Brandon Community Care Center

Inspectors wroteBased on observation, interview, record review and facility policy review 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 for one (1) of four (4) sampled residents reviewed for falls. Resident # 1.

Inspectors wroteBased on observations, interviews, record review and facility policy review, the facility failed to report allegations of abuse for one (1) of three (3) residents reviewed. Resident #1Findings include: A record review of the facility's Abuse Prevention policy with a revision date of 1/25 revealed alleged violations involving abuse, neglect. are reported immediately, but not later than 2 hours after the allegation is made. On 10/2/25 at 11:15 AM in an interview with the Director of Nursing (DON) she stated that on 9/7/25 Certified Nursing Assistant (CNA) #2 told her that CNA #1 asked for help giving Resident #1 a bed bath. She stated the resident is blind and deaf. She stated they communicate by writing simple words in the resident hands with their fingers to let her know what they are doing. [...]

Inspectors wroteBased on interviews, record review and facility policy review, the facility failed to ensure staff honored a resident's preference to be put back to bed after therapy, resulting in the resident experiencing pain and emotional distress for one (1) of (35) sampled residents. Resident #216.

Inspectors wroteBased on observation, interview, record review and facility policy review, the facility failed to ensure that residents were transferred in a manner that could prevent accidents and potential injury for one (1) of (3) residents reviewed for accident hazards and safety. Resident #11.

Inspectors wroteBased on observations, interviews, facility policy review and record review, the facility failed to provide a diet taking into consideration preferences of the resident for one (1) of 35 sampled residents. Resident #42Findings include:Record review of the facility policy revealed residents have a right to reside and receive services in the facility with reasonable accommodation of resident's preferences except when to do so would endanger the health or safety of the resident or other residents. During an observation on 07/29/2025 at 12:27 PM, Resident 42 was served a tray consisting of turkey, dressing, and a sweet potato. During an interview on 7/29/25 at 12:27 PM, Resident #42, asked CNA#4 to exchange her meal for a turkey sandwich. CNA #4 went to the kitchen and brought back a tray consisting of a piece of ham, broccoli and cheese and mandarin fruit cup and black-eyed peas. [...]

Inspectors wroteBased on observation, interview and facility policy review, the facility failed to practice hand hygiene in accordance with professional standards for food services as evidenced by the District Dietary Manager (DDM) placing her fingers in food on the food line for one (1) of three (3) kitchen observations.

Inspectors wroteBased on observation, interviews, and record review the facility failed to protect the residents' right to be free from neglect by not ensuring staff implemented measures to mitigate the risk to prevent elopement for one (1) of six (6) sampled residents, Resident #5. On 5/01/25 at approximately 3:00 PM, the facility failed to prevent Resident #5, a resident who had recently exhibited new exit-seeking behaviors from exiting the facility unnoticed and unsupervised. The facility was unaware of Resident #5's whereabouts for approximately fifteen (15) minutes until a staff member went to his car on break and located her sitting in the passenger seat of his car with the windows up in an unshaded parking space approximately thirty-five yards from the facility entrance at approximately 3:15 PM. [...]

Inspectors wroteBased on record review, policy review and interviews it was determined that the facility failed to ensure that allegations of neglect and incident of elopement were reported to the appropriate agencies, including State Agency, in accordance with State law through established procedures for one (1) of six (6) sampled residents, Resident #5. On 5/01/25 the facility failed to report to the required agencies an allegation of resident neglect related to lack of adequate supervision resulting in the elopement of Resident #5. On 5/01/25 at approximately 3:00 PM, Resident #5, who had recently exhibited new exit-seeking behaviors, exited the facility unnoticed and unsupervised. [...]

