Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
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 Community Place during CMS and state inspections, most recent first.
Improper Storage of Frozen Food: Surveyors observed nine frozen food items in the freezer that were not properly sealed, including sausage, dinner rolls, cobbler crust, bread sticks, lima beans, and frozen cookies. The DM confirmed bags in the freezer and cooler should be sealed to prevent freezer burn and stated the cook was responsible for ensuring food was sealed; the NHA also confirmed dietary staff should have closed the bags to keep food fresh and prevent spoilage.
The facility failed to ensure advance directives were completed and readily available in the medical records for several residents. Despite facility policy requiring this information to be prominently displayed, a review revealed a lack of documentation for residents with various diagnoses, including Hemiplegia and Parkinson's Disease. Interviews with staff confirmed the absence of documentation, with the Admissions Director suggesting it might be stored elsewhere and the Administrator acknowledging a potential training issue.
A resident's right to a dignified existence was compromised when their urinary catheter drainage bag was left without a privacy cover, making the urine visible from the open door. This was against the facility's policy, as confirmed by both a CNA and an LPN. The resident, who was cognitively intact and had a suprapubic catheter, was admitted with a pressure ulcer diagnosis.
A resident with Hemiplegia and Hemiparesis was unable to take showers due to the facility's failure to provide a necessary shower chair, despite the resident's expressed desire and previous use of such equipment. The resident's mother had raised concerns with facility management, who acknowledged the need but did not provide the equipment. The Director of Rehabilitation noted safety concerns without proper equipment, and the Administrator confirmed the resident's right to shower access.
A resident with severe cognitive impairment was inappropriately restrained with a lap tray for fall prevention, contrary to the facility's policy. The lap tray was not consistently removed every two hours as per the physician's order, and the resident had a history of falls despite the restraint. Staff interviews revealed the restraint was used for convenience, and documentation did not support the required removal schedule.
A facility failed to provide necessary nail care to a diabetic resident, resulting in long, dirty, and jagged fingernails. The resident, who is dependent on staff for personal hygiene due to mild cognitive impairment, did not receive the required weekly nail care by an RN as per the physician's order. The ADON confirmed the oversight, which was documented in the resident's records.
A facility failed to prevent catheter contamination for a resident with a suprapubic catheter, as the drainage bag was observed touching the floor multiple times. Staff interviews confirmed this was against facility policy, which aims to prevent catheter-associated infections. The resident, who was cognitively intact and had a pressure ulcer diagnosis, had a physician's order for regular catheter changes.
A resident with Obstructive Sleep Apnea was found to have her CPAP mask improperly stored, as it was left on a dresser instead of in a designated bag. Staff interviews confirmed that the mask should be stored in a bag to prevent contamination and infection. The resident's records indicated an order for the mask to be bagged after each use, which was not adhered to.
A medication cart was found unlocked and unattended with an unlabeled tablet on top, contrary to facility policy. An LPN admitted to leaving the cart unsecured while attending to another resident, acknowledging the safety risk. The ADON confirmed that carts should be locked when not attended by licensed staff.
The facility's Facility Assessment failed to include specific staffing needs by shift, a plan for recruitment and retention of staff, and contingency plans for non-emergency events. The Administrator confirmed these omissions, noting the assessment was completed before regulatory revisions.
A facility failed to ensure proper hand hygiene during PEG site care for a resident. An LPN did not change gloves throughout the procedure, using the same gloves to remove the soiled dressing, cleanse the site, and pat it dry. This was confirmed by the Infection Preventionist and the Assistant Director of Nursing, who stated that gloves should be changed multiple times to prevent infection. The resident had a diagnosis of Gastrostomy Status and a physician's order for daily PEG site cleaning.
Improper Storage of Frozen Food
Penalty
Summary
The facility failed to properly store frozen foods in the freezer, with nine food items observed not being sealed or properly closed. During the initial kitchen tour with the Dietary Manager, surveyors found red sausage in a plastic bag that was not sealed, dinner rolls in a brown box with a plastic liner that was torn open, cobbler crust in a box with a torn plastic bag, bread sticks in a 10-pound box with a torn plastic bag, sausage with a torn liner bag, lima beans in a 30-pound box with a torn plastic liner, frozen sugar cookies in a box with a torn plastic liner bag, frozen chocolate chip cookies with a torn plastic liner bag, and Dean sausage links in a 10-pound box with a torn plastic liner bag. The facility policy on frozen food storage stated that opened boxes with liners should be closed and sealed tightly with packing tape or twist ties. During interview, the Dietary Manager confirmed that bags in the freezer and cooler should be sealed to prevent freezer burn and stated that the cook is responsible for ensuring food is sealed in the freezer and cooler. She also stated that improperly stored food could spoil and make residents sick. The Nursing Home Administrator later confirmed that dietary staff should have closed the bags to keep food fresh and prevent spoilage, and stated his expectation that dietary staff follow rules and regulations for serving safe food and not serving contaminated food to residents.
