Below average — CMS composite of the measures below.
The next survey window likely opens around November 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 Bethany Home - Brandon during CMS and state inspections, most recent first.
A resident received 2.5 mL of Morphine Sulfate PO instead of the ordered 0.25 mL dose after a CNA/MA medication error. The resident then developed decreased O2 levels, lethargy, respiratory distress, and apnea, and required Narcan. The EMR lacked documentation of post-error assessments, call times to hospice or Ecare, an incident report, and a documented physician order for the Narcan given by hospice.
Failure to Protect Resident Privacy During Vaginal Cream Administration: An RN administered vaginal cream to two residents in a dining area while other residents and staff were present. Both residents had dementia-related cognitive impairment and orders for vaginal cream, and a CNA/MA reported the incident to the DON after witnessing the treatment. Facility policy required resident privacy, dignity, and bodily privacy during personal care and treatment procedures.
Failure to Report Suspected Abuse and Neglect: An RN administered vaginal cream to two residents in a public dining area, and the facility did not report the incident to law enforcement or the ombudsman because it was treated as a dignity concern rather than abuse. In a separate event, a CNA verbally abused a resident during personal care, but the facility did not notify the ombudsman, family, PCP, or the state agency in a timely manner. The residents involved had dementia or severely impaired cognition, and the facility’s FRI substantiated the abuse/neglect allegation for the medication administration incident.
A resident with moderately impaired cognition fell forward from his wheelchair when a CNA pushed him to the dining room without attaching the wheelchair foot pedals, despite a known history of putting his feet down while moving. He hit his face and sustained a forehead lump, nasal abrasions, and a small hand skin tear; staff interviews and the incident report confirmed the CNA had been trained on the pedal requirement and did not follow it.
A CNA/CMA engaged in verbal abuse and neglect by withholding fluids, denying requests for beverages, yelling, and attempting to force-feed several residents in a memory care unit. These actions caused distress and agitation among cognitively impaired residents, and were corroborated by staff observations and interviews.
Advance directive and code status documentation was not consistently completed or available for several residents. Five residents’ PCPs were not involved in the advance directive process at the time the forms were signed, and the EMR contained mismatches between the dashboard, care plan, and scanned code status documents. For one resident, the dashboard showed DNR while the care plan still said full code, and staff reported they relied on the dashboard but could not access the Document Manager where the most current forms were stored.
Respiratory equipment was not managed per policy for multiple residents with COPD, hypoxia, OSA, and acute respiratory failure. Oxygen tubing, humidification bottles, nebulizer tubing, and masks were observed undated, improperly stored, or overdue for replacement, including tubing left on the floor or without a storage bag and a nebulizer machine stored on the floor. Staff and the DON confirmed the facility expected oxygen tubing and humidification bottles to be changed twice monthly and nebulizer equipment to be changed every 7 days, but those expectations were not followed.
Food storage and sanitation were not maintained in a neighborhood pantry room and kitchenette, where clean items were stored on an unclean cart and multiple food and kitchen items were left uncovered or stored directly on dirty shelving. Handwashing sinks in resident areas were observed with food debris and staining, and staff gave conflicting accounts about who cleaned them. Two residents with personal refrigerators also lacked thermometers and temperature logs, and staff stated refrigerator temperatures were not being checked and documented daily as required by the facility’s policy.
Surveyors found infection control failures in utility rooms and throughout the facility, including cluttered clean and soiled utility areas, dirty sinks and floors, missing hopper splash guards, and no PPE available near hopper sinks. They also found expired hand sanitizer dispensers and bottles, along with expired or dried germicidal wipes in multiple locations. The ADON stated there was no set process to check expiration dates on hand sanitizer or germicidal wipes, and maintenance/housekeeping and the DON identified those areas as their responsibility to keep organized and clean.
A resident had a pill left in a cup on his bedside table and said staff sometimes left his meds there for him to take later. The resident had no MD order or documented assessment for self-administration, and staff confirmed that meds should have been observed being taken unless self-administration was authorized. The DON stated that self-administration required a cognition-based assessment and documentation in the medical record and care plan.
Damaged Resident Room Walls Not Maintained: Two residents had extensive wall damage in their rooms, including gouges, chipped paint, exposed drywall, scratch marks, and a large hole behind one bed. Both residents stated the damage occurred when their electric wheelchairs struck or came too close to the walls. Maintenance and housekeeping staff acknowledged awareness of the damaged walls, and the DON stated those departments were responsible for keeping resident rooms maintained, organized, and clean.
An LPN walked away from a medication cart during med pass and left it unsecured and unattended while residents were seated in the dining area. The LPN later stated she made a mistake, and an RN confirmed the cart should be locked anytime the nurse steps away. The facility policy stated the cart must be secured during med pass and locked whenever it is out of view.
Unsecured Hot Liquids Cabinet in Memory Care Dining Area: A memory care dining area had a coffee maker and hot water dispenser stored behind cabinet doors that were not securely locked. The cabinet’s safety device was broken, the cam lock was not engaged, and the dispenser was turned on and measured 170 degrees. A CNA reported residents had wandered toward the cabinet and were redirected by staff, and the admin and maintenance supervisor were unaware the safety devices were broken.
