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 Brandon Court during CMS and state inspections, most recent first.
Failure to Notify Physician and RR After Fall-Related Injury: A resident with dementia, depression, anxiety, and a history of falls was found with abrasions to both knees after a CNA discovered the resident on the floor but did not report the event as a fall. The LPN cleaned the injuries and notified the NP, but the resident’s physician and RR were not immediately notified of the change in condition. Later interviews confirmed the resident had likely fallen and had been returned to bed without another staff member present.
Several residents reported ongoing issues with CNAs on the night shift displaying rude and dismissive behavior, such as entering rooms with negative attitudes and turning off call lights without assisting. Despite grievances being forwarded to the Staff Development Nurse and Administrator, the issue persisted, and in-service training did not include the CNAs from the affected shift.
A facility failed to follow proper infection control practices during PEG tube care for a resident. An RN did not perform hand hygiene between glove changes, which was confirmed by the RN, DON, and IP. The resident had a history of dysphagia and severe cognitive impairment. The RN had attended prior infection control training.
Two residents were unable to follow their preferred bathing schedules and clothing choices due to a lack of clean linens and delayed return of personal clothing items. Interviews confirmed the issue, and the facility's Administrator acknowledged the responsibility to ensure residents' preferences are respected.
A facility failed to obtain consent from a resident before changing her private insurance plan, resulting in her disenrollment from managed care without her knowledge. The resident, who was alert and oriented, was notified of the change by mail after her discharge. Interviews confirmed that the disenrollment was processed without her consent, and there was no written authorization for this action.
The facility failed to provide sufficient bath linens, affecting two residents' ability to bathe at their preferred times. One resident reported not having washcloths, preventing her from washing up and getting into her wheelchair. Another resident had to wait for clean linens, delaying her morning routine. Interviews with CNAs confirmed the delay due to unavailable clean linens. The Housekeeping Supervisor admitted the facility was behind on laundry, and the Administrator acknowledged the responsibility to ensure clean linens are available.
Failure to Notify Physician and Resident Representative After Fall-Related Injury
Penalty
Summary
The facility failed to immediately notify the resident’s physician and resident representative after a change in condition involving a resident who was later found to have abrasions to both knees. On the night of 3/15/26, a CNA reported finding the resident on the floor earlier in the evening, but the CNA did not report that the resident had fallen and instead told the LPN that the resident had been found lying in an awkward position in bed. The LPN cleaned the resident’s knees and notified the NP, who ordered an x-ray. The resident’s family later came to the facility on 3/19/26 with concerns about the injuries. Further interviews showed that the CNA eventually admitted the resident had been found on her knees on the floor and had been returned to bed without another staff member witnessing or assisting with the transfer. The NP stated she believed the injuries were consistent with a fall that had not been reported by the CNA. The resident had diagnoses including unspecified dementia with behavioral disturbance, major depressive disorder, anxiety disorder, and a history of falling, and the MDS indicated the resident was unable to complete a BIMS.
Unresolved Grievances Regarding Rude CNA Behavior
Penalty
Summary
The facility failed to resolve grievances regarding rude staff behavior in a timely manner for five residents. These residents reported consistent issues with Certified Nurse Aides (CNAs) on the 11:00 AM to 7:00 PM shift, who displayed rude and dismissive behavior. The CNAs were reported to enter rooms with negative attitudes, using phrases like "What do you want?" and "Didn't someone help you earlier?" Additionally, there were instances where CNAs turned off call lights without providing assistance or explanations. Resident #8 recounted a specific incident where she requested help due to hand pain and muscle weakness, and the CNA responded rudely, questioning her ability to do it herself before reluctantly assisting. Resident #45 also shared experiences of CNAs entering her room with short tempers and expressing irritation at having to assist her. These behaviors were reported during Resident Council meetings, and the Social Services Director confirmed the persistence of these complaints. The Staff Development Nurse acknowledged receiving these grievances and noted that in-service training is typically used to address such concerns. However, a review of the in-service sign-in sheets revealed that none of the CNAs from the 11:00 PM to 7:00 AM shift attended these sessions. The Administrator confirmed that grievances are discussed in morning meetings with a goal of resolving them within 48 hours, but acknowledged the recurring complaints about rude CNAs on the night shift.