Advance Directives Not Readily Available in Resident Charts
Penalty
Summary
The facility failed to ensure that advance directives were completed and readily available in the medical records for seven out of twenty-three residents reviewed. The facility's policy on advance directives requires that information about whether a resident has executed an advance directive be prominently displayed in their medical record. However, a review of the medical records for these residents revealed a lack of documentation regarding their advance directive status. The residents involved had various diagnoses, including Hemiplegia, Hemiparesis, Parkinson's Disease, and Hypertension, and had been admitted to the facility over a range of years. Interviews with facility staff, including the Admissions Director and the Administrator, confirmed the absence of readily available advance directive documentation in the residents' charts. The Admissions Director indicated that the documentation might be stored in the facility's storage area rather than in the active medical records. The Administrator acknowledged the issue, suggesting it might be related to a training deficiency regarding the execution of advance directive requirements.
Failure to Provide Privacy Cover for Catheter Bag
Penalty
Summary
The facility failed to ensure a resident's right to a dignified existence by not providing a privacy cover for a urinary catheter drainage bag. During observations, it was noted that the catheter drainage bag of a resident was positioned in a way that made the urine visible from the open door, and it lacked a privacy cover. This was confirmed by both a Certified Nursing Assistant (CNA) and a Licensed Practical Nurse (LPN), who acknowledged that the absence of a privacy cover was against the facility's policy and compromised the resident's dignity. The resident involved was admitted with a diagnosis that included a pressure ulcer of the sacral region and had a suprapubic catheter with specific orders for maintenance. The resident was cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 15. Despite the facility's policy requiring privacy covers for catheter bags to maintain dignity, the staff failed to adhere to this policy, resulting in the deficiency.
Failure to Provide Adaptive Equipment for Resident Showers
Penalty
Summary
The facility failed to accommodate the needs and preferences of a resident who required adaptive equipment to take a shower. The resident expressed a desire to take showers but was informed that no shower chair was available, resulting in reliance on bed baths. A Certified Nursing Assistant confirmed the lack of a shower chair for the resident, despite providing daily bed baths. The resident's mother and representative had previously communicated concerns to the Director of Nursing and the Administrator, who acknowledged the need for a bariatric shower chair similar to one used at a previous facility location. The Director of Rehabilitation evaluated the resident and determined that due to poor upper trunk control, showers were deemed unsafe without appropriate equipment. The Administrator confirmed that the resident should have access to showers and necessary equipment, noting that a suitable chair was left behind during a facility move. An inspection of the current shower chair suggested that with further evaluation and additional staff assistance, it might be possible for the resident to use it. The resident, admitted in 1996, has a diagnosis of Hemiplegia and Hemiparesis and is cognitively intact with a Brief Interview Mental Score of 15.
Inappropriate Use of Physical Restraint for Fall Prevention
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints imposed for staff convenience. The deficiency involved a resident who was observed with a lap tray secured to her wheelchair, which was used to prevent her from falling. The facility's policy stated that restraints should only be used to treat medical symptoms and not for staff convenience or fall prevention. Interviews with staff revealed that the lap tray was used to prevent falls, and it was not consistently removed every two hours as per the physician's order. The resident had a history of falls and severe cognitive impairment, with a BIMS score of four, indicating severe cognitive impairment. The resident's medical records showed a physician's order for the lap tray to be released every two hours for repositioning and ADL care, but documentation indicated that this was not consistently followed. The resident had a history of over 20 falls and had been assessed for restraint use due to unsteady gait, agitated behavior, and frequent falls. Despite the use of the lap tray, the resident had fallen twice in recent months, including once with the lap tray in place. The facility's failure to adhere to the restraint policy and physician's orders resulted in the inappropriate use of a physical restraint for the resident.
Failure to Provide Diabetic Nail Care
Penalty
Summary
The facility failed to provide appropriate nail care to a diabetic resident, leading to a deficiency in personal hygiene maintenance. Resident #31, who has Type 2 Diabetes Mellitus with Hyperglycemia, was observed with long, dirty, and jagged fingernails on multiple occasions. The facility's policy requires that residents who cannot perform activities of daily living independently receive necessary services to maintain good grooming and personal hygiene. Despite this, the resident's nails were not cleaned or cut as required. The Assistant Director of Nursing (ADON) confirmed that two RNs are responsible for providing diabetic nail care, which should occur weekly. However, a review of the resident's records revealed that the RN staff did not document the provision of diabetic nail care on the specified dates. The resident's Comprehensive Minimum Data Set (MDS) indicated a mild cognitive impairment and dependency on personal hygiene, further emphasizing the need for staff assistance. The failure to adhere to the physician's order for weekly nail care by an RN contributed to the deficiency observed by surveyors.