Multiple residents sustained serious injuries after CNAs failed to use whirlpool bath chair safety belts as required and did not follow care plan instructions for mechanical lift transfers. In two cases, residents fell from bath chairs after the safety belt was removed and staff turned away, resulting in fractures and hospitalization. In another case, a resident was transferred alone with the wrong lift device, leading to a leg fracture. Staff interviews and records confirmed that safety protocols were not followed despite prior training.
A resident with a history of falls and moderate cognitive impairment fell forward from her wheelchair and sustained a head laceration requiring sutures when staff transported her without the required wheelchair foot pedals in place. Staff interviews and record review confirmed that the facility's policy mandated the use of foot pedals for wheelchair users, but the pedals were not attached at the time of the incident, leading to the resident's injury.
Two residents with severe cognitive impairment experienced abuse and neglect by CNAs: one was subjected to aggressive handling and verbal abuse during care, while another was left on a bedpan for an extended period, resulting in a skin injury. Both incidents involved failure to follow care plans and required interventions for dependent residents.
A nurse failed to properly document the administration of controlled medications for a resident, leaving medications unattended and incorrectly recording doses of lorazepam and oxycodone. Discrepancies were found between medication cards, controlled drug records, and the MAR, with some doses not documented or signed out as required. These actions resulted in inaccurate records and a lack of proper accountability for controlled substances.
The facility failed to maintain proper sanitation practices in the kitchen and neighborhood kitchenettes, with expired sanitizer test strips and inconsistent dishwasher temperature logs. Additionally, a CNA was observed handling a resident's food with bare hands, contrary to policy. These deficiencies increased the risk of foodborne illnesses for residents.
The facility failed to ensure proper oversight in the food and nutrition services department, as the dietary director was unaware of nursing home kitchen regulations and no food service audits were conducted. The consultant dietitian's visits were undocumented, and the dietary director's responsibilities, including policy development and kitchen maintenance, were not fulfilled. This lack of oversight increased the risk of foodborne illnesses for residents.
The facility failed to maintain privacy and obtain consent for audio and video monitoring devices in residents' rooms. Observations revealed that 13 residents had monitoring devices without proper signage or consent, compromising privacy. Several residents were unaware of the devices, and their EMRs lacked documentation of consent or care plan updates. Staff were not adequately informed about the devices, and the facility's privacy policy did not address their use.
The facility failed to implement an effective grievance process, compromising residents' rights to file grievances and have them addressed. Issues included lack of documentation, investigation, and follow-up on grievances, as well as outdated policies and no formal tracking system. Residents reported unresolved concerns about food quality and missing personal items, while staff interviews revealed inconsistencies in handling grievances.
The facility failed to accurately code MDS assessments for two residents using seat belts in their wheelchairs. One resident, with intact cognition, used a seat belt daily by choice, while the other, moderately cognitively impaired, rarely used it. Observations and interviews revealed discrepancies in MDS coding, with the director of nursing confirming the seat belts were coded as restraints, despite stating they were not used as such.
A CNA suspected of being intoxicated was allowed to work a weekend shift without thorough investigation by the facility. Despite staff reports of strange behavior and the smell of alcohol, the CNA continued working until termination the following Monday. The facility's failure to enforce its policies on alcohol use and conduct a timely investigation represents a deficiency.
Significant morphine dosing error with respiratory depression
Penalty
Summary
The provider failed to ensure a resident was free from a significant medication error when a CNA/medication aide administered 2.5 mL of Morphine Sulfate orally instead of the ordered 0.25 mL dose. The resident had an order for Morphine Sulfate 100 mg/5 mL to be given as needed for pain or shortness of breath. The incorrect dose was 2.25 mL over the prescribed amount. After the incorrect dose was given, the resident developed decreased oxygen levels, lethargy, respiratory distress, and apnea. The resident required Narcan after the medication error. The record states that Ecare, the DON, hospice, and nursing staff were notified, and the resident was monitored after the event. The hospice RN later reported that the resident had shallow breathing with pauses up to 20 seconds and oxygen saturation dropping into the mid to lower 80s before Narcan was ordered. The resident's EMR did not document vital signs or assessments completed after the morphine error, and there was no documentation of the time calls were made to hospice or Ecare. There was also no incident report completed for the medication error, no physician's order documented for the Narcan given by hospice, and the verbal order for Narcan was not entered into the MAR with the ordering physician's name. The DON stated she expected a nursing assessment with respiratory rate, blood pressure, pulse, oxygen, temperature, and orientation or alertness documented after a narcotic medication error.
Failure to Protect Resident Privacy During Vaginal Cream Administration
Penalty
Summary
The provider failed to ensure resident privacy and dignity during the administration of personal care treatments for two residents who had orders for vaginal cream. One resident had an order for conjugated estrogen cream to be inserted vaginally at bedtime three times weekly and had impaired cognitive function related to dementia; her BIMS score could not be completed. The other resident had an order for estradiol vaginal cream three times weekly and had diagnoses including dementia with behavioral disturbances, Alzheimer’s disease, urinary incontinence, CKD stage three, and anxiety; her BIMS was documented as not applicable, indicating severe cognitive impairment. A CNA/MA reported witnessing an RN prepare and instill the vaginal cream in the dining room for both residents, including one resident sitting by the medication cart and another sitting at a dining table, while other residents and staff were present. The CNA/MA notified the DON shortly after the incident because she believed administering vaginal cream in the dining room was not appropriate. The DON acknowledged that the vaginal cream was administered in the dining room and agreed that it was not an appropriate area for that treatment. Facility policies stated that residents have the right to privacy and confidentiality and that staff are to promote and protect resident privacy, including bodily privacy during personal care and treatment procedures.
