Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Hutsonwood At Brazil during CMS and state inspections, most recent first.
Failure to Follow EBP and Laundry Infection Control Practices: Staff did not consistently use gowns and proper containment when handling clothing, linens, and waste for residents on EBP or with MDROs. A receptionist carried dirty clothing out of a room without a bag, residents reported staff often used gloves but not gowns during high-contact care, and laundry staff handled soiled items without the expected barrier precautions. The facility’s policies required gown and glove use for EBP and proper bagging of soiled linens.
A facility failed to provide ROM or other appropriate interventions for two residents reviewed for ROM and mobility. One cognitively impaired resident developed a contracted left hand and arm with nails pressing into the palm, while records lacked ROM orders, contracture documentation, and preventive interventions; staff said no restorative program was provided in the memory care unit and CNA ROM was only done during care. A second resident with Alzheimer’s disease and a prior femur fracture had declined in ambulation after therapy was stopped, and the care plan lacked updated interventions while staff acknowledged ROM recommended by PT was not being provided.
Dietary staff were observed using a dishwasher that was not within the required sanitation temperature range, with inaccurate temperature logs documented by staff. The Dietary Manager and Dietary Aide also dried their hands on damp rolled paper towels placed on a counter because the paper towel dispenser was not working, and the Dietary Manager acknowledged the towels were not sanitary. Interviews showed the Dietary Manager and Assistant Dietary Manager were unsure about the risks of serving food on unsanitized dishes, while another dietary staff member stated it could cause resident illness.
Food safety practices were deficient when the dishwasher was observed operating below the facility’s required wash and rinse temperatures, frozen foods were found without date markings, and staff used damp rolled paper towels for hand drying because the paper towel dispenser was not working. During meal service, a CNA returned an ice scoop to the ice container with the scoop and handle touching the ice, and a QMA later moved the scoop without sanitizing it first, contrary to facility policy.
Resident Information Left Exposed During Medication Administration: An LPN used a desk computer to rectify medications for three residents and then left the nurse's station to administer the medications while each resident's personal information remained visible on the screen. The DON stated resident information was expected to be covered when the nurse was away from the cart or desk, and the facility's confidentiality policy stated that resident personal or medical information must not be left unattended or viewable by unauthorized persons.
Failure to update fall-prevention interventions for a resident with Alzheimer’s disease, cognitive impairment, and dependence for transfers and ambulation. The resident had repeated falls in the room, dining area, doorway, wheelchair, and from bed, including a fall that resulted in a right hip fracture. Documentation often lacked vital signs, nonskid footwear status, and evidence of new, specific fall interventions. Staff interviews showed therapy had been discontinued, no restorative program was provided in the memory care unit, and the care plan was not consistently updated with specific interventions after falls.
A resident with a history of UTI and overactive bladder had an indwelling urinary catheter without documented physician orders or a catheter care plan in the record. Surveyors observed the catheter bag and tubing in contact with the floor, and later saw the drainage bag positioned so urine was exposed to view. The resident’s chart also lacked documentation of the catheter’s placement, the voiding trial results, and the catheter removal, and the DON stated she could not find documentation or orders for the catheter.
Pharmacy review processes were not followed for two residents. One resident with diabetes, overactive bladder, and CKD had a pharmacist recommendation to discontinue phenazopyridine, but the physician’s disagreement lacked a documented rationale. Another resident with hemiplegia, dementia, DM2, and pain had a pharmacist recommendation to reduce routine Norco dosing, the physician agreed, but the MAR and chart did not show the change as recommended, and pain assessments were not documented each shift as expected per the DON.
A resident with stroke-related deficits, dementia, diabetes, and pain received routine hydrocodone-acetaminophen without documented pain assessments. The MDS showed cognitive impairment and opioid use, the care plan addressed pain, and the MAR/vital signs record lacked pain documentation. A pharmacy review noted no pain symptoms and recommended reducing Norco frequency, but the facility did not change the order. An LPN said pain should be assessed each shift, and the DON acknowledged the missing pain-level documentation.
Medication Error Rate Exceeded 5 Percent During Observed Pass: An LPN made three medication administration errors during an observed med pass, resulting in an 11.54% error rate. Two residents received fluticasone nasal spray without being instructed to pinch the opposite nostril during administration, and one resident received tiotropium inhalation powder without being told to rinse and spit afterward, contrary to the physician’s orders and facility policy.
Medication Bottles Lacked Open Dates: An observation of a medication cart found open bottles of nasal spray and fluticasone propionate nasal spray without documented open dates for two residents. Both residents had orders for nasal spray medications to treat nasal congestion, and the Unit Manager stated the bottles would be dated when opened. The DON later provided the facility policy stating multi-use vials must include the date they were initially opened or accessed.
A resident’s indwelling urinary catheter bag and tubing were observed in contact with the floor while the resident sat in a wheelchair, and the resident had a history of UTIs and overactive bladder. In a separate observation, an LPN washed her hands before a med pass, handled items for a visitor, and then began medication administration without sanitizing her hands again after touching the ice bucket, scoop, and cart netting.