Failure to Prevent Catheter Contamination
Penalty
Summary
The facility failed to adhere to its policy regarding catheter care, specifically in preventing catheter-associated urinary tract infections. During observations, it was noted that a resident with an indwelling suprapubic catheter had their catheter drainage bag in direct contact with the floor. This was observed on multiple occasions, indicating a lapse in following the facility's infection control procedures, which explicitly state that catheter tubing and drainage bags should be kept off the floor to prevent contamination. Interviews with staff, including a CNA and an LPN, confirmed that the drainage bag should not have been touching the floor, as per the facility's policy. The Assistant Director of Nursing also emphasized the expectation that all nursing staff manage urinary catheters according to the policy. The resident involved was admitted with a diagnosis of a pressure ulcer in the sacral region and was cognitively intact, as indicated by a BIMS score of 15. The resident had a physician's order for regular catheter changes, which underscores the importance of proper catheter management to prevent complications.
Improper Storage of CPAP Mask for Resident
Penalty
Summary
The facility failed to ensure the proper storage of a Continuous Positive Airway Pressure (CPAP) mask for a resident, which could lead to potential complications. Resident #47, who has a diagnosis of Obstructive Sleep Apnea and is cognitively intact, reported using her CPAP machine nightly. However, she stated that her CPAP mask was never stored in a designated bag and was left on top of the dresser by her bedside. Observations confirmed that the mask was not stored in a bag, as it was seen on the table during a lunch observation. Interviews with facility staff, including an LPN, the Infection Preventionist, and the Assistant Director of Nursing, confirmed that the CPAP mask should be stored in a bag to prevent it from getting dirty and causing complications. The ADON further explained that the bag should be labeled with the date, and the mask should be cleaned weekly, placed in a clean bag after cleaning, and the bag replaced weekly to prevent infection. A review of the resident's records showed an active order for the CPAP mask to be placed in a bag after each use daily, which was not being followed.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure that medications and a medication cart were properly secured, as observed during a survey. An unattended and unlocked medication cart was found with an unlabeled white tablet in a medication cup left on top of it. This cart remained unattended for approximately three minutes, which is against the facility's policy that requires medication carts to be locked and medications not to be left on top of the cart without supervision. During an interview, an LPN admitted to leaving the medication cart unlocked and unattended while responding to another resident, acknowledging this as a safety issue that could lead to potential medication errors. The Assistant Director of Nursing confirmed that the expectation is for all medication carts to be locked when not attended by licensed staff, and no medications should be left on top of the carts without full nursing supervision.
Facility Assessment Lacks Key Elements
Penalty
Summary
The facility failed to ensure that all required elements were included in their Facility Assessment, which is crucial for determining necessary resources to care for residents competently. The assessment, signed on July 1, 2024, outlined an average daily schedule of direct care staff but did not specify staffing needs for each shift or account for changes in the resident population. Additionally, the assessment lacked a plan for staff recruitment and retention, as well as contingency plans for events that do not necessitate the activation of the emergency operations plan. During an interview, the Administrator confirmed these deficiencies, acknowledging that the Facility Assessment did not address specific staffing needs based on different shifts, time of day, or resident needs. Furthermore, the Administrator admitted that the assessment did not include plans for recruitment and retention of staff or contingency plans for non-emergency events. The Administrator noted that the assessment was completed using a form or template prior to the revision of regulations in August 2024.
Failure in Hand Hygiene During PEG Site Care
Penalty
Summary
The facility failed to ensure proper hand hygiene during the care of a Percutaneous Endoscopic Gastrostomy (PEG) site for a resident. During an observation, a Licensed Practical Nurse (LPN) did not change gloves throughout the procedure, using the same gloves to remove the soiled dressing, cleanse the site, and pat it dry. The LPN acknowledged that gloves should have been changed between removing the soiled dressing and cleaning the site. This was confirmed by the Infection Preventionist and the Assistant Director of Nursing, who both stated that gloves should be changed multiple times during the procedure to prevent cross-contamination and infection. The resident involved was admitted to the facility with a diagnosis of Gastrostomy Status and had a physician's order to clean the PEG site daily. The resident's cognitive status was moderately impaired, as indicated by a Brief Interview for Mental Status (BIMS) score of 10. The failure to change gloves during the procedure was a deviation from the facility's policy, which requires washing and drying hands thoroughly and changing gloves at specific steps to ensure infection control.
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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 Court | 5.9 mi | ★★★★★ | 1 | 0 |
| Brandon Community Care Center | 6.1 mi | ★★★★★ | 2 | 0 |
| Wisteria Gardens | 6.7 mi | ★★★★★ | 3 | 0 |
| Alyce G Clarke Center For Medically Fragile Childr | 8.3 mi | — | 0 | 0 |
| Lakeland Community Care Center | 8.6 mi | ★★★★★ | 5 | 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.