Failure to Report Suspected Abuse and Neglect
Penalty
Summary
The facility failed to report suspected abuse or neglect to the proper authorities after an RN administered vaginal cream to two residents in the dining room where other staff and residents were present. One CNA/MA reported that the RN pulled the residents’ pants and incontinent briefs down and to the side and placed her hand in the brief to squirt the cream into the vaginal area. The DON and ADON spoke with the RN, who acknowledged the administration method, and the DON told her the medication should have been given in the privacy of the resident’s room. The RN was sent home and later terminated, and the facility’s FRI substantiated the abuse/neglect allegation. The two residents involved had cognitive impairment. One resident had dementia with impaired cognitive function/thought process and an order for conjugated estrogen cream to be inserted vaginally at bedtime on Monday, Wednesday, and Friday for urinary incontinence. The other resident had dementia with other behavioral disturbances, Alzheimer’s disease, urinary incontinence, CKD stage three, and anxiety, with an order for estradiol vaginal cream to be inserted vaginally three times weekly for vaginal health. The facility did not notify law enforcement or the ombudsman about the incident involving these two residents because it did not classify the event as abuse, but rather as a dignity concern. The facility also failed to report a separate verbal abuse incident involving another resident. A CNA was reported to have verbally abused the resident while providing personal care, and the incident was reported to the DON by text message the following day. The resident had severely impaired cognition. The facility did not notify the ombudsman, the resident’s family, or the resident’s physician, and the incident was not reported to the state health department in a timely manner. The DON stated the facility’s process included reporting abuse allegations and resident injuries to DOH, law enforcement, DHS, family members, and the PCP, but those notifications were not made for this incident.
Failure to Use Wheelchair Foot Pedals During Resident Transport
Penalty
Summary
A nursing home failed to ensure a resident’s safety when a CNA pushed the resident in a wheelchair to the dining room without attaching the wheelchair foot pedals as required. The resident had moderately impaired cognition, with a BIMS score of 11, and had a documented history of putting his feet down while the wheelchair was moving and falling forward. According to the facility-reported incident, the resident put his feet down, fell forward onto the floor, and hit his face while being transported in the wheelchair without the foot pedals in place. After the fall, the resident had a raised egg-shaped lump to the center of his forehead, open skin abrasions to the bridge of his nose, and a small skin tear on his right hand between his thumb and pointer finger. The area was cleansed, skin was repositioned, and a steri-strip bandage was applied. Neurological checks were started and were within normal limits. The CNA acknowledged not following the policy requiring wheelchair foot pedals when pushing residents, and staff interviews confirmed that the CNA had been trained on that requirement and had been told by nursing leadership that the pedals were to be used.
Failure to Protect Residents from Verbal Abuse and Neglect by CNA/CMA
Penalty
Summary
The facility failed to protect multiple residents from verbal abuse and neglect by a certified nurse aide/certified medication aide (CNA/CMA). The incident involved the CNA/CMA withholding fluids from residents during meals as a form of punishment for making a mess or for concerns that they would not eat if given drinks. Additionally, the CNA/CMA denied a resident's repeated requests for coffee, yelled at residents, and attempted to force-feed residents by shoving large bites of food into their mouths while yelling at them to eat. These actions caused distress and agitation among the residents, particularly those with significant memory and cognitive decline residing in a secured memory care unit. The report details that the CNA/CMA also scolded a resident for wanting to change her clothes frequently, attributing it to creating extra work and laundry for staff. Staff interviews and record reviews confirmed that these behaviors were observed and reported by another CNA/CMA, and additional staff corroborated the allegations. The affected residents included those with cognitive impairments who were particularly vulnerable to such treatment, and the incidents occurred in a specialized memory care neighborhood designed to provide a structured and supportive environment. Prior to the incident being reported, there were no documented concerns or disciplinary actions related to the CNA/CMA's care or treatment of residents, aside from previous medication administration errors. The deficiency was substantiated through staff interviews and review of the facility's records, which confirmed that the residents were subjected to verbal abuse and neglect by the CNA/CMA during the provision of care.