A resident was admitted late in the evening and multiple ordered meds were not available or not administered on time, including ascorbic acid, enoxaparin, metoprolol succinate, metronidazole, sodium bicarbonate, and venlafaxine. The MAR and progress notes lacked documentation that the MD or pharmacy were contacted about the missed doses, and the record did not show that the pharmacy was notified of the admission or that meds were obtained from a back-up pharmacy or the EDK, even though some ordered meds were listed as available in the EDK.
A resident with right-sided hemiplegia was not accurately assessed in the MDS, as the assessment failed to document her upper extremity range of motion (ROM) limitation despite clear evidence from medical records, staff interviews, and care plans. Staff confirmed the resident could not use her right arm or hand, but the MDS Coordinator and DON acknowledged the impairment was not coded as required.
Three residents with cognitive impairment and upper or lower extremity limitations did not have proper assessment, documentation, or communication of interventions such as hand splints and tray tables. Staff were unaware or only informally notified of these devices, and there were no timely physician orders or care plan updates, contrary to facility policy.
A hospice nurse conducted a resident assessment and took vital signs in a dining area during meal service, violating the resident's privacy and dignity. The resident, who had severe cognitive impairment and was on hospice care, was assessed in the presence of other residents and staff. The facility's policy emphasizes the importance of privacy and dignity in care.
A resident with Alzheimer's and cognitive impairments was found without accessible call light devices, as observed in a hot room with reddened cheeks. The resident's call lights were out of reach, and a CNA confirmed the lack of accessibility. The DON noted that residents with mobility or cognitive issues could have soft touch call devices, which were later installed by the Administrator. The facility's policy requires call light accessibility and timely response.
A facility failed to implement a pharmacy recommendation for a gradual dose reduction of Zoloft for a resident with major depressive disorder and dementia. Despite agreement from the physician and psychologist, the order was not documented or executed until over a year later due to the DON's unexpected absence and lack of verification by the ADON.
A registered nurse in an LTC facility improperly handled medications by placing them in her bare hand and failed to prime insulin pens before administration, leading to a medication error rate over 5%. Additionally, the nurse did not instruct a resident to swish and spit after administering an inhaled corticosteroid, contrary to prescription directions.
The facility failed to properly label and dispose of insulin vials and pens, as observed on two medication carts. A multidose vial of insulin was found without an opening date, and two insulin pens were not discarded within 28 days as required. Interviews revealed staff confusion about the correct expiration period, despite facility policies aligning with FDA guidelines.
During a snack distribution, an Activity Assistant and a CNA were observed handling fudge round cream cookies with bare hands and distributing them to residents without using gloves or hand sanitizer. Interviews with staff confirmed that the facility's protocol required the use of gloves or packaging to handle food items. The Administrator acknowledged the issue and referred to the facility's existing food safety policy.
A facility failed to document insulin administration for a resident with multiple diagnoses, including diabetes. Physician orders required administering Lispro Insulin per a sliding scale and Basaglar KwikPen U-100 Insulin at bedtime. However, several doses were not documented in the EMAR for September and October. The resident was cognitively intact and had been administered insulin during the assessment period, but the care plan was not followed, and the facility's policy on medication administration was not adhered to.
The facility failed to ensure proper hand hygiene and disinfection of glucometers during resident care. An LPN and an RN were observed not following handwashing protocols, turning off faucets with bare hands. Additionally, they did not adhere to the manufacturer's guidelines for disinfecting glucometers, failing to keep the device wet for the required two minutes. The RN admitted to not knowing the necessary wet time for effective disinfection.
The facility failed to provide adequate wound care for two residents, leading to deficiencies in pressure ulcer management. One resident with a history of amputation complications had a dressing that was not changed as per physician orders, and the wound condition worsened. Another resident, with a history of stroke and COPD, was observed without prescribed heel boots and with an outdated dressing. Facility policies on dressing standards and skin condition management were not consistently followed, resulting in these deficiencies.
