensers in accordance with NFPA 101 as hand sanitizer dispensers were installed above light switches in the dining area and near resident rooms 107, 206, and 229. This affected 4 of 12 smoke compartments.
Report Facts
Deficiencies cited: 3
Inspection Report — Jan 28, 2022
Complaint Investigation
Date: Jan 28, 2022
Visit Reason
The State Agency conducted a Complaint Survey at the facility from 1/26/2022 through 1/28/2022 for Complaint Investigations (CI) MS #18458 for alleged staff to resident physical abuse, CI MS #18455 for a fire in the facility caused when a resident used a cigarette lighter while wearing oxygen causing a fire with injuries of burns to the resident, CI MS #18372 for alleged neglect of a resident not being changed timely, and CI MS #18364 for alleged pressure ulcers developed in the facility.
Complaint Details
Complaint Investigations (CI) MS #18458 for alleged staff to resident physical abuse, CI MS #18455 for a fire in the facility caused when a resident used a cigarette lighter while wearing oxygen causing a fire with injuries of burns to the resident, CI MS #18372 for alleged neglect of a resident not being changed timely, and CI MS #18364 for alleged pressure ulcers developed in the facility. The SA did not substantiate MS #18458, MS #18372, and MS #18364. The SA did substantiate MS #18455 and cited F689.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements due to failure to provide adequate supervision to Resident #1, who set fire to his bed linens, mattress, oxygen equipment, and privacy curtain with a cigarette lighter, resulting in serious injury and hospitalization. The Immediate Jeopardy was removed prior to the surveyor's entrance after corrective actions were implemented.
Deficiencies (1)
F0689 - The facility failed to provide Resident #1 with the supervision required to prevent accidents and hazards, resulting in a fire that caused severe burns and hospitalization. Resident #1 set fire to his bed linens, mattress, oxygen tubing, mask, oxygen concentrator, and privacy curtain while using a cigarette lighter in his bed wearing oxygen.
Report Facts
Deficiencies cited: 1
Licensed beds: 230
Smokers: 33
Staff interviewed: 63
Inspection Report — Nov 23, 2021
Complaint Investigation
Date: Nov 23, 2021
Visit Reason
On 11/23/21 the State Agency conducted a desk review of the information provided related to the complaint survey conducted on 10/20/21. The information confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements.
Complaint Details
CI MS#26995 complaint investigation conducted on 10/20/21; the facility was found in compliance with no deficiencies cited.
Findings
The State Agency found the facility in compliance and recommended it be placed back in compliance effective 11/20/21. No deficiencies were cited in this document.
Inspection Report — Oct 20, 2021
Complaint Investigation
Date: Oct 20, 2021
Visit Reason
The State Agency conducted a complaint survey to investigate MS #17886 and MS #17999 at the facility from 10/19/21 through 10/20/21. The SA did not substantiate MS #17886 related to an allegation of inappropriate room transfer. The SA substantiated MS #17999 for the allegation related to resident's rights to visitation but was unable to substantiate the allegations of failure to provide services in accordance with physician orders, not providing Activities of Daily Living (ADL) care, misappropriation, or weight loss.
Complaint Details
Complaint MS #17999 alleged the facility was limiting resident visitation despite no COVID positive cases. The complaint was substantiated with deficiencies cited. Complaint MS #17886 alleging inappropriate room transfer was not substantiated.
Findings
The facility was found not to be in compliance with requirements for the Minimum Standards for Institutions for The Aged or Infirm and cited M490 for failing to ensure residents' right to visitation for three of six residents investigated. The facility continued to limit visitation by requiring appointments, limiting visitors to two at a time, and restricting visit length despite no COVID-19 outbreak and a vaccination rate above 80%.
Deficiencies (1)
M490 - Residents' rights. The facility failed to ensure residents' right to visitation for three of six residents investigated, limiting visits by appointment only, restricting visitor numbers and visit duration despite no COVID-19 outbreak.