Advance Directive and Code Status Documentation Not Kept Consistent
Penalty
Summary
The facility failed to involve five sampled residents’ PCPs in the development of their advance directives, and the residents’ code status documentation was not consistently maintained in the EMR. Resident 4, resident 9, resident 19, resident 44, and resident 59 all had code status forms completed by the resident or representative, but none of those forms had been forwarded to the residents’ PCPs at the time of the survey. Review of the forms showed resident 4 signed for DNR, resident 9 signed for DNR, resident 19’s representative signed for DNR, resident 44 signed for CPR/full code, and resident 59’s representative signed for DNR. There were no PCP signatures on any of the forms when reviewed. The EMR review also showed inconsistencies between the dashboard code status, the care plan, and the scanned documentation. Resident 4, resident 9, and resident 19 each had DNR listed on the dashboard and on the care plan, but there was no scanned signed code status form available in the Miscellaneous section, and resident 4 had no documentation anywhere in the EMR regarding code status. Resident 44 had DNR listed on the dashboard, but the care plan still contained an intervention stating, "I am a FULL CODE," and the most recent scanned code status form available in the Miscellaneous section indicated the resident wanted CPR if in cardiac arrest. Resident 59 had DNR listed on the dashboard, but her care plan did not include code status and there was no scanned signed code status form in the Miscellaneous section. Interviews confirmed that SSD F was responsible for obtaining code status forms, having them witnessed, forwarding them to the PCP, and scanning the signed forms into the EMR. SSD F stated that the forms for residents 4, 9, 19, 44, and 59 had not been sent to the PCPs until during the survey, and resident 19’s PCP had not yet returned a signed form. LPN V and LPN J stated they would check the dashboard code status before responding to an unresponsive resident, but LPN V also found that resident 44’s accessible scanned form still showed Full Code while the dashboard showed DNR. LPN J stated the floor staff did not have access to the Document Manager section where the most current forms were stored, and she confirmed resident 44’s electronic care plan had not yet been updated even though the paper copy had been changed.
Respiratory equipment was not dated, stored, or replaced per policy
Penalty
Summary
The provider failed to follow its respiratory care policy and provide necessary respiratory care and services for four sampled residents, resulting in inadequate storage, humidification, and replacement of respiratory devices. Resident 49, who had COPD and an order for oxygen via nasal cannula as needed to keep oxygen saturation above 90 percent, was observed with an oxygen concentrator, oxygen tubing stored on top of the concentrator without a date or storage bag, and a nebulizer machine on the floor with tubing and mask attached, undated, and draped over a recliner and blanket rather than stored on a clean barrier. Her EMR showed no documentation that oxygen was used in December 2025 and no orders for scheduled replacement of the humidification bottle, oxygen tubing, nebulizer tubing, or mask. Resident 4, who had an order for oxygen via nasal cannula as needed to keep oxygen saturation above 90 percent, was observed with an oxygen concentrator next to his bed and no markings on the oxygen tubing or humidifier bottle to show when they were last changed. He stated he had used the oxygen when first admitted but had not used it in a long time. His record showed the last documented use of the oxygen concentrator was on 11/19/25, and there were no physician or nursing orders for scheduled changes of the humidifier bottle or oxygen tubing. Resident 8, who had diagnoses of hypoxia and orders for oxygen via nasal cannula as needed and oxygen titration up to 5 liters to maintain saturation above 90 percent, was observed wearing oxygen with a concentrator running at 4 liters, but the connection tube, humidification bottle, and nasal cannula tubing were not dated. She also had a nebulizer machine with tubing wrapped around it, and the tubing was not dated. Resident 10, who had obstructive sleep apnea and acute respiratory failure with hypoxia and orders for CPAP at night and oxygen as needed, was observed with a humidification bottle and oxygen tubing dated 10/26, with the tubing on the floor and no storage bag. Interviews with nursing staff and the DON confirmed that oxygen tubing was expected to be changed twice monthly, dated, and stored in a bag when not in use, humidification bottles were to be changed on the same schedule, and nebulizer tubing and masks were to be replaced every seven days and stored on a clean barrier; the DON also stated nebulizer machines should not be stored on floors.
Food Storage, Sink Sanitation, and Resident Refrigerator Monitoring Deficiencies
Penalty
Summary
Food safety requirements were not maintained in the Maple Valley neighborhood pantry room and kitchenette, and the [NAME] Creek neighborhood handwashing sinks were not kept clean and sanitary. In the Maple Valley pantry room, clean drinking cups, coffee mugs, silverware wrapped in napkins, a water pitcher, and a plate guard were stored on a towel on a wheeled cart that had multiple dried white-colored runs on the inside lip near the clean kitchenware. Additional items in the pantry were stored directly on shelving surfaces, including a rolling pin, muffin tin, opened plastic bag of Styrofoam food storage boxes, lidded plastic cup with straw, stacked bowls, plastic water pitcher, measuring cup, insulated lids, plastic cups, dish rags, Styrofoam cup lids, open sleeves of lids and cups, plastic forks, a sanitizer spray bottle, an opened box with plastic spoons and Styrofoam cups, a baking sheet with a plastic fork on it, Styrofoam plates and plastic lids, cleaning supplies, and used flower vases. A Dirty sign remained on one shelving unit, and the clean and dirty storage areas were not clearly organized or maintained. In the Maple Valley kitchenette, Styrofoam bowls, plates, canned soup, and snacks were stored in a cabinet whose doors and shelves appeared coffee-stained. Two soiled oven mitts and scissors were stored in the top drawer with a spatula and tongs. The DON stated that nursing and dietary staff were expected to maintain the pantry and kitchenette, but there was nothing for staff to refer to regarding expectations, responsibility, or frequency for cleaning and maintaining those areas. The DM stated nursing staff were responsible for maintaining those areas and returning dirty carts to the kitchen, while dietary staff returned cleaned carts to the neighborhood. Resident refrigerator monitoring was not implemented for two residents with personal refrigerators. Both residents had food items stored in their refrigerators, including opened condiments and food packages, and neither refrigerator had a thermometer or a temperature log present. One resident said his children were responsible for cleaning and disposing of expired food items and that staff checked the refrigerator temperature about once a week; the other resident said he was unsure whether staff checked the temperature daily. The DON stated housekeeping was responsible for checking resident refrigerator temperatures daily and maintaining logs, and that thermometers should have been in each refrigerator. The maintenance supervisor stated no resident refrigerator temperatures had been completed and no logs had been maintained, and housekeeping staff stated they had not checked or documented any resident refrigerator temperatures. The [NAME] Creek neighborhood handwashing sinks were observed with food debris and staining. One sink in the pantry room had unidentified food scraps that appeared to be tomato skins stuck to the drain catch, another sink in the dining room was stained with what appeared to be coffee or brown-colored rust, and later the kitchenette sink contained food scraps and coffee grounds while the pantry sink still contained the same debris. Interviews with nursing, housekeeping, dietary, and administrative staff showed conflicting understanding of who was responsible for cleaning the sinks, and no cleaning checklist could be found in the binders reviewed.