Inspectors wroteBased on record review, policy review and interviews it was determined that the facility failed to initiate a thorough investigation of an allegation of neglect and incident of elopement for one (1) of six (6) sampled residents, Resident #5. On 5/01/25 the facility failed to initiate an investigation of resident neglect related to lack of adequate supervision resulting in the elopement of Resident #5. Resident #5 was out of the facility unsupervised in the parking lot of the facility at shift change and got into a car in front of a sidewalk that led to a busy four-lane boulevard with no barrier or crosswalk. This car belonged to a staff member who found her in his car around 3:15 PM and escorted her back into the facility. [...]

Inspectors wroteBased on interviews, policy review and record review it was determined that the facility failed to develop a comprehensive care plan for one (2) of six (6) sampled residents, Resident #5 and Resident #6 On 5/01/25, Resident #5 with documented new wandering and exit seeking behaviors for at least a week eloped from the facility unnoticed and was outside unsupervised for approximately fifteen minutes. Documentation of the resident's change of behavior, including wandering had been reported to her primary healthcare provider with new orders noted for urinalysis to check for urinary tract infection, but the facility failed to identify exit seeking and elopement risk or develop her care plan to provide adequate supervision to prevent elopement. [...]

Inspectors wroteBased on observation, interviews, record review and facility policy review, the facility failed to provide adequate supervision and a secure environment to prevent the elopement of one (1) of six (6) sampled residents, Resident #5. On 5/01/25 at approximately 3:00 PM Resident #5 who had documented new wandering and exit seeking behaviors for at least a week exited the facility unnoticed and was outside unsupervised for approximately fifteen minutes until a staff member located the resident sitting in his unlocked car in an unshaded parking space approximately thirty-five feet from the facility entrance with windows up. The car was in front of a sidewalk that led to a busy four-lane boulevard with no barrier or crosswalk. [...]

Inspectors wroteBased on interviews, record review and facility policy review, the facility failed to provide appropriate care and services for Resident #6's nephrostomy tube. Specifically, the facility did not perform or document any nephrostomy tube dressing changes or flushes since admission, creating a potential for infection due to improper device care. This deficient practice affected Resident #6, one (1) of two (2) nephrostomy appliances in the building.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to implement the resident's care plan interventions related to daily skin and foot assessments for one (1) of four (4) residents reviewed for care planning, Resident #1, which resulted in the facility not identifying or addressing developing wounds on the resident's foot, which remained untreated by facility staff for five (5) days after being discovered and treated at the dialysis center.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to provide necessary care and services and respond appropriately to changes in a resident's condition for one (1) of four (4) sampled residents (Resident #1), when wounds were identified and treated by the dialysis clinic on 4/16/25 and the facility was notified, but failed to assess or initiate treatment until 4/21/25, resulting in a delay in care and placing the resident at risk for a worsening wound condition and infection.

Inspectors wroteBased on observation, interview, record review, and facility policy review, 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 (1) of four (4) sampled residents. Resident #4.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure timely removal of a pressure dressing from a dialysis access site for one (1) of one (1) resident reviewed for dialysis services. Resident #4.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to develop and implement care plans for two (2) of eight (8) residents reviewed, Resident #5 and Resident #6. Findings Included: Policy review of the facility policy titled COMPREHENSIVE PERSON-CENTERED CARE PLANS dated 8/11 (August 2011) revealed POLICY: Each resident will have a person-centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care . Resident #5 Record review of the comprehensive care plan revealed there was not a care plan developed related to catheter care for Resident #5. Record review of the comprehensive care plan revealed I am at risk for UTI's (urinary tract infections) and skin breakdown r/t (related to) bladder incontinence. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to meet current professional standards of care as evidenced by no physician order written for a resident who had an indwelling foley catheter for one (1) of eight (8) residents reviewed. Resident #5. Findings Included: Policy review of the facility policy titled PHYSICIAN ORDERS dated 1/25 (January 2025) revealed Orders received from a physician must be written on a hard script and signed by a physician. RESPONSIBILITY: All Licensed Nursing Personnel . During an observation on 3/04/25 at 5:50 PM, in the Unit 2 Dining Room revealed Resident #5 was seated in a wheelchair with a urine collection bag beneath the wheelchair, uncovered, with approximately eighty (80) milliliters of golden yellow urine visible in the collection bag. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, 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 common area for one (1) of eight (8) residents reviewed. Resident #5 Findings Included: Policy review of the facility-provided Resident [NAME] of Rights with Review Date 1/15 (January 2015) revealed the document stated, It is the objective of the Facility to herein forth the rights of Residents so as to assure the protection and preservation of dignity . Facility Residents shall have the right to: 1. Privacy in treatment and personal care .26. Treated with consideration, respect, and full recognition of his/her dignity and individuality. [...]

