Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Braden River Rehabilitation Center Llc during CMS and state inspections, most recent first.
A grievance was not filed or investigated after a resident's DPOA complained about a discharge and lack of notification. The DON acknowledged the complaint and referred it to the Social Service Director, but no documentation or follow-up occurred. Facility leadership misunderstood the grievance policy, resulting in the DPOA's valid complaint not being addressed.
A facility did not document, investigate, or communicate the outcome of a grievance after a resident's financial DPOA complained about a discharge and lack of notification. Although the complaint was acknowledged by the DON and intended for follow-up, no grievance was filed or investigated, and the DPOA received no response, resulting in noncompliance with grievance procedures.
The facility failed to maintain a sanitary and homelike environment, with surveyors observing missing paint, damaged laminate, and rusted drains across multiple units. Residents and family members reported unresolved maintenance issues, such as broken sinks and missing mirrors. Despite daily rounds intended to identify maintenance needs, many issues remained unaddressed, and the facility lacked a specific maintenance policy.
The facility failed to prevent food contamination during meal service by using a steam table without a sneeze guard, allowing staff to reach over exposed food. Staff handled food improperly, touching surfaces without washing hands before re-gloving. A cold salad was improperly stored next to a hot steam table. The Certified Dietary Manager and Nursing Home Administrator acknowledged these deficiencies.
A resident, who was cognitively intact, reported not receiving a shower or hair wash for two months and preferred bed baths due to discomfort. Despite expressing her concerns to staff, no grievance was filed, and her care preferences were not updated. Interviews with staff confirmed awareness of the issue, but the grievance process was not initiated as required by facility policy.
The facility failed to accurately complete the PASRR for three residents. One resident's PASRR omitted a schizophrenia diagnosis, another's did not include major depressive disorder, and a third's initial PASRR lacked documentation of qualifying mental illnesses. The DON acknowledged these errors and confirmed the need for updates.
The facility failed to accurately revise care plans for two residents. One resident was incorrectly marked as an elopement risk despite no supporting evidence, while another resident's preference for bed baths was not documented, leading to unmet care needs. The Care Plan Coordinator was unaware of these discrepancies, highlighting a lack of communication and documentation.
A resident requiring substantial assistance with personal care was not provided with grooming and hygiene support, despite expressing a preference for a clean-shaven appearance and short hair. The resident communicated his needs to staff across different shifts, but no assistance was given for shaving or hair care. The care plan indicated a need for extensive assistance, yet staff were unaware of the resident's requests until informed by the survey team, revealing a deficiency in care delivery.
A resident identified as a fall risk was exposed to a hazard due to fall mats being improperly placed on the floor while the resident was in a wheelchair. The mats, intended for use when a resident is in bed, were not removed as per facility protocol. Staff interviews confirmed the expectation to store mats out of the way when not in use, but this was not followed. The facility did not provide a relevant policy upon request.
A resident with dementia experienced a deficiency in care at an LTC facility, as staff failed to provide adequate nutritional support and cognitive stimulation. The resident was often found in a dark room with untouched meal trays, and despite significant weight loss, staff did not consistently assist or encourage eating. The care plan was not effectively implemented, and there was a lack of communication with the family about the resident's declining condition and potential care options.
The facility exceeded the acceptable medication error rate, with errors observed in the administration of medications to two residents. An LPN administered an incorrect dose of cranberry supplement and failed to ensure a resident rinsed their mouth after using an inhalation aerosol. Another LPN administered a lower dose of Lexapro than prescribed. The errors resulted in a 10.34% medication error rate, surpassing the acceptable threshold of 5%.
A resident was found unresponsive with a head injury and later died from a brain bleed. The facility did not report the incident to authorities as required. The Nursing Home Administrator concluded it was an unwitnessed fall, but did not consider other causes. The facility's incident log showed no reportable incidents, indicating non-compliance with reporting policies.