Infection Control Lapses in Utility Rooms and Expired Sanitizing Products
Penalty
Summary
The provider failed to maintain an infection prevention and control program by allowing clean and soiled utility rooms in the [NAME] Creek and [NAME] neighborhoods to remain cluttered, unkept, and not organized in accordance with the facility’s own expectations. In the [NAME] Creek soiled utility room, surveyors observed a disinfectant dispensing system, an unconnected discharge hose lying in the drain tub, black substance around the caulking of the drain tub, cluttered sink and counter areas, dirty water in a bucket, opened disinfectant containers with lids off, empty jars and a vase, a basin containing cleaning products and a soiled sponge, and visibly soiled floors. The hopper sink was missing its splash guard, the rinse hose was submerged in dirty water, and no gowns, gloves, or goggles were available near the hopper. In the [NAME] Creek clean utility room, surveyors observed items that were not clean or were stored on the floor, including a dirty oxygen concentrator with a humidification bottle, dusty storage containers, boxes of Halloween decorations, dirty drawers, stacked laundry baskets, opened cardboard boxes containing gowns and N95 masks, a dusty wooden stand, and a dirty nebulizer machine. The countertop next to the sink stored unopened and opened boxes of hand soap and N95 masks. In the [NAME] neighborhood clean utility room, the floor and countertops were blocked by multiple cardboard boxes, a maintenance cart, paint supplies, used paint tools, chemicals, and other items. The sink contained used paint pans and containers, the wall behind the sink was soiled with dried tan paint and a white film, and the hopper sink was missing its splash guard with no PPE available nearby. Surveyors also found expired infection control products in multiple areas of the facility. These included expired automatic hand sanitizer dispensers and bottles of hand sanitizer in the common area outside the beauty/barber shop, throughout the [NAME] Creek neighborhood, in the whirlpool tub room, in the dry storage room, and in the kitchen. Surveyors also found expired or dried germicidal wipes, including Micro-Kill and SANI-CLOTH BLEACH wipes, in the whirlpool tub room, clean utility closet, and hallway supply area. The ADON stated there was no set process to check expiration dates on hand sanitizers or germicidal wipes and confirmed the utility rooms were cluttered and unkept. Maintenance and housekeeping staff and the DON stated those areas were their responsibility to keep organized, maintained, and clean.
Medication Left at Bedside Without Self-Administration Order or Assessment
Penalty
Summary
The facility failed to ensure that one sampled resident who had a medication pill at his bedside was assessed for the ability to safely self-administer medications and did not have a physician's order to self-administer medications. During observation and interview, a small white oval pill in a plastic medication cup was found sitting on the resident's bedside table. The resident stated that if he was sleeping, staff would leave his pills on the bedside table so he could take them later, and he swallowed the medication with water when it was observed. Review of the resident's EMR showed that he was admitted to the facility on [DATE], had no physician's order to self-administer any medications, and had no record of medication self-administration assessments. His care plan did not include any medications that he could self-administer. Staff interviews confirmed that the resident was independent with some ADLs, but they did not know whether he had an order for medication self-administration. Staff also stated that if a resident did not have an order to administer medications by themselves, staff were to observe the resident take the medications rather than leave them with the resident. Additional interviews confirmed that the resident did not have an order to self-administer medications and had not been assessed for that ability. The DON explained that if a resident wished to self-administer medications, the nurse would assess cognition and complete the Self-Administration of Medications form by quizzing the resident on the medication name, purpose, side effects, dosage, route, and timing. The provider's policy stated that the IDT assesses cognitive and physical abilities to determine whether self-administration is safe and clinically appropriate, that the decision is documented in the medical record and care plan, and that medications found at the bedside without authorization are to be turned over to the nurse in charge.