Inspectors wroteBased on observation, record review, facility policy review, and interviews, the facility failed to provide necessary care for hygiene, bathing, and grooming for two (2) of eight (8) sampled residents, Resident #4 and Resident #6. Findings Included: Record review of the facility policy titled SHAVING-MALE AND FEMALE dated 8/11 (August 2011) revealed the policy stated, POLICY: Residents will be free of facial hairs - both male and female. If the resident is alert and oriented and requests not to be shaved, this will be noted in the Care Plan. RESPONSIBILITY: All Nursing Assistants monitored by Charge Nurse. Record review of the facility policy titled BATH/SHOWER-DEPENDENT dated 8/11 (August 2011) revealed, POLICY: A bath (shower/tub) for cleanliness and comfort is scheduled at least weekly for each resident. RESPONSIBILITY: Nursing Assistants or Licensed Nurses monitored by Charge Nurse . [...]

Inspectors wroteBased on observations, interviews, facility policy review and record review the facility failed to provide a safe, functional, sanitary environment for three (3) of four (4) days of survey that affected Residents #2, #4, #7 and #8.

Inspectors wroteBased on observations, interviews, record review and facility policy review, the facility failed to ensure that a resident that required assistance with toilet use and toilet hygiene received care in a routine or timely manner for one (1) of eight (8) sampled residents, Resident #6.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to provide care/services to a resident who had a feeding tube according to the resident needs and consistent with practitioner's orders for one (1) of two (2) sampled residents reliant on feeding tubes for nutrition.

Inspectors wroteBased on observation, staff interviews, and record review, the facility failed to ensure sufficient nursing staff to meet the needs of residents for eight (8) of 16 staffing days reviewed in December 2024, (12/16/24, 12/23/24, 12/24/24, 12/25/24, 12/26/24, 12/27/24, 12/28/24 and 12/31/24). Findings Include: On 12/21/24 an anonymous complaint revealed a lack of housekeeping staff and inadequate direct care staff to provide adequate care for residents. On 1/28/25 at 4:03 PM, interview with Certified Nursing Assistant (CNA) #1 revealed CNA #3 left at approximately 1:30 PM. Her group of residents was added to CNA #1. CNA #1 stated that she had not had time to provide incontinence monitoring or care for Resident #6 between approximately 1:30 PM and 3:00 PM. [...]

Inspectors wroteBased on observation, interviews, and facility policy review, the facility failed to ensure a safe, clean homelike environment for two (2) of six (6) residents' rooms (Resident #3 and Resident #4), one (1) of three (3) shower rooms, and one (1) of three (3) hallways observed.

Inspectors wroteBased on observation, staff interviews and facility policy review, the facility failed to ensure foods were stored safely in the walk-in refrigerator, as evidenced by food stored without being labeled or dated with use-by dates and boxes of food stored on the floor in the walk-in freezer for one (1) of two (2) kitchen observations.