Report Facts
Deficiencies cited: 1
Inspection Report — Jun 24, 2021
Complaint Investigation
Date: Jun 24, 2021
Visit Reason
The State Agency conducted four complaint surveys, CI MS #17484, CI MS# 17846, CI MS# 17358 and CI MS# 17837 at the facility from 6/23/21 to 6/24/21.
Complaint Details
Four complaint investigations were conducted (CI MS #17484, CI MS# 17846, CI MS# 17358, CI MS# 17837) and no deficiencies were cited.
Findings
The State Agency determined the facility was in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm, state licensure requirements and no deficiencies were cited.
Report Facts
Complaint surveys conducted: 4
Inspection Report — Jun 24, 2021
Complaint Investigation
Date: Jun 24, 2021
Visit Reason
The State Agency conducted four complaint investigations, CI MS #17484, CI MS# 17846, CI MS# 17358 and CI MS# 17837 at the facility from 6/23/21 to 6/24/21.
Complaint Details
Four complaint investigations were conducted: CI MS# 17484, CI MS# 17846, CI MS# 17358, and CI MS# 17837. None were substantiated due to lack of evidence of neglect, poor quality of care, infection control issues, or staffing problems.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements. None of the four complaints were substantiated due to lack of evidence of neglect or poor quality of care.
Report Facts
Complaint investigations conducted: 4
Inspection Report — Jun 21, 2021
Routine
Date: Jun 21, 2021
Visit Reason
The facility was surveyed for compliance with COVID-19 reporting requirements under §483.80(g).
Findings
The facility failed to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day period.
Deficiencies (1)
F0884 - The facility failed to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a seven-day period as required by regulation.
Report Facts
Deficiencies cited: 1
Inspection Report — Dec 28, 2020
Routine
Date: Dec 28, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 12/28/20. No new observations related to infection control were noted, but the facility remains out of compliance based on deficiencies cited during the 12/9/20 COVID-19 Focused Infection Control survey.
Findings
The survey found no new infection control deficiencies during this survey, but the facility remains out of compliance due to prior cited deficiencies from the 12/9/20 survey.
Inspection Report — Dec 28, 2020
Routine
Date: Dec 28, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency (SA) on 12/28/2020.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to E-0024(b)(6).
Inspection Report — Dec 9, 2020
Routine
Date: Dec 9, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency (SA) from 12/08/2020 through 12/09/2020.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to E-0024(b)(6).
Inspection Report — Dec 9, 2020
Routine
Date: Dec 9, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey, along with Complaint Investigation (CI) #17328, MS #17268, and MS #17313, was conducted by the State Agency from 12/08/2020 through 12/09/2020. The facility was found to be in compliance with infection control regulations and has implemented CMS and CDC recommended practices to prepare for COVID-19. CI MS#17268 and CI MS#17328 were substantiated with findings cited at F583 and F729 respectively. CI MS#17313 was not substantiated with no deficiencies cited.
Complaint Details
Complaint Investigation CI MS#17268 was substantiated with deficiencies cited at F0583. CI MS#17328 was substantiated with findings cited at F729. CI MS#17313 was not substantiated with no deficiencies cited.
Findings
F0583 - The facility failed to protect resident privacy by allowing a video of Resident #1 to be posted on social media by a Certified Nursing Assistant. The video was removed after discovery, and the responsible employee was terminated. The facility implemented staff in-service and social media audit rounds to prevent recurrence.
Deficiencies (1)
F0583 - The facility failed to ensure resident privacy when a video of Resident #1 was posted on social media by a Certified Nursing Assistant, violating confidentiality policies. The video was removed, the employee was terminated, and corrective actions including staff in-service and social media audits were implemented.
Report Facts
Deficiencies cited: 1
Inspection Report — Nov 16, 2020
Routine
Date: Nov 16, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 11/16/20. The facility was found to be in compliance with infection control regulations and has implemented the Centers for Medicare and Medicaid (CMS) and the Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Findings
The facility was found to be in compliance with infection control regulations and no deficiencies were cited.
