Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bremond Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to ensure accurate EMR documentation for three residents placed on a secured unit, as required by its Secured Unit Placement policy. Each resident had severe cognitive impairment and was care planned for impaired safety awareness and elopement risk, with interventions specifying residence in a locked or secured environment. However, physician orders authorizing secured unit placement were absent from their EMRs, even though one resident had documented wandering that placed her at significant risk. Interviews with the Corporate DON and the MD confirmed that residents were evaluated and placed on the secured unit without corresponding physician orders being entered into the EMR, contrary to policy requirements.
The facility did not ensure that clinical records were complete and accurately documented for three residents following falls. In one case, a resident's progress notes lacked details about being found on the floor, hospital transfer, and return. Another resident's care plan was not updated after a reported fall and injury. For a third resident, no progress note was made after an unwitnessed fall, despite staff acknowledging the event. These actions did not meet professional standards for health information management.
Surveyors found that the facility did not maintain an area free from accident hazards and failed to provide adequate supervision to prevent accidents, resulting in an environment that posed risks for resident safety.
Dietary staff failed to follow food safety protocols by not wearing required beard guards and not practicing proper hand hygiene during food preparation. One staff member with significant facial hair was observed over clean dishes without a beard guard, and another staff member handled food after touching contaminated clothing without changing gloves. Both staff had received in-service training on these requirements, and facility policy mandates the use of hair restraints and proper glove use to prevent food contamination.
A resident who was unable to perform activities of daily living did not receive the necessary care and assistance from staff, resulting in unmet care needs.
A resident with severe cognitive impairment, depression, and anxiety did not receive required in-room activities for over a month, despite a care plan specifying personalized engagement and one-on-one activities. The resident was found without any stimulation, and both the Activity Director and Administrator acknowledged the failure to provide activities as required by policy.
The facility did not have an infection prevention and control program in place, as observed by surveyors. This deficiency reflects the absence of systematic infection control measures for residents and staff.
A resident with severe cognitive impairment and multiple mental health diagnoses was discharged to a behavioral hospital under emergency detention without the required written notification being sent to the Ombudsman. Although the resident's guardian received a discharge notice, it lacked the Ombudsman's correct information, and the Ombudsman confirmed not receiving any written notice. The ADM admitted to not sending the required notice, and no documentation was provided to show compliance with notification requirements.
The facility failed to maintain food safety and sanitation standards in its kitchen. Observations revealed improper food storage, inadequate hand hygiene, and glove use by dietary staff, and non-compliance with hair net protocols. Partially frozen chicken was left open and unlabeled, and personal items were placed on food prep surfaces. Staff did not consistently wash hands or change gloves between tasks, leading to potential cross-contamination. Additionally, hair nets and beard nets were not worn by all individuals entering the kitchen, increasing the risk of contamination.
Two residents in an LTC facility were found with inadequate personal hygiene and grooming, despite their need for assistance with ADLs. One resident, with rheumatoid arthritis, had unclean and rough nails, while another, with severe dementia, had facial hair and dirty nails. Staff interviews revealed challenges in providing consistent nail care, highlighting systemic issues in meeting residents' hygiene needs.
A resident with cerebral palsy and contractures was improperly transferred by a CNA who did not follow the care plan requiring a two-person assist with a Hoyer lift. The CNA performed the transfer alone without locking the lift's wheels, contrary to facility policy and manufacturer instructions. The resident was not injured but noted that sometimes only one person assisted with transfers. The DON confirmed the expectation for two-person assistance for safety.
A resident with Alzheimer's and Major Depressive Disorder was prescribed psychotropic medications without necessary behavior and side effect monitoring. The facility failed to complete required monitoring for antidepressants and antipsychotics, as revealed by record reviews and staff interviews. This oversight placed the resident at risk of adverse consequences.
A resident with Alzheimer's and Dementia received seven doses of Haloperidol beyond the physician-ordered stop date due to a failure to update the paper MAR with the correct stop date. The facility's continued use of paper MARs, despite having updated the computer system, led to the oversight, placing the resident at risk for adverse side effects.
The facility failed to ensure the Dietary Manager completed the necessary certified Dietary Manager course, posing a risk to residents' nutritional needs. The Dietary Manager admitted to not completing the certification test and lacked proof of course completion. The Registered Dietician Consultant and the facility's Administrator were unaware of the certification deficiency, and the policy on dietary manager qualifications was not provided during the survey.
The facility failed to prepare pureed food according to established protocols, as the Dietary Manager did not measure ingredients or follow recipes, using water instead of recommended liquids. Despite having access to online recipes, the manager relied on personal judgment, which was contrary to the facility's policy. The Registered Dietician Consultant and Administrator acknowledged the importance of following recipes to ensure proper food consistency.
A facility failed to document a resident's education on the benefits and side effects of influenza and pneumococcal vaccines, and the receipt or refusal of these vaccines. The resident's care plan lacked immunization status entries, and staff interviews revealed that the absence of the MDS coordinator led to missed immunizations. Facility policy requires documentation of education on vaccine benefits and risks, which was not followed.
A facility failed to educate and document a resident's COVID-19 vaccination status, as required by policy. The resident, with severe cognitive impairment and multiple diagnoses, did not have records of receiving education or the vaccine itself. The absence of the MDS coordinator led to this oversight, confirmed by interviews with the RNC and DON.