Damaged Resident Room Walls Not Maintained
Penalty
Summary
The provider failed to maintain resident rooms in a clean and well-kept manner, free from damage to walls, for two residents in Cottonwood Court. In one resident room, observation showed multiple gouges, chipped paint, exposed drywall, and vertical scratch marks on the walls, bathroom wall, bathroom door frame, and baseboard beneath the window. The resident stated that some of the larger damage occurred when his electric wheelchair caught on the bed and the bed hit the wall, and that the smaller gouges and scratches were caused by moving his electric wheelchair too close to the walls. In another resident room, observation showed numerous gouges with chipped paint on both walls near the door, scratch marks along the wall and baseboard, several gouges with exposed drywall between the bed and dresser, and a hole with exposed drywall and chipped paint behind the bed about the size of a football. The resident stated that the wall damage occurred when he accidentally ran his electric wheelchair into the walls or maneuvered it too close to them. Staff interviews showed that maintenance requests were to be completed on forms and placed in a maintenance box, and that maintenance staff responded quickly to repair requests. Maintenance and housekeeping staff acknowledged they were aware of the damaged walls in the two residents' rooms and agreed it was their responsibility to keep those areas maintained, organized, and clean. The DON stated that maintenance and housekeeping were responsible for maintaining resident rooms and all facility areas organized, well-maintained, and cleaned. The facility's maintenance policy stated that maintenance was responsible for keeping the building in good repair and free from hazards and for routinely scheduled maintenance service to all areas.
Unsecured Medication Cart During Medication Pass
Penalty
Summary
The nursing facility failed to ensure that a medication cart was secured while medications were being administered. During observation on 12/17/25 at 11:35 a.m., an LPN walked away from the [NAME] Way medication cart to speak with a resident in the dining area and left the cart unsecured and unattended. The LPN was not standing at the cart and returned to lock it at 11:41 a.m., while several residents were seated in the dining area. During interview, the LPN stated she recalled walking away from the cart without locking it and said she made a mistake, noting that she usually locked it when she walked away. An RN neighborhood leader witnessed the event and stated she expected the medication cart to be locked anytime the employee administering medications walked away from it and confirmed that medications should be secured at all times. The facility’s 1/2025 Security of a Medication Cart policy stated that the nurse/medication aide must secure the medication cart during the medication pass and that medication carts must be securely locked at all times when out of the nurse's/medication aide's view.
Unsecured Hot Liquids Cabinet in Memory Care Dining Area
Penalty
Summary
The nursing home failed to ensure that the Maple Valley neighborhood dining area was free from an accessible accident hazard when a coffee maker with a hot water dispenser was stored behind cabinet doors that were not securely locked. During observation, the dining area was noted to be part of a memory care unit where residents used the space for meals, snacks, and structured social activities, and some residents were ambulatory while others depended on staff for mobility. The cabinet doors on the countertop were close enough to open easily, had a broken plastic safety device near the top, and the cam lock at the bottom of the right door was not engaged, leaving nothing to prevent access to the equipment behind them. The unsecured cabinet contained a coffee maker with a warmer and hot water dispenser that was turned on and able to dispense hot liquids. When the water temperature was tested, it measured 170 degrees. A CNA stated that residents who wandered toward the cabinet doors had been redirected by staff before opening them, and she was unaware how long the safety device had been broken or whether maintenance knew about it. The administrator and maintenance supervisor stated they were not aware the safety devices were broken or unusable and expected staff to notify maintenance so a temporary measure could be put in place to keep residents safe from potential burns until a permanent solution was available. The facility policy stated that the cabinet containing hot liquids on Maple Valley was to remain inaccessible by childproof locks and that staff were to provide oversight to ensure residents did not access hot liquids when unable to do so safely.
Failure to Follow Safety Protocols During Bathing and Transfers Resulting in Resident Injuries
Penalty
Summary
Certified nursing assistants (CNAs) failed to follow established safety protocols during resident bathing and transfers, resulting in serious injuries to multiple residents. In two separate incidents, CNAs removed the whirlpool bath chair safety belt before the residents were ready to be transferred, leaving the residents unsecured. In one case, a CNA turned away from a resident after removing the safety belt to retrieve nail clippers, and the resident fell forward out of the bath chair, sustaining a pelvic fracture. In another case, a CNA removed the safety belt to dry a resident and turned away, leading to the resident falling out of the chair and suffering multiple fractures, including to the spine, pelvis, and tibia. Both residents required hospitalization for their injuries. Additionally, a CNA failed to follow the care plan for a resident requiring transfer with a mechanical total lift and assistance from two staff members. Instead, the CNA transferred the resident alone and used the incorrect lift device, contrary to the resident's care plan and facility policy. This resulted in the resident sustaining an acute fracture of the proximal tibia in her lower left leg. The injury was discovered later when a bruise was noted, and subsequent assessment and imaging confirmed the fracture. The resident was under hospice care at the time of the incident. Interviews and observations confirmed that staff were aware of the facility's policies requiring the use of safety belts during bathing and the need for two staff members during mechanical lift transfers. Documentation showed that the involved CNAs had previously received training on these procedures. Despite this, the protocols were not followed, directly leading to the residents' injuries during routine care activities.