Failure to File and Investigate Grievance for Resident's DPOA
Penalty
Summary
A deficiency was identified when the facility failed to file and investigate a grievance for one resident out of three reviewed for grievances. The issue arose when the resident's Durable Power of Attorney (DPOA) visited the facility and complained to the Director of Nursing (DON) about the resident being discharged and transferred to another facility without her approval or notification. The DPOA expressed significant dissatisfaction with the lack of communication regarding the discharge and expected the facility to address her concerns. Upon review, it was found that the DPOA held financial authority only, as indicated by the Durable Power of Attorney form. Despite this, the facility's policy clearly stated that any resident or anyone acting on their behalf could file a grievance, and staff were required to assist in filing and investigating such grievances. The DON acknowledged the DPOA's complaint and passed it to the Social Service Director for follow-up, but no documentation was found to show that the complaint was investigated or that the DPOA was informed of any outcome. The Social Services Assistant confirmed that no investigation or resolution was pursued, and the DPOA was not communicated with regarding the complaint. Interviews with facility leadership, including the DON, Social Services Assistant, and Nursing Home Administrator (NHA), revealed a misunderstanding or misapplication of the facility's grievance policy. The NHA believed that the financial-only DPOA was not acting on the resident's behalf in a medical capacity and therefore did not warrant follow-up. However, both the DON and Social Services Assistant later confirmed that the DPOA's complaint should have been treated as a valid grievance according to facility policy, but it was not filed, investigated, or resolved as required.
Plan Of Correction
1. On , a grievance was initiated by the Social Service assistant for resident #1 regarding the resident's fiduciary DPOA concern regarding resident #1 being discharged to another center without their knowledge. A final resolution was delivered to the fiduciary DPOA on . 2. By an audit of current residents was completed by the Social Service Manager to ensure any resident with power of attorney is clarified on the sheet to ensure proper notification of any discharge plans. On the Director of Nursing was re-educated by the NHA to ensure any concerns are brought to the interdisciplinary team as a grievance and a conclusion/resolution is brought to the person filing the grievance. By staff were re-educated on the Grievance process by the Staff development coordinator. 3. Random interviews of residents/family/visitors 3 times a week for 12 weeks to ensure all concerns are brought through the grievance process. Interviews to be conducted by social services. 4. Interviews will be brought to the Quality Assurance and Assessment/Quality Assurance Performance Improvement committee for a minimum of three months or until substantial compliance is achieved.
Failure to File and Investigate Grievance for Resident's DPOA Complaint
Penalty
Summary
The facility failed to file and investigate a grievance for one resident out of three reviewed, as required by both state statute and the facility's own grievance policy. The policy mandates that any grievance, whether submitted orally or in writing by a resident or anyone acting on their behalf, must be documented, investigated, and communicated back to the complainant. In this case, the resident's Durable Power of Attorney (DPOA) visited the facility and expressed dissatisfaction to the DON regarding the resident's discharge and transfer without her approval or notification. The DPOA reported feeling upset and believed the facility should have communicated with her about the discharge. Upon review, it was found that the DPOA held financial authority only, as indicated by the Durable Power of Attorney form. Despite this, the DON acknowledged the DPOA's complaint and noted it, intending to pass it to the Social Service Director for follow-up per policy. However, the facility's grievance logs did not show any record of a grievance being filed or investigated regarding this complaint. Interviews with the DON, Social Services Assistant, and Nursing Home Administrator confirmed that no documentation existed to show the complaint was addressed, investigated, or communicated back to the DPOA. The Nursing Home Administrator stated that the facility's policy only required grievances to be filed by residents or those acting on their behalf, and after assessment, determined the financial DPOA was not acting on the resident's behalf in this context. However, both the DON and Social Services Assistant later confirmed that the DPOA had a valid complaint that should have been processed as a grievance. The facility did not investigate, resolve, or communicate the outcome of the complaint, resulting in noncompliance with statutory and policy requirements for grievance handling.