Inspectors wroteBased on interviews, record review and facility policy review, the facility failed to ensure residents who smoked were allowed to exercise their right to smoke during the facility's designated smoking times for two (2) of 38 residents who smoke. Resident #6 and Resident #27 Findings Include: Review of the facility's policy titled, Resident [NAME] of Rights, dated 1/23, revealed, Each resident has a right to a dignified existence, self-determination, and communication .in a manner and in an environment that promotes maintenance or enhancement of (his or her) quality of life . A. Facility residents shall have the right to: . 15. Self determination, which the facility must promote and facilitate through support of resident choice . Resident #6 During an interview on 3/11/24 at 7:39 AM, Resident # 6 stated that they were not receiving their smoking breaks as scheduled or at all. [...]

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure the attending physician was notified of repeated medication refusals for one (1) of five (5) residents reviewed for medications.

Inspectors wroteBased on observations, interviews and record review the facility failed to maintain a clean, homelike environment as evidenced by the facility failing to ensure clean linen was available for two (2) of 35 sampled residents. Resident #120 and #194 Findings Include: Resident #120 During an observation and interview on 03/11/24 at 09:15 AM, Resident #120 was observed lying in bed. The room had a strong odor. Resident said he had a bowel movement and needed somebody to clean him up. The resident turned the call light on. On 03/11/24 9:45 at AM, an observation of Resident #120 revealed that the call light was turned off and the resident had not received the care he needed. The resident's brief was saturated with urine and a large amount of brown stool. [...]

Inspectors wroteBased on observations, interviews, record reviews, and facility policy review, the facility failed to resolve a resident's grievance related to Activities of Daily Living (ADL) care and shower for one (1) of 35 sampled residents reviewed for ADLs.

Inspectors wroteBased on observation, interviews, record reviews, and facility policy review, the facility failed to ensure residents were not left soiled for extended periods of time and received incontinent care timely for one (1) of four (4) dependent residents reviewed for activities of daily living/incontinent care.

Inspectors wroteBased on observations, staff interviews, record review and facility policy review, the facility failed to maintain less than a 5% medication error administration rate, as evidenced by not administering medications per physician's orders for four (4) of 33 medications administered, resulting in a 12.12% medication error rate.

Inspectors wroteBased on observation, interviews and record review the facility failed to serve the residents food in a manner that was appealing and palatable for two (2) of 35 sampled residents.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure a resident with indwelling urinary drainage tubes received appropriate care and services to prevent possible complications, as evidenced by a nephrostomy drainage bag was left over filled, for one (1) of six (6) residents reviewed with urinary drainage bags. Resident #2.

Inspectors wroteBased on record review, resident interview, staff interview, and facility policy review the facility failed to respond and resolve group grievances in resident counsel for six (6) of six (6) months of resident counsel meetings reviewed. Findings Include: Record review of the facility policy titled, Grievance/Missing Property, dated 08/17, revealed, Policy; All residents, resident representatives and families also have the right to report property/items that may be missing. Purpose: To provide an opportunity for residents, resident representatives, and/or family to present concerns or grievances to the proper authorities at the facility and to receive responses to the issue(s) raised. Procedure: A. Grievances may be presented to any staff member 1. Respective Department Head, Executive, Director and/or Grievance Official will follow-up on issues as noted .b. [...]

Inspectors wroteBased on interviews, observation, record review, and facility policy review, the facility failed to develop a comprehensive care plan (Resident #119) and failed to implement a care plan related to Activities of Daily Living (ADLs) (Resident #9) and feeding assistance (Resident #200) for three (3) of thirty-five (35) resident's care plans reviewed. Findings Include: A review of the facility's policy, Comprehensive Person Centered Care Plans, dated 3/18, revealed Policy: Each resident will have a person centered plan of care to identify problems, needs, strengths, preferences and goals that will identify how the interdisciplinary team will provide care .Definitions .Comprehensive Person Centered Care Plan (CCP) contains services provided, preference, ability, goals for admission and desired outcomes, and care level guidelines .Procedure: 1. [...]