Failure to Follow EBP and Laundry Infection Control Practices
Penalty
Summary
The facility failed to follow infection control measures when handling clothing and waste for residents on Enhanced Barrier Precautions (EBP) and residents with multidrug-resistant organisms (MDROs). During an observation, Receptionist 1 was seen walking out of Resident C and Resident D’s room wearing gloves and carrying a pile of clothing in her hands without a bag, and the clothing would brush against the front of her shirt as she walked. She stated the clothes were dirty items she was taking to the soiled utility and that she could not find a bag, so she carried them while wearing gloves. Resident C was cognitively intact, used a walker and/or wheelchair, required substantial to maximum assistance with bathing, dressing, transfers, and toileting, and was occasionally incontinent of bowel. His care plan required EBP related to colonized targeted MDRO and indwelling devices, with staff to wear gown and gloves depending on bodily fluid exposure. He stated he had not observed staff putting on a gown when entering his room for catheter care and bowel incontinent care, and that dirty clothing and linens were carried out in a clear plastic bag rather than a red bag. Resident D was cognitively intact, used a wheelchair or cane, required staff supervision for showering, and had an indwelling urinary catheter. His care plan required EBP related to colonized targeted MDRO and an indwelling device, with gown and gloves depending on bodily fluid exposure. Resident B had a urinary tract infection and ESBL, moderate cognitive impairment, and required assistance with toileting, transferring, showering, and dressing; her care plan called for isolation related to ESBL in urine and use of protective equipment as indicated. Resident E was cognitively intact, used a walker or wheelchair, had a urostomy and colostomy, and required staff assistance with bathing, dressing, bed mobility, and emptying ostomies; he stated staff rarely, if ever, put on a gown when caring for his ostomies and that his dirty clothing was collected in a clear plastic bag. His physician’s order indicated EBP isolation, but that order was not included in the resident’s health care plan record. Laundry and housekeeping practices also did not match the stated infection control expectations. In the laundry room, a laundry aide was observed folding blankets and towels while resting them on his chest and abdomen; he said he wore gloves when sorting dirty clothing and was trained to wear gloves when processing red bags, but he was not instructed to wear a gown or other barrier and was not aware that some EBP resident laundry arrived in clear plastic bags. The Housekeeping Supervisor stated isolation linens should be placed in a red bag and laundry staff were to gown and glove when handling this clothing and linens, while the Infection Preventionist stated that in isolation rooms dirty clothing and linens should be placed in a red bag and trash in a separate red bag. The facility policy required PPE use according to policy, transmission-based precautions as recommended by CDC guidelines, and soiled linen to be collected at the bedside and placed in a linen bag, while the EBP policy required targeted gown and glove use during high-contact resident care activities and identified ESBL-producing Enterobacterales as an MDRO covered by the policy.
Failure to Provide ROM and Mobility Support
Penalty
Summary
The facility failed to provide range of motion services or other appropriate interventions to maintain or improve ROM and mobility for two residents reviewed for ROM. One resident with neurocognitive disorder with Lewy bodies and diabetic neuropathy was cognitively impaired and dependent on staff for mobility and positioning. During observations, the resident was seen sitting in a high-back wheelchair with the left arm bent upward at the elbow, the left hand contracted, and nails pressing into the palm. No anticontracture devices were observed in place, and later the resident was again observed slumped low in the wheelchair with the left arm hanging unsupported and a loosely rolled washcloth in the left hand. The medical record lacked documentation of contractures, preventive measures, ROM treatments, or orders for ROM, and the care plans lacked documentation of contractures and preventive measures. Staff interviews showed that therapy had been discontinued after the resident acted afraid, that the facility did not provide a restorative program in the memory care unit, and that CNA staff only provided ROM when moving or dressing residents rather than active or passive ROM. An LPN acknowledged the resident’s left hand was very contracted and that nails were pressing into the palm, but did not know when the contracture started. Another LPN stated the resident would not allow staff to reposition her or move the fingers of the left hand or arm, and that the resident was not receiving a specific ROM program to prevent contractures. The therapy manager stated she had not been informed of the contracture until it was identified during the survey and said anticontracture devices were used to help prevent and limit contractures. A second resident with a history of right femur fracture and Alzheimer’s disease was cognitively impaired and dependent on staff for all daily care needs, including transferring and ambulation. The resident had previously walked with therapy, but therapy was discontinued because the resident resisted and became distressed. The resident’s POA reported the resident had been walking and receiving PT in the hospital but declined rapidly after returning to the facility and was no longer walking. Observation showed the resident sleeping in bed with the head hyperextended, the bed in low position, a padded mat on the floor, and the call light lying on the foot of the bed. The care plan contained outdated functional rehabilitation interventions and lacked updated specific interventions to prevent decline in ADLs. Staff and the DON acknowledged that ROM should have been followed as recommended by therapy, but the facility had not been providing ROM as recommended by PT, and there was no specific documentation of staff education regarding ROM and decline in mobility.
Dietary Staff Failed to Follow Infection Control and Dishwashing Procedures
Penalty
Summary
The facility failed to ensure dietary staff were trained and competent in infection control measures to prevent food borne illness during observations of the dietary department. During a kitchen observation with the Dietary Manager, the dishwasher temperature was not within the recommended range for sanitation, and review of the temperature logs showed the logs were incorrect. The Dietary Manager confirmed the documentation had been recorded inaccurately by an employee. During multiple observations, the Dietary Manager washed her hands and dried them on rolled damp paper towels that were placed on top of the counter in the food prep area because the paper towel dispenser was not working. The Dietary Manager acknowledged the paper towels were not sanitary. During interviews, the Dietary Manager asked whether disposable plates and utensils should be used because the dishwasher temperature was not reaching recommended levels, and she did not know whether the service provider had been to the facility to repair the dishwasher. The Assistant Dietary Manager stated she did not know the risks if food was served on dishes that had not been sanitized, and the Dietary [NAME] stated that unsanitized dishes could cause illness to residents including stomach issues.