Inspection Report — Oct 29, 2020
Routine
Date: Oct 29, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and seven Complaint Investigations, CI #17220, CI #16922, CI #16849, CI #17139, CI #16821, CI #16994, and CI #170000 were conducted by the State Agency from 10/27/20 through 10/29/20.
Complaint Details
Seven complaint investigations (CI #17220, CI #16922, CI #16849, CI #17139, CI #16821, CI #16994, and CI #170000) were conducted and none were substantiated; no deficiencies were cited.
Findings
The facility was found to be in compliance with infection control regulations and has implemented CMS and CDC recommended practices to prepare for COVID-19. The State Agency did not substantiate the complaints and cited no deficiencies.
Report Facts
Complaint investigations: 7
Inspection Report — Jul 20, 2020
Routine
Date: Jul 20, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on 7/20/2020.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).
Inspection Report — Jul 20, 2020
Routine
Date: Jul 20, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 7/20/20.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Inspection Report — Jun 25, 2020
Complaint Investigation
Date: Jun 25, 2020
Visit Reason
The State Survey Agency conducted a complaint investigation on 6/25/2020 regarding Neglect and Quality of Care related to Resident Not Groomed Adequately.
Complaint Details
CI MS #16822: Complaint investigation for Neglect and Quality of Care related to Resident Not Groomed Adequately was unsubstantiated with no deficiencies cited.
Findings
The investigation was unsubstantiated with no deficiencies cited. The facility was found in compliance with Medicare and Medicaid requirements for participation.
Report Facts
Complaints investigated: 1
Inspection Report — May 25, 2020
Routine
Date: May 25, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 5/25/20.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Deficiencies cited: 0
Inspection Report — Jan 10, 2020
Complaint Investigation
Date: Jan 10, 2020
Visit Reason
The State Agency conducted an abbreviated/partial survey investigating MS CI #16528 and MS CI #16498 beginning 1/9/20 through 1/10/20. The areas reviewed for investigation included sexual abuse of Resident #1 and no hot water in the shower.
Complaint Details
Complaint investigation MS CI #16528 and MS CI #16498 involved allegations of sexual abuse and no hot water in the shower; both complaints were not substantiated and no deficiencies were cited.
Findings
The surveyor did not substantiate the complaints for sexual abuse or for the water being cold in the showers and no deficiencies were cited. The facility was determined to be in substantial compliance with Medicare and Medicaid requirements.
Report Facts
Complaint investigations: 2
Inspection Report — Nov 6, 2019
Abbreviated Survey
Date: Nov 6, 2019
Visit Reason
The State Agency conducted an abbreviated/partial extended survey investigating CI MS #16265, CI MS #16210, CI MS #16296, and CI MS #16270 beginning 11/05/19 through 11/06/19. Concerns identified in the complaint were related to Patient's Rights (Other) and Quality of Care/Treatment.
Complaint Details
Complaint investigation numbers CI MS #16265, CI MS #16210, CI MS #16296, and CI MS #16270 were investigated for concerns related to Patient's Rights (Other) and Quality of Care/Treatment. These concerns were not substantiated and no deficiencies were cited.
Findings
These concerns were not substantiated and no deficiencies were cited. The facility was found to be in substantial compliance with requirements for participation in Medicare and Medicaid.
Report Facts
Complaint investigations: 4
Inspection Report — Aug 30, 2019
Complaint Investigation
Date: Aug 30, 2019
Visit Reason
A complaint investigation was conducted on August 30, 2019 in the facility. The State Agency was unable to substantiate the Resident/Patient/Client Neglect or Quality of Care/Treatment complaints.
Complaint Details
Complaint Investigation CI# MS 15978. The complaint involved allegations of Resident/Patient/Client Neglect or Quality of Care/Treatment. The complaint was unsubstantiated with no deficiencies cited.
Findings
The investigation was unsubstantiated with no deficiencies cited.
Inspection Report — Aug 20, 2019
Complaint Investigation
Date: Aug 20, 2019
Visit Reason
A complaint investigation was conducted on August 20, 2019 in the facility.