Inadequate Hand Hygiene During PEG Tube Care
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices during the care of a Percutaneous Endoscopic Gastrostomy (PEG) tube for one resident. During an observation, a Registered Nurse (RN) did not perform hand hygiene between glove changes while providing PEG tube care. The RN removed the dressing from the PEG tube site, changed gloves multiple times, and cleaned the wound without washing her hands between these actions. This oversight was confirmed by the RN during an interview, where she acknowledged the potential for contamination and infection due to her failure to perform hand hygiene. The Director of Nurses (DON) and the Infection Preventionist (IP) both confirmed that the RN should have performed hand hygiene between glove changes to prevent cross-contamination and reduce the risk of infection. The resident involved had a history of dysphagia and severe cognitive impairment, as indicated by their medical records. The RN had previously attended an in-service training on infection control, as evidenced by her signature on the training sign-in sheet.
Failure to Respect Resident Autonomy in Bathing and Clothing Preferences
Penalty
Summary
The facility failed to ensure that two residents had the opportunity to exercise their autonomy regarding preferences related to their bathing schedules and clothing choices. On the morning of July 30, 2024, Resident #2 was unable to wash up and get into her wheelchair at her preferred time due to the unavailability of clean washcloths. Similarly, Resident #1 had to wait for clean linens to be delivered from the laundry, which delayed her morning routine. She was unable to wear her preferred clothing because her personal items, including slips and undershirts, had not been returned from the laundry. Interviews with CNAs and the Housekeeping Supervisor confirmed the lack of clean linens and the delay in returning personal clothing items. The Administrator acknowledged the facility's responsibility to provide clean linens and ensure residents' preferences for daily routines are respected. Both residents involved had no cognitive impairments, as indicated by their BIMS scores, and had specific medical conditions, including atrial fibrillation and end-stage renal disease, which were not directly related to the deficiency but provide context for their care needs.
Failure to Obtain Consent for Insurance Change
Penalty
Summary
The facility failed to obtain consent from a resident before changing her private insurance plan, resulting in a deficiency. The resident, who was admitted for a short-term stay to receive therapy services following a fall, was enrolled in managed care insurance that allowed for 20 days of therapy. After her discharge, the resident was notified by mail of her disenrollment from the managed care plan, which she had not authorized. Interviews with the resident, her family member, the Business Office Manager (BOM), and the Administrator confirmed that the disenrollment was processed without the resident's consent, and there was no written authorization for this action. The resident was alert, oriented, and capable of making her own decisions, as indicated by her Brief Interview for Mental Status (BIMS) score of 15, which showed no cognitive impairment. Despite the lack of immediate harm or financial loss to the resident during the two months without managed care coverage, the facility's failure to secure consent for the insurance change could have had significant financial implications if the resident had experienced a major illness. The Business Office Manager admitted to using online access to disenroll the resident without evidence of consent, and the Administrator confirmed the lack of written authorization.
Deficiency in Providing Sufficient Bath Linens
Penalty
Summary
The facility failed to provide sufficient bath linens, impacting residents' ability to bathe at their preferred times. On the morning of 7/30/24, Resident #2 reported not having any washcloths available, which prevented her from washing up and getting into her wheelchair at her preferred time. Observations confirmed the absence of washcloths in her room and attached bathroom. Similarly, Resident #1 had to wait for clean linens to be delivered from the laundry, delaying her morning routine. She expressed a preference for getting up earlier, but was unable to do so due to the lack of clean washcloths and bath towels. Observations confirmed the absence of these items in her room as well. Interviews with CNAs revealed that both residents had to wait past their preferred times for morning care due to the unavailability of clean linens. The Housekeeping Supervisor acknowledged that the facility had adequate linens but was behind on that particular day, causing delays in providing clean linens. The Administrator confirmed the facility's responsibility to ensure residents have access to clean linens according to their preferred routines. Resident #1 had diagnoses of atrial fibrillation, congestive heart failure, and chronic peripheral venous insufficiency, with no cognitive impairment. Resident #2 had diagnoses of end-stage renal disease, hypertension, and osteoarthritis, also with no cognitive impairment.
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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.
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Nursing homes near Brandon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brandon Community Care Center | 0.2 mi | ★★★★★ | 2 | 0 |
| Wisteria Gardens | 1 mi | ★★★★★ | 3 | 0 |
| Jnh-jaquith Inn | 4.3 mi | ★★★★★ | 7 | 0 |
| Jnh-jefferson Inn | 4.3 mi | ★★★★★ | 8 | 0 |
| Jnh-madison Inn | 4.3 mi | ★★★★★ | 2 | 0 |
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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.