Failure to Ensure Use of Wheelchair Foot Pedals Resulting in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with a history of repeated falls, traumatic subdural hemorrhage, and moderate cognitive impairment fell from her wheelchair and sustained a laceration to her forehead that required sutures. The incident took place when the resident was being transported in her wheelchair without the required foot pedals in place, contrary to facility policy. The absence of the foot pedals caused the resident to fall forward out of the wheelchair, resulting in injury. Record review showed that the resident had a care plan identifying her as being at risk for falls, with multiple falls reported in the previous six months, including one that led to her current admission. On the day of the incident, staff responded to a call for help and found the resident on the floor, bleeding from her forehead. The injury could not be controlled with pressure, and the resident was transported to the emergency department, where she received sutures before returning to the facility. Interviews with staff revealed that the use of wheelchair foot pedals was expected and outlined in facility policy, which required pedals to be used unless otherwise care planned. However, at the time of the incident, the pedals were not attached to the resident's wheelchair. Staff acknowledged awareness of the importance of using foot pedals, and the director of nursing confirmed that no formal monitoring mechanism was in place to ensure compliance with this requirement.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A cognitively impaired resident residing in a secured memory care unit, who was dependent on staff for activities of daily living and known to be resistive to care, was subjected to verbal and physical abuse by a certified nursing assistant (CNA). The CNA became frustrated while assisting the resident with undressing, aggressively removed the resident's arm from his sweatshirt, and attempted to pry the shirt from his hands, causing the resident to verbally express pain. The incident was witnessed by another staff member, who reported discomfort with the CNA's actions and observed a change in the CNA's demeanor upon realizing she was being watched. The resident had severe cognitive impairment and was unable to be interviewed about the incident. In a separate incident, another cognitively impaired resident who required total staff assistance for toileting and repositioning was left on a bedpan for an extended period of time by a CNA. The resident was unable to reposition herself and was found with linear, slow-to-blanch marks on her buttock, consistent with prolonged pressure from a bedpan. Documentation and staff interviews confirmed that the resident had been placed on the bedpan during the night shift and was not removed until discovered by day shift staff several hours later. The resident's care plan required frequent repositioning and total assistance with toileting, which was not provided as required. Both incidents involved residents with significant cognitive impairment and dependency on staff for care. In the first case, the resident's care plan included specific interventions for resistance to care, such as reassurance and re-approaching after a short interval, which were not followed. In the second case, the failure to remove the resident from the bedpan in a timely manner resulted in a skin injury. The events were substantiated through staff interviews, record reviews, and direct observation, demonstrating failures to protect residents from abuse and neglect.
Failure to Accurately Document and Account for Controlled Medications
Penalty
Summary
A deficiency occurred when a nurse failed to correctly document the administration of controlled medications for a resident. Specifically, the nurse left controlled medications unattended on top of a medication cart and incorrectly signed out three doses of lorazepam on the controlled drug record, while the actual medication card count did not match the documentation. Additionally, the nurse signed out doses of oxycodone on the medication administration record (MAR) but did not document the administration of lorazepam in the MAR, and a scheduled lorazepam dose was documented at a different time. There were also discrepancies in the narcotic count sheets for both lorazepam and oxycodone, with mismatched counts between the medication cards and the controlled drug records. Further review revealed that another nurse administered a dose of oxycodone but failed to sign it out on the controlled drug record. During shift changes and narcotic counts, discrepancies were noted, and requests to correct the narcotic records were not immediately addressed. The nurse responsible for the errors admitted to incorrectly signing out doses and not documenting medication administration in the MAR. These actions and inactions led to inaccurate records and discrepancies in the accountability of controlled substances for the resident.
Sanitation and Food Handling Deficiencies
Penalty
Summary
The facility failed to ensure proper sanitation practices in the main kitchen and neighborhood kitchenettes, leading to potential risks of foodborne illnesses for residents. Observations revealed that staff were unable to verify the chemical sanitation levels required for cleaning kitchen surfaces, as the sanitizer test strips were expired and not used. Additionally, there was no system in place to document the testing of sanitizer solutions, and the dishwasher temperatures were not consistently recorded, with some rinse cycles failing to meet the manufacturer's required minimum of 180 degrees Fahrenheit. In the neighborhood kitchenettes, the dishwashers were not consistently reaching the required rinse temperature of 180 degrees Fahrenheit, as specified by the manufacturer's manual. Maintenance staff were responsible for overseeing the dishwashers but did not keep logs of temperature checks, and the dishwashers were only monitored about once every three weeks. This lack of consistent monitoring and documentation increased the risk of unsanitary dishware being used for resident meals. Furthermore, a hospice CNA was observed assisting a resident with eating a sandwich using bare hands, contrary to the facility's policy that required the use of gloves or utensils when handling ready-to-serve foods. The CNA later acknowledged the mistake and received additional training. The facility's director of nursing confirmed that the CNA should have worn gloves, highlighting a lapse in adherence to food handling protocols.
Deficiency in Food and Nutrition Services Oversight
Penalty
Summary
The facility failed to ensure that the dietitian and dietary director effectively carried out the functions of the food and nutrition services department. This failure was identified through observation, interviews, record reviews, and job description reviews. The dietary director, who had been in her position for two months, was not aware of the regulations applicable to nursing home kitchens and had not seen the necessary policies until the survey week. Additionally, there were no food service-related audits conducted since she started. The consultant registered dietitian visited weekly but did not record these visits, although documentation was made in residents' medical records. The dietary director's position description outlined responsibilities such as consulting with the dietitian, maintaining a clean kitchen environment, and developing policies in compliance with food service regulations. However, these responsibilities were not fulfilled, as evidenced by the lack of oversight in cleaning, sanitization, and record-keeping in the main kitchen and four kitchenettes. The contract for registered dietitian services was not signed by the current facility administrator, and the maintenance director's position description did not include oversight of the kitchenettes or monitoring of dishwasher temperatures. This lack of oversight increased the potential risk of foodborne illnesses for residents receiving meals from these areas.