Food Safety and Ice Handling Deficiencies
Penalty
Summary
The facility failed to ensure frozen foods were dated before use and failed to ensure the dishwasher was sanitizing dishes and utensils at the recommended temperatures during multiple dietary observations. During a kitchen observation, the dishwasher was found running below the facility’s documented wash and rinse temperature standards, and the Dietary Manager acknowledged the temperatures were not appropriate and that the temperature log entries showing the same wash and rinse readings for every meal were inaccurate. Frozen eggs, frozen chicken, and frozen angel food cakes were also observed in the freezer without dates marked on them, despite the facility policy requiring food to be clearly marked with the date or day by which it should be consumed or discarded. Hand hygiene practices in the food prep area were also observed to be unsanitary because the paper towel dispenser was not working, and the Dietary Manager and a Dietary Aide dried their hands using damp rolled paper towels placed on a counter in the food prep area. The Dietary Manager stated the dispenser batteries were low and later confirmed the dispenser was still not working during a follow-up observation. The Administrator stated he had not been informed of the dishwasher temperature issue on the day it was first identified. The facility also failed to ensure ice was distributed in a sanitary manner during lunch meal service in the main dining room. A CNA used an ice scoop to serve drinks to two female residents and returned the scoop to the ice container with the scoop and handle in contact with the ice. A QMA later observed the scoop in the ice container and moved it to an empty plastic container without sanitizing it first. The Activity Director stated the scoop should not be stored in the ice container and should have its own container when not in use, and the facility policy stated ice scoops should be cleaned every 24 hours and stored outside the bin or cart after each use.
Resident Information Left Exposed During Medication Administration
Penalty
Summary
The facility failed to ensure resident personal information was protected from exposure during medication administration observations involving three residents. On 1/8/26 at 8:28 a.m., an LPN used the desk computer at the nurse's station to rectify medications for Resident 34, then left the nurse's station to administer the medications while the resident's personal information remained exposed on the computer screen without being closed or covered. The LPN stated she was using the desk computer because the laptop on the medication cart would not stay charged. The same sequence occurred later that morning for Resident 78 at 8:41 a.m. and Resident 8 at 8:59 a.m. The LPN again used the desk computer to rectify medications and left the nurse's station to administer them without closing or covering the screen, leaving resident personal information exposed. During interview, the DON stated the expectation was that resident personal information be covered when the nurse was away from the cart or desk, and that the nurse should have been using the computer on the cart if possible. The DON also provided the facility's confidentiality policy, which stated that paper notes and/or electronic medical records or reminders with resident personal or medical information shall not be left unattended or viewable by unauthorized persons.
Failure to Update Fall-Prevention Interventions
Penalty
Summary
The facility failed to initiate or revise interventions to prevent falls for a resident with a history of repeated falls and significant mobility and cognitive impairment. The resident had diagnoses including a right femur fracture, right hip pain, and Alzheimer’s disease, and a significant change MDS indicated the resident was cognitively impaired and dependent on staff for all daily care needs, including transferring and ambulation. The care plan identified the resident as at risk for falls related to weakness, gait and balance deficits, medications that may cause dizziness, and changes in routine and environment, with interventions such as assistance with transfers, nonskid footwear, call light access, and clutter-free pathways. The record showed multiple falls over time, including falls in the resident’s room, dining room, doorway, and while attempting to stand from a wheelchair or bed. Documentation after these events often lacked evidence of vital signs, lacked documentation that the resident was wearing nonskid footwear, and lacked evidence of new or specific interventions to prevent additional falls. After the resident fell on 9/22/25 and was sent to the hospital with a right hip fracture, the record lacked documentation of new fall-prevention interventions when the resident returned to the facility. After another fall on 11/12/25, the only documented intervention was adding a touch pad call light, and the record still lacked documentation of new interventions to prevent falls. During observations in January 2026, the resident was seen lying in bed with the bed in low position, a padded mat on the floor beside the bed, and the call light lying on the foot of the bed. Staff interviews indicated the resident had previously walked with therapy but therapy was discontinued because she resisted, the facility did not provide a restorative program in the memory care unit, and preventive measures included keeping the resident in her wheelchair at the nurse’s station to observe and prevent falls. The MDS nurse stated care plans would be updated after falls, but she did not enter therapy care plans, and the DON acknowledged staff should look at why the resident fell and enter specific interventions. The facility policy stated fall events would be reviewed by the IDT to establish root cause and update interventions and treatment plans as needed.
Missing catheter orders and improper catheter bag handling
Penalty
Summary
The facility failed to ensure a resident had a physician's order and care plan for an indwelling urinary catheter, and failed to ensure the catheter tubing and drainage bag were kept off the floor and maintained in a dignified manner. During observation, the resident’s catheter bag was seen in contact with the floor, the tubing was later observed in contact with the floor, and the drainage bag was positioned so urine was exposed to view from the hallway. The resident was sitting in a wheelchair in her room during these observations. Record review for the resident showed a history of urinary tract infections and overactive bladder, with documentation of UTIs on multiple occasions. The quarterly MDS indicated the resident was dependent with toileting, always incontinent of bladder, and had no documentation of an indwelling urinary catheter. The record also lacked a catheter care plan and lacked physician’s orders showing the catheter was ordered on admission. Nursing assessments and progress notes reviewed for the resident did not document an indwelling urinary catheter. The record further showed a physician’s order on 12/14/25 to remove the catheter and start a voiding trial, and another order on 12/16/25 to anchor a Foley if retaining urine over 200 ml and no voiding within 6 hours. However, the record lacked documentation of the results of the voiding trial to justify placement of a catheter, and later review found no documentation of orders or nursing notes showing when the catheter was removed. The DON stated she was not aware there were no orders for the catheter, believed the resident came with one on admission, and was unable to find documentation or orders for the new catheter or its removal.
