Brandon Community Care Center

In the surveyor’s words

From the most serious findings on record at Brandon Community Care Center, in the surveyor’s own words.

• Immediate jeopardy, patternF689Jan 28, 2022

  Amendment 3/24/2022 Upon secondary review with CMS (Centers for Medicare and Medicaid Services) Regional Office staff and State Quality Assurance, the State Survey Agency (SSA) determined the scope and severity of the Immediate Jeopardy to be K, Past Non-Compliance which began on 1/20/2022 and was removed on 1/22/2022, prior to SSA entry on 1/26/2022. Based on observation, interview, record review and facility policy and procedure review the facility failed to provide Resident #1 (Res #1) with the supervision that he required to prevent accidents, hazards of a facility fire, which caused Res #1 severe [CONDITION(S)] and hospitalization , with numerous surgeries of skin grafts. Resident #1 received more than minimal harm from the facility's lack of supervision. […]

• Immediate jeopardy, isolatedF600May 12, 2025

  Based on observation, interviews, and record review the facility failed to protect the residents' right to be free from neglect by not ensuring staff implemented measures to mitigate the risk to prevent elopement for one (1) of six (6) sampled residents, Resident #5. On 5/01/25 at approximately 3:00 PM, the facility failed to prevent Resident #5, a resident who had recently exhibited new exit-seeking behaviors from exiting the facility unnoticed and unsupervised. The facility was unaware of Resident #5's whereabouts for approximately fifteen (15) minutes until a staff member went to his car on break and located her sitting in the passenger seat of his car with the windows up in an unshaded parking space approximately thirty-five yards from the facility entrance at approximately 3:15 PM. […]

• Immediate jeopardy, isolatedF609May 12, 2025

  Based on record review, policy review and interviews it was determined that the facility failed to ensure that allegations of neglect and incident of elopement were reported to the appropriate agencies, including State Agency, in accordance with State law through established procedures for one (1) of six (6) sampled residents, Resident #5. On 5/01/25 the facility failed to report to the required agencies an allegation of resident neglect related to lack of adequate supervision resulting in the elopement of Resident #5. On 5/01/25 at approximately 3:00 PM, Resident #5, who had recently exhibited new exit-seeking behaviors, exited the facility unnoticed and unsupervised. […]

• Immediate jeopardy, isolatedF610May 12, 2025

  Based on record review, policy review and interviews it was determined that the facility failed to initiate a thorough investigation of an allegation of neglect and incident of elopement for one (1) of six (6) sampled residents, Resident #5. On 5/01/25 the facility failed to initiate an investigation of resident neglect related to lack of adequate supervision resulting in the elopement of Resident #5. Resident #5 was out of the facility unsupervised in the parking lot of the facility at shift change and got into a car in front of a sidewalk that led to a busy four-lane boulevard with no barrier or crosswalk. This car belonged to a staff member who found her in his car around 3:15 PM and escorted her back into the facility. […]

• Immediate jeopardy, isolatedF656May 12, 2025

  Based on interviews, policy review and record review it was determined that the facility failed to develop a comprehensive care plan for one (2) of six (6) sampled residents, Resident #5 and Resident #6 On 5/01/25, Resident #5 with documented new wandering and exit seeking behaviors for at least a week eloped from the facility unnoticed and was outside unsupervised for approximately fifteen minutes. Documentation of the resident's change of behavior, including wandering had been reported to her primary healthcare provider with new orders noted for urinalysis to check for urinary tract infection, but the facility failed to identify exit seeking and elopement risk or develop her care plan to provide adequate supervision to prevent elopement. […]