Failure to Maintain Privacy and Obtain Consent for Monitoring Devices
Penalty
Summary
The deficiency report highlights the failure of the provider to maintain privacy and obtain consent for the use of audio and video monitoring devices in residents' rooms. Observations and interviews revealed that 13 residents had monitoring devices in their rooms, but there was no signage indicating their presence, and consent was not obtained for six of these residents. The devices were used for monitoring purposes, such as fall prevention, but the lack of consent and signage compromised residents' privacy. Several residents were unable to identify the monitoring devices in their rooms, and there was no documentation in their electronic medical records (EMR) indicating that consent had been obtained or that care plans had been updated to reflect the use of these devices. For instance, resident 13's EMR lacked documentation of consent, and the care plan was not updated. Similarly, resident 106 had an audio device in their room without consent or care plan updates, and the device was later removed without explanation. The report also notes that the facility's staff, including newly hired employees, were not adequately informed about the presence and use of these monitoring devices. Interviews with staff members revealed a lack of awareness and training regarding the devices, and the facility's privacy policy did not specifically address the use of monitoring devices. The absence of a formal consent process and the failure to post notices about the monitoring devices contributed to the deficiency in maintaining residents' privacy and confidentiality.
Failure to Implement Effective Grievance Process
Penalty
Summary
The facility failed to implement an effective grievance process, which compromised the residents' right to file grievances and have them addressed appropriately. The provider did not ensure that all written grievance decisions included essential details such as the date the grievance was received, a summary of the grievance, steps taken to investigate, findings, conclusions, and any corrective actions. Additionally, the facility did not maintain grievance documentation for the required period of three years, nor did it make prompt efforts to resolve grievances or keep residents informed of progress. Interviews with residents and staff revealed multiple instances where grievances were not documented or followed up on. Resident 20 expressed ongoing concerns about the quality of food, which were voiced to staff, at resident council meetings, and during care plan conferences, yet remained unaddressed. Similarly, resident 41's husband reported a missing bag of personal items and concerns about the quality of fish served, but these issues were not formally documented or resolved. Staff interviews indicated a lack of clarity and consistency in handling grievances, with some staff not filling out grievance forms for reported concerns. The facility's grievance policy was outdated, and there was no formal grievance tracking system in place. The social services director was unaware of the updated grievance policy and continued to use an outdated form. The life enrichment director documented resident concerns during council meetings but did not fill out grievance forms or receive consistent responses from department directors. The administrator confirmed the absence of a grievance log and formal grievances, indicating a systemic failure to document and address resident grievances effectively.
Inaccurate MDS Coding for Wheelchair Seat Belts
Penalty
Summary
The provider failed to ensure accurate coding of the Minimum Data Set (MDS) assessments for two residents who used seat belts in their wheelchairs. Resident 23, who had intact cognition, used a seat belt on her electric wheelchair by choice and could independently apply and remove it. However, her MDS inaccurately coded the trunk restraint as not used, despite an edit note indicating daily use of the seat belt. Her care plan and restraint assessment confirmed her ability to manage the seat belt independently and her preference for its use for safety. Resident 32, who was moderately cognitively impaired, had a seat belt for wheelchair positioning but rarely used it. Observations showed the seat belt was not fastened, and the resident was unsure of its purpose or her ability to use it. Her MDS inaccurately coded the trunk restraint as not used, with an edit note stating she could remove it herself, although she rarely did. The director of nursing confirmed the seat belts were coded as restraints on the MDS, despite stating they were not used as restraints.
Failure to Investigate Alleged Intoxication of CNA
Penalty
Summary
The facility failed to thoroughly investigate an incident involving a certified nursing assistant (CNA) suspected of being intoxicated while on duty. The incident occurred when staff reported that the CNA was acting strangely and smelled of alcohol during her shift. Despite these concerns, the CNA was allowed to continue working the following weekend without any follow-up investigation by the administration. The police were contacted, but they did not conduct a breathalyzer test as they did not find sufficient evidence of intoxication. The Director of Nursing (DON) was informed of the situation but did not take immediate action to investigate further or remove the CNA from the schedule. The CNA was eventually terminated on the following Monday after a container smelling of alcohol was found in the staff break room. However, the facility's failure to act promptly and investigate thoroughly left residents at risk during the weekend when the CNA continued to work. Interviews with other staff members revealed that they were unaware of any alcohol use in the facility, and the CNA in question had not been seen consuming alcohol. The facility's employee handbook outlines strict policies against working under the influence of alcohol, but these policies were not effectively enforced in this instance. The lack of immediate and thorough investigation into the allegations of intoxication represents a deficiency in the facility's handling of the situation.
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What surveyors actually found near you
We read the 109 citations issued within 25 miles in the last 12 months — including the 1 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.
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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) |
|---|---|---|---|---|
| Avera Prince Of Peace | 9.2 mi | ★★★★★ | 13 | 0 |
| Palisade Healthcare Center | 9.3 mi | ★★★★★ | 5 | 1 |
| Good Samaritan Society Sioux Falls Center | 9.7 mi | ★★★★★ | 19 | 0 |
| Tuff Memorial Home | 10.3 mi | ★★★★★ | 9 | 0 |
| Dow Rummel Village | 10.4 mi | ★★★★★ | 6 | 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.