Pharmacy Recommendations Not Documented or Addressed Timely
Penalty
Summary
The facility failed to ensure a licensed pharmacist’s monthly drug regimen review was handled according to its policy for irregularity reporting. For Resident 11, who had diagnoses including diabetes mellitus, overactive bladder, and chronic kidney disease stage 3 and was cognitively intact on the significant change MDS assessment, a pharmacy recommendation dated 11/5/25 asked whether phenazopyridine 100 mg daily, which had been continued since return from the hospital, could be discontinued. The physician marked the recommendation as disagree and signed it on 11/19/25, but the medical record did not contain a documented rationale explaining why the recommendation was declined. During interviews, the DON stated she was unsure whether documentation existed for the physician’s reason for declining the pharmacy recommendation and later said she could not find any rationale in the record. She also stated she was new to the role and was still learning the regulations for pharmacy recommendations. The DON provided the facility’s Medication Regimen Review policy, which stated that written communications from the pharmacist become a permanent part of the resident’s medical record and that pharmacy recommendations requiring physician action are to be brought to the physician’s attention in a timely manner within 7 business days. For Resident 13, who was admitted with hemiplegia/hemiparesis following cerebral infarction, dementia, type 2 diabetes mellitus, and pain, a pharmacy review dated 8/9/25 noted the resident had been receiving Norco 5/325 mg every 6 hours routinely since 10/20/24 and no symptoms of pain were noted on the most recent assessment. The pharmacist recommended changing Norco to three times per day, and the attending physician agreed, but the facility did not change the medication administration to TID as recommended. A later physician order dated 9/10/25 instead directed hydrocodone-acetaminophen 5/325 mg four times a day for pain. Review of the vital signs record and MAR from 8/1/25 to 1/5/26 lacked documentation of pain assessment, and the DON acknowledged the record lacked pain level documentation and that if a resident was not experiencing pain, the nurse should notify the physician and request reduction or discontinuance of routine pain medication.
Failure to Document Pain Assessment With Routine Narcotic Administration
Penalty
Summary
The facility failed to assess a resident for pain and administered a routine narcotic medication without documentation of pain symptoms for one resident reviewed for unnecessary medications. The resident had a history of hemiplegia and hemiparesis following cerebral infarction, dementia, type 2 diabetes mellitus, and pain. The annual MDS indicated the resident was cognitively impaired, required maximum assistance for daily care needs, and received opioid medications during the assessment period. The care plan addressed pain and included interventions such as medications as ordered, routine observation for effectiveness, use of a numeric pain scale, and interventions before pain became severe. The resident had orders for acetaminophen as needed for pain, hydrocodone-acetaminophen 5-325 mg four times daily for pain, and an order to evaluate pain using a verbal rating, FACES scale, or PAIN scale and to record pain ratings each shift. A pharmacy review noted the resident had been receiving Norco 5/325 mg every 6 hours routinely since 10/20/24 and that no symptoms of pain were noted on the most recent assessment; the pharmacist recommended changing the medication to three times daily, and the attending physician agreed, but the facility did not change the administration to TID. Review of the vital signs record and MAR from 8/1/25 to 1/5/26 lacked documentation of pain assessment. During interviews, an LPN stated she would assess pain at least every shift, and the DON acknowledged the record lacked documentation of pain level and that if a resident on routine pain medication was not experiencing pain, the nurse should notify the physician and request reduction or discontinuance.
Medication Error Rate Exceeded 5 Percent During Observed Pass
Penalty
Summary
The facility failed to ensure it was free of a medication error rate greater than 5 percent during observation of medication administration for 3 of 7 residents. Surveyors observed 26 opportunities for error and identified 3 medication errors, resulting in an 11.54 percent medication error rate involving Residents 34, 78, and 8. During the medication pass, an LPN administered fluticasone propionate nasal spray to Resident 34 and Resident 78 but did not instruct either resident to pinch off the opposite nostril while the spray was given. The physician’s orders for both residents directed administration of fluticasone propionate nasal spray to both nostrils, and the pharmacist stated the manufacturer’s guidelines required closing the opposite nostril during administration. The DON stated nasal sprays were expected to be administered according to the physician’s order, facility policy, and acceptable standards of practice. The same LPN also administered tiotropium inhalation powder to Resident 8, who inhaled one puff and returned the inhaler, after which the LPN left the room without having the resident rinse and spit as ordered. The DON stated inhalers were expected to be administered according to the physician’s order, facility policy, and acceptable standards of practice.