Plan Of Correction
N 042 1. On , a grievance was initiated by the Social Service assistant for resident #1 regarding the resident's fiduciary DPOA concern regarding resident #1 being discharged to another center without their knowledge. A final resolution was delivered to the fiduciary DPOA on . 2. By , an audit of current residents was completed by the Social Service Manager to ensure any resident with power of attorney is clarified on the sheet to ensure proper notification of any discharge plans. On the Director of Nursing was re-educated by the NHA to ensure any concerns are brought to the interdisciplinary team as a grievance and a conclusion/resolution is brought to the person filing the grievance. By staff were re-educated on the Grievance process by the Staff development coordinator. 3. Random interviews of residents/family/visitors 3 times a week for 12 weeks to ensure all concerns are brought through the grievance process. Interviews to be conducted by social services. 4. Interviews will be brought to the Quality Assurance and Assessment/Quality Assurance Performance Improvement committee for a minimum of three months or until substantial compliance is achieved.
Facility Fails to Maintain Sanitary and Homelike Environment
Penalty
Summary
The facility failed to maintain a sanitary and homelike environment across four out of five units, as evidenced by multiple observations and interviews. On several occasions, surveyors noted missing paint and plaster, exposed nail heads, and damaged wood laminate in various rooms. Bathrooms were found with missing sink handles, rusted drains, and large openings in the walls covered with makeshift materials like plastic bags and tape. Ceiling vents were observed with black spots, stains, and peeling plaster, while handrails were loose and separated from the walls. Interviews with residents and family members revealed ongoing maintenance issues that had not been addressed for weeks, such as broken sinks and missing mirrors. A family member reported that maintenance staff were aware of these issues but prioritized other tasks. Observations on subsequent dates showed that many of the initial concerns remained unaddressed, indicating a lack of timely maintenance intervention. During a tour with the Regional Maintenance Director and the Nursing Home Administrator, it was acknowledged that several rooms had unresolved issues, and the facility lacked a specific policy for upkeep and maintenance. The Regional Maintenance Director admitted to having a backlog of work orders and stated that daily rounds were supposed to identify maintenance needs. However, the absence of a structured maintenance policy and the presence of numerous unresolved issues highlighted significant deficiencies in maintaining a safe and comfortable environment for residents.
Food Contamination Risk Due to Improper Storage and Handling
Penalty
Summary
The facility failed to ensure that cooked and prepared food was stored in a manner to prevent contamination during meal observations on multiple occasions. During these observations, a satellite steam table was used in the main dining room without a barrier or sneeze guard, allowing staff to reach over exposed food items. Staff were observed handling food with gloves, but then touching their clothing, face, and other surfaces without washing their hands before re-gloving. This improper handling of food and lack of protective barriers posed a risk of contamination. Additionally, a cold prepared salad was left on a cart next to the hot steam table for an extended period, which was not an appropriate method for storing cold food items. The Certified Dietary Manager acknowledged the absence of a sneeze guard and the improper practices observed. The Nursing Home Administrator confirmed the deficiencies in food service procedures and provided a quote for a sneeze guard after the initial observations. The facility's food service policy, revised in August 2023, was intended to ensure sanitary conditions, but the practices observed did not align with this policy.
Failure to Address Resident Grievance on ADL Care
Penalty
Summary
The facility failed to address a grievance regarding Activities of Daily Living (ADL) care for a resident, who had not received a shower or hair wash in two months. The resident, who was cognitively intact with a BIMS score of 15, expressed her dissatisfaction to various staff members, stating her preference for bed baths due to discomfort when getting up. Despite her complaints, no grievance was filed on her behalf, and her care preferences were not updated in her care plan. Interviews with staff revealed that the resident's complaints were known, but no formal grievance process was initiated. A CNA acknowledged the resident's request for hair washing, while an LPN admitted to not filing a grievance despite being aware of the resident's dissatisfaction with her showering routine. The Unit Manager and the Director of Nurses confirmed that a grievance should have been filed according to the facility's policy, which mandates that grievances be reported and addressed promptly.
