ElderGrade

Inspection citations at Complete Care At Brackenville Llc

41 citations on record, 2 of which inspectors scored at actual harm or immediate jeopardy. Each one is the state surveyor's own finding, not our summary.

Reading the scope & severity code

A–C

No harm, minimal potential

D–F

No harm, potential for harm

G–I

Actual harm to a resident

J–L

Immediate jeopardy

The letter also encodes how many residents were affected — isolated, a pattern, or widespread. Full explainer.

Citations by survey year

Year Citations Involving harm or jeopardy
2026 1 0
2025 8 0
2024 16 1
2022 16 1
E March 5, 2026 Tag F0610 Complaint investigation Corrected Apr 2026

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

No actual harm, potential for more than minimal harm

D September 15, 2025 Tag F0760 Complaint investigation Corrected Oct 2025

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

No actual harm, potential for more than minimal harm

D September 15, 2025 Tag F0658 Complaint investigation Corrected Oct 2025

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

No actual harm, potential for more than minimal harm

D September 15, 2025 Tag F0656 Complaint investigation Corrected Oct 2025

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

No actual harm, potential for more than minimal harm

D February 14, 2025 Tag F0725 Complaint investigation Corrected Mar 2025

Nursing and Physician Services Deficiencies

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

No actual harm, potential for more than minimal harm

D February 14, 2025 Tag F0700 Corrected Mar 2025

Quality of Life and Care Deficiencies

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

No actual harm, potential for more than minimal harm

D February 14, 2025 Tag F0578 Corrected Mar 2025

Resident Rights Deficiencies

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

No actual harm, potential for more than minimal harm

D February 14, 2025 Tag F0554 Corrected Mar 2025

Resident Rights Deficiencies

Allow residents to self-administer drugs if determined clinically appropriate.

No actual harm, potential for more than minimal harm

E February 14, 2025 Tag F0565 Corrected Mar 2025

Resident Rights Deficiencies

Honor the resident's right to organize and participate in resident/family groups in the facility.

No actual harm, potential for more than minimal harm

D February 2, 2024 Tag F0880 Complaint investigation Corrected Mar 2024

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

D February 2, 2024 Tag F0761 Complaint investigation Corrected Mar 2024

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

No actual harm, potential for more than minimal harm

D February 2, 2024 Tag F0726 Complaint investigation Corrected Mar 2024

Nursing and Physician Services Deficiencies

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

No actual harm, potential for more than minimal harm

D February 2, 2024 Tag F0695 Complaint investigation Corrected Mar 2024

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

No actual harm, potential for more than minimal harm

D February 2, 2024 Tag F0684 Complaint investigation Corrected Mar 2024

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

No actual harm, potential for more than minimal harm

D February 2, 2024 Tag F0641 Complaint investigation Corrected Mar 2024

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

No actual harm, potential for more than minimal harm

D February 2, 2024 Tag F0610 Complaint investigation Corrected Mar 2024

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

No actual harm, potential for more than minimal harm

D February 2, 2024 Tag F0609 Complaint investigation Corrected Mar 2024

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

No actual harm, potential for more than minimal harm

D February 2, 2024 Tag F0600 Complaint investigation Corrected Mar 2024

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

No actual harm, potential for more than minimal harm

D February 2, 2024 Tag F0554 Complaint investigation Corrected Mar 2024

Resident Rights Deficiencies

Allow residents to self-administer drugs if determined clinically appropriate.

No actual harm, potential for more than minimal harm

D February 2, 2024 Tag F0550 Complaint investigation Corrected Mar 2024

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

No actual harm, potential for more than minimal harm

E February 2, 2024 Tag F0812 Complaint investigation Corrected Mar 2024

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

No actual harm, potential for more than minimal harm

E February 2, 2024 Tag F0809 Complaint investigation Corrected Mar 2024

Nutrition and Dietary Deficiencies

Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

No actual harm, potential for more than minimal harm

E February 2, 2024 Tag F0804 Complaint investigation Corrected Mar 2024

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

No actual harm, potential for more than minimal harm

E February 2, 2024 Tag F0725 Complaint investigation Corrected Mar 2024

Nursing and Physician Services Deficiencies

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

No actual harm, potential for more than minimal harm

G February 2, 2024 Tag F0689 Complaint investigation Corrected Mar 2024

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Actual harm to a resident

D July 25, 2022 Tag F0943 Corrected Sep 2022

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

No actual harm, potential for more than minimal harm

D July 25, 2022 Tag F0803 Corrected Sep 2022

Nutrition and Dietary Deficiencies

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

No actual harm, potential for more than minimal harm

D July 25, 2022 Tag F0791 Corrected Sep 2022

Quality of Life and Care Deficiencies

Provide or obtain dental services for each resident.

No actual harm, potential for more than minimal harm

D July 25, 2022 Tag F0685 Corrected Sep 2022

Quality of Life and Care Deficiencies

Assist a resident in gaining access to vision and hearing services.

No actual harm, potential for more than minimal harm

D July 25, 2022 Tag F0684 Corrected Sep 2022

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

No actual harm, potential for more than minimal harm

D July 25, 2022 Tag F0677 Corrected Sep 2022

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

No actual harm, potential for more than minimal harm

D July 25, 2022 Tag F0661 Corrected Sep 2022

Resident Assessment and Care Planning Deficiencies

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

No actual harm, potential for more than minimal harm

D July 25, 2022 Tag F0655 Corrected Sep 2022

Resident Assessment and Care Planning Deficiencies

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

No actual harm, potential for more than minimal harm

D July 25, 2022 Tag F0644 Corrected Sep 2022

Resident Assessment and Care Planning Deficiencies

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

No actual harm, potential for more than minimal harm

D July 25, 2022 Tag F0641 Corrected Sep 2022

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

No actual harm, potential for more than minimal harm

D July 25, 2022 Tag F0561 Corrected Sep 2022

Resident Rights Deficiencies

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

No actual harm, potential for more than minimal harm

E July 25, 2022 Tag F0812 Corrected Sep 2022

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

No actual harm, potential for more than minimal harm

E July 25, 2022 Tag F0688 Corrected Sep 2022

Quality of Life and Care Deficiencies

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

No actual harm, potential for more than minimal harm

E July 25, 2022 Tag F0656 Corrected Sep 2022

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

No actual harm, potential for more than minimal harm

F July 25, 2022 Tag F0880 Corrected Sep 2022

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

Citations are published by CMS from state survey agency findings. A citation describes what an inspector observed on a specific date; homes are required to submit a correction plan, and many findings are resolved long before you read them. Ask the administrator what happened and what changed.