Complaint Details
CI MS #16082 and CI MS #16094 were investigated and found unsubstantiated with no deficiencies cited.
Findings
The result of the investigation was unsubstantiated with no deficiencies cited.
Inspection Report — Jun 12, 2019
Complaint Investigation
Date: Jun 12, 2019
Visit Reason
The State Agency (SA) conducted an abbreviated/partial extended survey investigating MS CI 15887 beginning 6/11/19 through 6/12/19. Concerns identified in the complaint were related to possible abuse and neglect.
Complaint Details
CI MS#15887 investigated possible abuse and neglect; the concerns were not substantiated and no deficiencies were cited.
Findings
These concerns were not substantiated and no deficiencies were cited. During the survey the SA determined the facility was in substantial compliance with requirements for participation in Medicare and Medicaid.
Report Facts
Complaint investigations: 1
Inspection Report — Jun 12, 2019
Abbreviated Survey
Date: Jun 12, 2019
Visit Reason
The State Agency conducted an abbreviated/partial extended survey investigating MS CI 15887 beginning 6/11/19 through 6/12/19. Concerns identified in the complaint were related to possible abuse and neglect.
Complaint Details
CI MS #15887: Concerns related to possible abuse and neglect were investigated and found not substantiated; no deficiencies were cited.
Findings
The concerns were not substantiated and no deficiencies were cited. The facility was determined to be in substantial compliance with requirements for participation in Medicare and Medicaid.
Report Facts
Complaint investigations: 1
Inspection Report — Apr 18, 2019
Annual Inspection
Date: Apr 18, 2019
Visit Reason
An Annual Recertification survey was conducted at Brandon Health and Rehab from 4/15/19 through 4/18/19. In addition, Complaint Intake Number CI MS#15817 was investigated in conjunction to this Recertification survey. The complaint was not substantiated for quality of care, call lights not answered by staff.
Complaint Details
Complaint Intake Number CI MS#15817 was investigated in conjunction with the recertification survey. The complaint was not substantiated for quality of care related to call lights not answered by staff.
Findings
The recertification survey revealed that the facility was not in substantial compliance with Medicare/Medicaid regulations requirements for Long Term Care Facilities. Two deficiencies were cited related to the Annual Recertification survey: F0656 and F0690.
Deficiencies (2)
F0656 - The facility failed to develop and implement a comprehensive care plan for Resident #186 with specific instructions on preventing cross contamination during Foley catheter care to avoid urinary tract infections.
F0690 - The facility failed to ensure appropriate aseptic technique during catheter care for Resident #186, as the same washcloth was repeatedly used and rinsed in contaminated water, risking urinary tract infections.
Report Facts
Deficiencies cited: 2
Inspection Report — Apr 18, 2019
Annual Inspection
Date: Apr 18, 2019
Visit Reason
The State Agency (SA) determined during an annual recertification survey conducted on April 17, 2019, the facility was in compliance for State Licensure requirements.
Findings
The facility was found in compliance with no deficiencies cited.
14 CMS Surveys
CMS Survey — Apr 19, 2023
Apr 19, 2023
CMS Survey — Jan 18, 2024
Jan 18, 2024
CMS Survey — Mar 15, 2024
Mar 15, 2024
CMS Survey — Jun 12, 2024
Jun 12, 2024
CMS Survey — Jan 31, 2025
Jan 31, 2025
CMS Survey — Mar 6, 2025
Mar 6, 2025
CMS Survey — Apr 1, 2025
Apr 1, 2025
CMS Survey — Apr 22, 2025
Apr 22, 2025
CMS Survey — May 12, 2025
May 12, 2025
CMS Survey — Nov 18, 2025
Nov 18, 2025
CMS Survey — Jan 12, 2026
Jan 12, 2026
CMS Survey — May 26, 2022
May 26, 2022
CMS Survey — Mar 15, 2024
Mar 15, 2024
CMS Survey — Jul 31, 2025
Jul 31, 2025
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