Inaccurate PASRR Completion for Residents
Penalty
Summary
The facility failed to ensure the Preadmission Screening and Resident Review (PASRR) was completed accurately for three residents. Resident #38 was admitted with multiple mental health diagnoses, including bipolar disorder, schizophrenia, post-traumatic stress disorder, and major depressive disorder. However, the PASRR completed at the facility did not include the schizophrenia diagnosis. The Director of Nursing (DON) acknowledged the error, stating that the PASRR should have been updated to reflect the schizophrenia diagnosis. Resident #60 was admitted with diagnoses including dysphagia and major depressive disorder. The PASRR completed at the hospital prior to admission did not mark any mental illness, omitting the major depressive disorder diagnosis. The DON confirmed that the PASRR was incorrect and should have been updated at admission to include the depressive disorder diagnosis. Resident #93 had multiple diagnoses, including unspecified dementia, generalized anxiety disorder, and major depressive disorder. The initial PASRR did not document any qualifying mental illness diagnoses. The DON later updated the PASRR to include anxiety disorder, depressive disorder, psychotic disorder, and schizophrenia. The DON confirmed that the initial PASRR was incorrect and should have included the qualifying diagnoses.
Inaccurate Care Plans for Two Residents
Penalty
Summary
The facility failed to ensure the revision and accuracy of care plans for two residents. Resident #16, who was in the facility for short-term care, was inaccurately identified as being at risk for elopement despite having no history or current behaviors indicating such a risk. The resident required maximum assistance for transfers and mobility, and there were no physician orders or documentation in the medical record to support the elopement risk. The Care Plan Coordinator confirmed that the care plan did not accurately reflect the resident's condition. Resident #91, a long-term care resident, expressed dissatisfaction with not having had a shower or hair wash in two months and preferred bed baths due to discomfort when getting out of bed. Despite this preference being known to some staff, it was not documented in the resident's care plan. The care plan indicated the need for assistance from two staff members for bathing but did not reflect the resident's preference for bed baths. The Care Plan Coordinator was unaware of this preference, indicating a lack of communication and documentation regarding the resident's care needs.
Failure to Provide Grooming Assistance to Resident
Penalty
Summary
The facility failed to provide grooming and personal hygiene assistance to a resident who was unable to perform these activities independently. The resident, who had been admitted with diagnoses including osteoarthritis and required substantial assistance with personal care, was observed on multiple occasions with unshaven facial hair and unkempt hair. Despite the resident's expressed preference for a clean-shaven appearance and short hair, consistent with his past military service, he reported not receiving the necessary assistance from staff since his admission. Interviews with the resident and staff revealed that the resident had communicated his needs to various staff members across different shifts, but no assistance was provided for shaving or hair care. The resident's care plan indicated a need for extensive assistance with bathing and personal hygiene, yet staff interviews revealed a lack of awareness and action regarding the resident's requests. The Unit Manager confirmed that the resident had not received a shave since admission and was unaware of the resident's concerns until informed by the survey team. The facility's policy on resident rights emphasizes the importance of assisting residents in exercising their rights and maintaining a dignified existence, which was not upheld in this case. The deficiency was identified through observations, interviews, and medical record reviews, highlighting a failure in the facility's care delivery for this resident.
Failure to Maintain Hazard-Free Environment Due to Misplaced Fall Mats
Penalty
Summary
The facility failed to maintain a hazard-free environment for a resident identified as a fall risk. Observations on multiple occasions revealed fall mats placed on the floor in a room where the resident was present in a wheelchair, despite the mats being intended for use when a resident is in bed. The resident expressed that the mats were a tripping hazard and mentioned having tripped over them in the past. The mats were reportedly intended for a roommate who was not present, indicating a misplacement of safety equipment. Interviews with staff members revealed a protocol for fall mats that was not followed. Staff were expected to remove fall mats from the floor when residents were out of bed and store them out of the way, such as against the wall or behind the bed. However, the mats were observed on the floor next to the resident's wheelchair, contrary to the stated procedure. The facility was unable to provide a policy on fall mats or accident/hazard environment management upon request, further indicating a lack of adherence to safety protocols.