Inspectors wroteBased on facility policy review, resident interview, staff interviews, and record review, the facility failed to allow a resident to participate in the care planning process, as evidenced by no documentation of resident participation in care planning in the medical record for one (1) of 35 resident care plans reviewed. Resident #30. Findings Include: Review of the policy titled, Interdisciplinary Care Plan Meeting, (ICP) dated 11/17, revealed, Policy: [...]

Inspectors wroteBased on staff interviews, resident interview, and record review, the facility failed to allow a resident to manage her monthly income allotment as evidence by review of monthly trust fund statements for one (1) of three (3) residents reviewed for personal funds. (Resident #30). Findings Include: Review of the Resident [NAME] of Rights, the document used by the facility as their policy regarding resident funds, dated 11/17, revealed, A. Facility resident shall have the right to: .22. Manage his or her financial affairs . An interview on 05/23/22 at 03:30 PM, with Resident #30, revealed the facility was keeping her $44 monthly income allotment from Social Security, towards her outstanding balance owed to the facility for skilled services, and she did not remember signing an agreement with the facility to give up her money. [...]

Inspectors wroteBased on staff interview, record review, and facility policy review the facility failed to submit a Significant Change in Status Minimum Data Set (MDS) Assessment for a resident admitted to hospice (Resident #62).

Inspectors wroteBased on observation, resident and staff interview, record review, and facility policy review, the facility failed to ensure Activities of Daily Living (ADL) assistance was provided for residents who were dependent for assistance with showering for two (2) of twelve (12) residents reviewed for ADL assistance. (Resident #129 and Resident #9).

Inspectors wroteBased on observation, staff and resident interviews, and facility policy review the facility failed to properly secure a resident in a sit to stand lift while being transferred from wheel chair to bed for one (1) of two (2) residents observed (Resident #18). Findings Include: Review of the facility's policy, Subject: Invacare Sit-To-Stand Lift with a date of 8/16 revealed, .Procedure: .5. Transfer Sling a place sling behind resident and fasten waist belt in a comfortable manner . On 05/25/22 at 03:50 PM, the State Agency (SA) observed Certified Nurses Assistant #1 (CNA), bring Resident #18 into her room via wheelchair. CNA #1 and Licensed Practical Nurse (LPN) #2 connected the transfer sling to the sit-to-stand mechanical lift with the straps, but failed to secure the waist belt by fastening it to Resident #18. [...]

Inspectors wroteBased on observation, staff interview and facility policy review the facility failed to ensure a suprapubic catheter was secured by a leg strap for one (1) of (1) residents observed with catheters. Resident #18 Findings Include: Record review of the facility's policy, Catheter Care, with a revision date of 5/22, revealed, .Procedure .5. Secure the urinary catheter with a catheter strap . On 05/24/22 at 08:17 AM, during an observation and interview Resident #18 was sitting in a wheelchair. The State Agency (SA)observed a catheter bag hanging beside wheelchair. Resident #18 stated she has a suprapubic catheter and it came out a few weeks ago. Resident #18 pulled up her gown and pointed to the catheter site. The SA did not see a leg strap in place. The SA asked Resident #18 if she usually has a leg strap on. Resident #18 responded no. [...]

Inspectors wroteBased on observations, staff interviews, and record reviews, the facility failed to ensure soiled linen was discarded in a manner to prevent the spread of infection and ensure a contaminated object did no come in contact with a clean area for two (2) of four (4) days of survey (Resident #18 and Resident #119). Findings Include: Resident #18 Observation on 5/25/22 at 3:50 PM revealed Certified Nursing Assistant (CNA) #1, assisted by Licensed Practical Nurse (LPN) #1, bring Resident #18 in the room via wheelchair. The State Agency (SA) observed two white sheets and a blanket on the floor upon entering the room. She knocked the white heel protector from the from the bed on to the floor, picked it up, and placed it on Resident #18's bed. The resident adjusted herself in the bed and CNA #1 put the heel protectors onto her feet. CNA #1 placed a blanket on top of the pile of linen on the floor. [...]