Inspection Reports for
Brandon Community Carew Center

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.