Medication Bottles Lacked Open Dates
Penalty
Summary
The facility failed to ensure that multi-use vials of medication were labeled with an open date. During observation of medication cart 1 on the back hall, an open bottle of nasal spray for Resident 71 was found without documentation of an open date, and an open bottle of fluticasone propionate nasal spray for Resident 19 was also found without an open date. Resident 71’s record showed diagnoses including nasal congestion, and a physician’s order dated 1/6/26 directed administration of Vicks 12-hour non-aerosol nasal spray, 2 sprays in each nostril, two times a day. Resident 19’s record showed diagnoses including nasal congestion, and a physician’s order dated 10/29/25 directed administration of fluticasone propionate spray 50 mcg, 1 spray in both nostrils, two times a day. During interview, the Unit Manager stated the medications would be dated when the bottles were opened, and that the bottles would be opened when the seal was broken. The DON later provided the facility policy titled, Labeling of Medication and Biologicals, which stated that labels for multi-use vials must include the date the vial was initially opened or accessed.
Catheter Equipment Contact With Floor and Break in Hand Hygiene During Medication Pass
Penalty
Summary
The facility failed to ensure that Resident 21’s indwelling urinary catheter bag and tubing were kept from contacting the floor. During an initial observation on 1/6/26, the resident was sitting in a wheelchair next to the bed and the catheter bag was observed in contact with the floor. During a later observation on 1/7/26, the resident was again observed in the room in a wheelchair, and the catheter tubing was in contact with the floor. The resident’s record showed admission for diagnoses including UTI and overactive bladder, and the events review documented a UTI on 11/17/25 with additional UTIs on 12/11/25 and 12/26/25. The facility also failed to ensure proper hand hygiene during medication administration for 1 of 2 medication administration observations. During an observation on 1/8/26, an LPN washed her hands before setting up her first medication administration, then obtained ice for a visitor and touched the outside of the ice bucket, the ice scoop, and the netting around the ice cart. She then proceeded to set up and perform the initial medication pass without sanitizing her hands again. The DON stated that hand washing and sanitation should always be completed before and after each medication pass, and if the nurse touched anything prior to administration, she should have washed her hands again before starting the administration.
Delayed Medication Availability After Admission
Penalty
Summary
The facility failed to obtain a resident's medications in a timely manner after admission for one of six residents reviewed for pharmaceutical services. Resident B was admitted to the facility at 10:00 p.m. on 12/18/25, and the record showed multiple medication orders dated 12/19/25 that were not available or not administered as ordered because the pharmacy delivery had not yet occurred. The MAR documented missed administrations for ascorbic acid, enoxaparin, metoprolol succinate, metronidazole, sodium bicarbonate, and venlafaxine, with notations such as "pharmacy delivery tonight" and "awaiting from pharmacy." The record also showed that the first dose of several medications was delayed until the next day, while ascorbic acid was missed on multiple dates in December 2025. The MAR lacked documentation that the physician or pharmacy were contacted regarding the missed administrations. A progress note dated 12/18/25 lacked documentation that the pharmacy was notified of the admission or that medications were ordered from a back-up pharmacy. Progress notes dated 12/19/25 also lacked documentation that the physician or pharmacy were contacted about the missed medication administrations. During interview, the ADON stated that when a resident was admitted, orders were entered into the EMR and a medication list should have been faxed to the pharmacy. The ADON stated that if a resident was admitted at 10:00 p.m., the nurse should have used available medications from the EDK and called the pharmacy for stat delivery from a back-up pharmacy. The DON provided the facility's EDK medication list, which showed metoprolol succinate and metronidazole were available, but no documentation was provided that either medication was pulled from the EDK for Resident B. The facility policy stated emergency pharmacy services were available 24 hours a day and described use of the emergency medication supply or special order from the pharmacy.
Inaccurate MDS Assessment for Resident with Hemiplegia
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for one resident. The resident, who had a diagnosis of hemiplegia affecting the right dominant side, was observed sitting in a wheelchair with her right arm resting on a tray table. Documentation in the resident's record, including an admission observation and a physician's progress note, indicated impairment and weakness on the right side. The care plan also identified a self-care deficit related to right-sided hemiplegia. However, the admission MDS assessment did not reflect any functional limitation in range of motion (ROM) for the upper or lower extremities. Interviews with staff confirmed that the resident was unable to use her right arm or hand and relied on her left side for activities of daily living. The MDS Coordinator expressed uncertainty about whether the resident's hemiplegia should have been coded as an impairment in ROM, and the DON later acknowledged that the limitation should have been coded but was missed. The facility's policy, based on the CMS Resident Assessment Instrument (RAI) Manual, requires coding of functional ROM limitations that interfere with daily functions or place the resident at risk, which was not followed in this case.