Deficiency in Dementia Care and Nutritional Support
Penalty
Summary
The facility failed to provide adequate treatment and services to a resident diagnosed with dementia, resulting in a deficiency in maintaining the resident's highest practicable physical, mental, and psychosocial well-being. The resident was observed multiple times in a dark room, in a wheelchair, with her head on her knees, and her meal trays untouched. Despite the resident's significant weight loss and nutritional risk, staff did not consistently assist or encourage her to eat, nor did they provide adequate cognitive stimulation or social interaction. The resident's medical record indicated a primary diagnosis of dementia, along with other conditions such as osteoarthritis, neuralgia, and mood disorder. The care plan included interventions for cognitive stimulation and nutritional support, but these were not effectively implemented. The resident experienced a severe decline in participation in activities and a significant weight loss over several months, yet there was a lack of proactive engagement from the staff to address these issues. Interviews with staff revealed that while the resident's decline was discussed in meetings, there was insufficient follow-up or communication with the family regarding potential care options like palliative or hospice care. The family member of the resident expressed concerns about the lack of communication from the facility and the absence of discussions with medical providers about the resident's declining condition. Despite the facility's policy on nutritional risk evaluation and palliative care, there was no evidence of a comprehensive approach to address the resident's needs. The facility's failure to implement the care plan and engage with the family contributed to the deficiency in providing appropriate care for the resident with dementia.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by observations during medication administration. Out of 29 medication administration opportunities, three errors were identified, resulting in a 10.34% error rate. The errors involved two residents, with one resident receiving an incorrect dose of cranberry supplement and not being offered water to rinse their mouth after using an inhalation aerosol, as per the medication order. Another resident was administered a lower dose of Lexapro than prescribed. The errors were observed during medication administration by two LPNs. One LPN administered a cranberry supplement at a higher dose than ordered and failed to ensure the resident rinsed their mouth after using an inhalation aerosol. The other LPN administered a lower dose of Lexapro than prescribed. The Director of Nursing was informed of these errors but did not provide further comments or questions. The facility's procedural guidelines emphasize the importance of verifying medication labels against orders to ensure accurate administration, which was not adhered to in these instances.
Failure to Report Serious Injury and Death
Penalty
Summary
The facility failed to report an injury of unknown source that resulted in physical injury and subsequent death of a resident to the proper authorities within the prescribed timeframes. The resident was found unresponsive in bed with a hematoma and laceration on the back of the head, and blood was noted on the leg rest area of the wheelchair next to the bed. The incident was unwitnessed, and the resident was transferred to a hospital where a significant brain bleed was diagnosed. Despite the severity of the injury, the facility did not report the incident as required by their policies. The Nursing Home Administrator conducted an investigation and concluded that the injury was due to an unwitnessed fall, based on the placement of furniture and blood evidence. The administrator did not consider other potential sources of injury or the possibility of foul play. The facility's adverse and incident report log showed no reportable incidents during the relevant period, indicating a failure to comply with the facility's policies on reporting serious injuries to state and federal agencies.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 228 citations issued within 25 miles in the last 12 months — including the 17 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bradenton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aviata At Bradenton | 0.5 mi | ★★★★★ | 25 | 0 |
| Riviera Palms Rehabilitation Center | 1.8 mi | ★★★★★ | 0 | 0 |
| Greenbriar Healthcare Rehabilitation And Nursing C | 1.8 mi | ★★★★★ | 0 | 0 |
| Westminster Point Pleasant | 2.2 mi | ★★★★★ | 6 | 0 |
| Manatee Springs Rehabilitation And Nursing Center | 3.8 mi | ★★★★★ | 3 | 3 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.