Failure to Assess, Document, and Communicate Range of Motion Interventions
Penalty
Summary
The facility failed to ensure that limitations in range of motion (ROM) were properly assessed, treated, and that required interventions were effectively communicated to staff for three residents with ROM limitations. For one resident with severe cognitive impairment and upper extremity weakness, hand splints intended to prevent contractures were brought in at admission but not used until several days later. Staff were initially unaware of the splints, and there was a lack of timely physician orders, care plan documentation, and communication between therapy and nursing regarding the use of the splints. The care plan did not reflect the resident's functional limitation in ROM or the presence of hand splints, and therapy notes did not indicate communication of splint use to nursing staff. Another resident with severe cognitive impairment and right-sided hemiplegia was observed using a right-sided tray table for arm support. However, there was no physician order for the tray table, and the care plan did not document its use. Staff interviews revealed that the tray table intervention was communicated informally through verbal reports rather than through formal documentation or assignment sheets. The Director of Nursing was unaware of the tray table's use and could not find documentation or therapy notes supporting its implementation. A third resident with moderate cognitive impairment and left-sided hemiplegia was observed with a left-sided tray table, but again, there was no physician order or care plan documentation for the device. Staff were unsure when the tray table was introduced and relied on verbal communication for such interventions. The facility's policy required that assistive devices be based on comprehensive assessment and included in the plan of care, with staff training and monitoring, but these procedures were not followed for the residents in question.
Privacy Violation During Resident Assessment
Penalty
Summary
The facility failed to ensure that a contracted hospice nurse completed a resident assessment and vital signs in privacy for a resident during meal service. The incident occurred when the hospice nurse entered the dining area of the memory care unit and conducted an assessment on a resident sitting in a Broda chair at a table waiting for lunch. The nurse obtained various vital signs, including a temporal temperature, blood pressure, pulse oximeter reading, heart rate, and arm circumference, while other residents, a licensed practical nurse, and a certified nurse's aide were present. The hospice nurse also leaned in to ask the resident questions about her well-being. The resident involved had diagnoses of unspecified dementia and major depressive disorder and was receiving hospice services. The resident's quarterly Minimum Data Set assessment indicated severe cognitive impairment. Interviews with the LPN, Director of Nursing, and the Administrator confirmed that the hospice nurse should not have conducted the assessment during meal service, as it violated the resident's right to privacy and dignity. The facility's policy on resident rights emphasized the importance of personal privacy and dignity in care.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a call light device was within reach for a resident, identified as Resident 7, who was observed in a Broda chair facing the window with the left side of his face in direct sunlight. The room was hot, and the resident's cheeks were reddened. Two button-press call lights were observed on the beds, not within reach of the resident. A Certified Nursing Assistant (CNA) confirmed the room was hot and that the resident appeared to be leaning to get out of the sunlight. The CNA acknowledged that the resident did not have his call light and provided him with a button-press call light before leaving the room. Further observations revealed that the resident, who had diagnoses including Alzheimer's disease, cognitive communication deficit, and dementia, was resting in bed with two button-press call lights in a recliner at the foot of the bed, again not within reach. The Director of Nursing (DON) indicated that residents with mobility issues or cognitive impairments could have soft touch call devices. The Administrator later installed soft touch call devices for the resident, acknowledging that he was unaware the resident did not have one previously. The facility's policy on call lights emphasized ensuring accessibility and timely response, with special accommodations identified in the resident's person-centered plan of care.
Failure to Implement Pharmacy Recommendation for Dose Reduction
Penalty
Summary
The facility failed to address a pharmacy recommendation for a gradual dose reduction of Zoloft for a resident diagnosed with major depressive disorder and dementia with behavioral disturbance. The recommendation was initially made in October of the previous year, suggesting a reduction from 50 mg to 25 mg daily. Although the physician and psychologist agreed to the reduction, the order was not documented or implemented until December of the following year. This oversight was due to a series of events, including the Director of Nursing (DON) leaving the facility unexpectedly due to a car accident, which resulted in a six-month absence. During the DON's absence, the Assistant Director of Nursing (ADON) and corporate nursing support were responsible for managing unfinished tasks. However, the ADON did not verify the completion of the pharmacy recommendation in the resident's electronic medical record, leading to the oversight. The facility's policy on medication orders requires documentation of changes, but this was not adhered to in this case, resulting in the failure to implement the recommended dose reduction in a timely manner.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure proper handling and administration of medications, resulting in a medication error rate exceeding 5 percent for two residents. During a medication administration observation, a registered nurse placed medications for two residents into her bare hand before transferring them to a medication cup, which is against the facility's policy. Additionally, the nurse did not prime the insulin pens according to the manufacturer's guidelines before administering insulin to both residents. This failure to prime the insulin pens could lead to incorrect dosing. Furthermore, the nurse administered an inhaled corticosteroid to one of the residents without instructing them to swish and spit with water afterward, as required by the medication prescription label directions. The facility's policies on medication administration and insulin pen use were not followed, contributing to the medication errors observed during the survey.
Improper Labeling and Disposal of Insulin Products
Penalty
Summary
The facility failed to ensure proper labeling and timely disposal of insulin vials and pens, as observed during a survey. On two medication carts, a multidose vial of Amaolg insulin prescribed for a resident was found without an opening date, and two Lantus insulin pens for another resident were dated as opened but not discarded within the required 28 days. Additionally, a Basaglar insulin pen for a third resident lacked an opening date, although the prescription label indicated it was opened. These observations indicate non-compliance with the FDA guidelines and the facility's own policy, which require insulin products to be discarded 28 days after opening. Interviews with facility staff revealed a lack of understanding of the correct expiration period for insulin products. An LPN incorrectly stated that insulin vials and pens are good for 30 days once opened, while the DON confirmed the correct expiration period of 28 days. The facility's policy documents, provided by the DON, also specify that insulin pens should be disposed of after 28 days or according to the manufacturer's recommendation. The failure to adhere to these guidelines and policies resulted in the observed deficiencies.
Unsanitary Snack Distribution Observed
Penalty
Summary
The facility failed to ensure snacks were served in a sanitary manner during a random snack distribution observation. On the memory care unit, an Activity Assistant was observed removing fudge round cream cookies from their plastic packaging with bare hands and handing them to seven different residents without using gloves or hand sanitizer. Similarly, a Certified Nurse's Assistant (CNA) was seen in the nutrition room removing a cookie from its packaging with bare hands and giving it to a male resident, then touching the resident's shoulder without using gloves or hand sanitizer. Interviews with staff members, including a CNA and a Qualified Medication Aide (QMA), revealed that the facility's protocol was to use gloves or the plastic packaging to handle food items, indicating that staff should not touch food with bare hands. The Administrator confirmed that staff should not handle food with bare hands and mentioned plans to address the issue. The facility's policy on Food Safety and Sanitation, dated 8/14/2019, was provided, which emphasized handling all foods safely.
Failure to Document Insulin Administration
Penalty
Summary
The facility failed to document insulin administration for a resident, identified as Resident 23, who was reviewed for medication administration. The resident was admitted with multiple diagnoses, including COPD, type 2 diabetes mellitus with diabetic neuropathy, and GERD. Physician orders for the resident included administering Lispro Insulin per a sliding scale and Basaglar KwikPen U-100 Insulin at bedtime. However, a review of the electronic medication administration record (EMAR) revealed that several doses of Lispro sliding scale insulin, Lispro insulin, and Protonix were not documented as administered in September and October. The resident's annual Minimum Data Set (MDS) assessment indicated that the resident was cognitively intact and had been administered insulin during the assessment period. Despite this, the care plan, which included administering medication as ordered, was not followed as evidenced by the missing documentation. The facility's policy on medication administration required signing the MAR after administering medication, which was not adhered to in this case.
Improper Hand Hygiene and Glucometer Disinfection
Penalty
Summary
The facility failed to ensure proper hand hygiene and handling of medical equipment during resident care, specifically during medication administration. On two separate occasions, a Licensed Practical Nurse (LPN) and a Registered Nurse (RN) were observed not following proper handwashing procedures. Both nurses turned off the faucet with their bare hands after washing, which is against the facility's hand hygiene policy that requires using a paper towel to turn off the faucet. This improper handwashing practice was observed during routine handwashing observations. Additionally, the facility did not adhere to the manufacturer's guidelines for disinfecting glucometers used for measuring blood sugar levels. During medication administration, both the LPN and RN were observed cleaning the glucometer with a Sani wipe but failed to keep the device wet for the required two minutes as per the manufacturer's instructions. The nurses set the glucometer aside on a paper towel without ensuring the necessary contact time for effective disinfection. The RN admitted to not knowing the required wet time for the disinfectant to be effective, indicating a lack of awareness or training regarding the proper cleaning procedures for medical devices.
Deficiencies in Wound Care and Pressure Ulcer Management
Penalty
Summary
The facility failed to provide adequate wound care for two residents, leading to deficiencies in pressure ulcer management. Resident S, who had a history of complications from an amputation and other significant health issues, was observed with a dressing on the left foot that had not been changed over the weekend, contrary to the physician's orders for regular dressing changes. The treatment administration record showed missing documentation for several scheduled dressing changes, and the wound condition worsened over time. The Director of Nursing Services was unaware of the facility's policy regarding dating dressings, and the Licensed Practical Nurse confirmed that dressings were usually changed during the day shift. Resident C, who had a history of stroke and chronic obstructive pulmonary disease, was observed without the prescribed off-loading heel boots and with a dressing on the left heel that had not been changed since four days prior. The resident's care plan lacked documentation for the use of heel boots, and the dressing was not changed as per the physician's order. Interviews with nursing staff revealed inconsistencies in the application and dating of dressings, and the Certified Nurse Aide acknowledged the absence of pressure-relieving boots, which were not found in the resident's room. The facility's policies on treatment dressing standards and skin condition management were not adhered to, as evidenced by the lack of proper documentation and failure to follow physician orders for wound care. The Administrator provided the relevant policies, which emphasized the importance of dating dressings and elevating heels to prevent skin impairment, but these practices were not consistently implemented, leading to the identified deficiencies.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 163 citations issued within 25 miles in the last 12 months — including the 4 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Brazil
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cloverleaf Of Knightsville | 1.1 mi | ★★★★★ | 6 | 0 |
| Signature Healthcare Of Terre Haute | 14 mi | ★★★★★ | 19 | 0 |
| Majestic Care Of Deming Park | 14.5 mi | ★★★★★ | 4 | 2 |
| Hickory Creek At Sunset | 15.1 mi | ★★★★★ | 7 | 0 |
| Asbury Towers Health Care Center | 15.5 mi | ★★★★★ | 10 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.