Missing Physician Orders for Secured Unit Placement in EMRs
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records by not obtaining or documenting physician orders for placement of residents in a secured unit, as required by facility policy. For three residents reviewed, the EMR lacked physician orders authorizing their admission or continued stay on the secured unit, despite their being housed there. The facility’s own Secured Unit Placement policy required that placement in the secured unit be clinically indicated, based on a comprehensive assessment, and in accordance with physician orders, IDT recommendations, and resident rights, with documentation including a physician order. One resident was an elderly female with dementia, muscle wasting, delusional disorders, heart failure, gait abnormalities, and lack of coordination. Her quarterly MDS showed a BIMS score of 4, indicating severe cognitive impairment, and no documented wandering behaviors. The census showed she was moved to the secured unit on a specific date, but her physician orders contained no secured unit placement order prior to a later date. Her care plan, however, identified impaired safety awareness and elopement risk related to cognitive impairment, with an intervention that she reside in a locked/secured unit with monitored entry/exit doors. Another resident, an elderly male, was admitted directly to the secured unit with dementia, anxiety disorder, insomnia, hypertension, gait abnormalities, and difficulty walking. His admission MDS showed a BIMS score of 1, indicating severe cognitive impairment, and no wandering behaviors in the prior seven days. His physician orders contained no secured unit placement order, while his care plan documented progressive cognitive impairment with risk for injury or elopement and a goal to remain free from injury and elopement. A third resident, an elderly female admitted to the secured unit with dementia, cognitive communication deficit, lack of coordination, and muscle weakness, had an admission MDS showing a BIMS score of 3 and documented wandering on 1–3 days that placed her at significant risk of reaching a dangerous place. Her physician orders also lacked a secured unit placement order, although her care plan documented impaired safety awareness, elopement risk, wandering behavior, and the need for a secured environment. Interviews with the Corporate DON and the MD confirmed that residents were on the secured unit without corresponding physician orders in the EMR, contrary to facility policy.
Failure to Maintain Complete and Accurate Clinical Records After Resident Falls
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for three residents, as required by accepted professional health information management standards. For one resident, after being found on the floor and sent to the hospital for evaluation, there was no documentation in the progress notes regarding the date and time the resident was found, sent out, or returned to the facility. Interviews with staff confirmed that documentation of the incident and subsequent actions was incomplete, despite facility policy requiring thorough documentation of such events. Another resident reported a fall and sustained a laceration, but the care plan was not updated to reflect this change in condition. The resident's fall risk evaluation indicated a high risk for falls, and the facility's policy required care plan updates after any fall or change in condition. However, review of the care plan showed no revisions following the incident, indicating a failure to follow established protocols for documentation and care planning. A third resident experienced an unwitnessed fall, but no progress note was entered regarding the incident. The DON acknowledged witnessing the resident on the floor and initiating the required assessments and incident report, but admitted that a progress note was not completed as required. Facility policies reviewed by surveyors clearly outlined the need for timely and thorough documentation of incidents, assessments, and care plan updates, which were not followed in these cases.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. This deficiency was identified based on observations and findings by surveyors, indicating that the environment posed risks for accidents and that supervision measures in place were insufficient to prevent such incidents.
Failure to Follow Food Safety Protocols in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in the kitchen, as evidenced by two separate incidents involving dietary staff. In the first incident, a dietary aide with approximately 8 inches of beard growth was observed standing over clean dishes in the dishwashing room without wearing a beard guard. The aide acknowledged that he was expected to wear a beard guard in the kitchen and had previously received in-service training on this requirement, but could not recall the exact date of the training. The dietary manager confirmed that hair nets or caps and beard guards are required for all staff in the kitchen and that it is her responsibility to ensure compliance. In the second incident, another dietary staff member was observed preparing pureed food while wearing gloves, but touched her shirt with her gloved hand and then handled bacon without changing gloves. She admitted to contaminating the bacon and stated that she had been in-serviced on hand hygiene and the need to change gloves after touching contaminated items, such as clothing. The administrator and dietary manager both confirmed that gloves should be changed and hands washed after touching contaminated items, and that clothing is considered contaminated. Review of the facility's policy indicated that all dietary staff must wear appropriate hair restraints and change gloves as needed to prevent food contamination.
Failure to Assist Residents with Activities of Daily Living
Penalty
Summary
A deficiency was identified when care and assistance were not provided to residents who were unable to perform activities of daily living (ADLs) independently. The report notes that residents requiring help with ADLs did not receive the necessary support from staff, resulting in unmet care needs for those individuals. No additional details about the specific residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Provide Required In-Room Activities for Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to provide an ongoing activities program tailored to the comprehensive assessment, care plan, and preferences of a resident with severe cognitive impairment. Specifically, a female resident with diagnoses of depression, generalized anxiety disorder, and unspecified dementia, who was rarely or never understood and unable to communicate her preferences, did not receive in-room activities from early July through mid-August 2025. Her care plan required personalized engagement and at least two one-on-one activities per week to support her psychosocial well-being, but records showed no in-room visits during the specified period. Observations confirmed the resident was found in her room without any form of stimulation, such as television or other activities, and she was not interviewable due to her condition. The Activity Director acknowledged the lapse, stating there was no excuse for the lack of in-room activities and confirming her responsibility to ensure all residents received appropriate activities based on their needs and abilities. The Administrator also confirmed the expectation for in-room activities for residents who require them and recognized the Activity Director's responsibility for implementation and his own role in monitoring the program.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, as the facility did not have an established or operational program to prevent and control infections among residents and staff. The absence of such a program was directly observed and documented by surveyors, indicating a lack of systematic measures to address infection risks within the facility. No specific residents or staff members were mentioned in relation to the deficiency, and no additional details about individual medical histories or conditions were provided in the report.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to provide written notification to the Ombudsman regarding the transfer or discharge of a resident to a behavioral hospital. The resident, a female with severe cognitive impairment as indicated by a BIMS score of 5, had diagnoses including unspecified dementia with psychosis, major depressive disorder, and generalized anxiety disorder. She was discharged under a warrant for emergency detention due to poor and combative behavior that disturbed the peace of the community. While a Notice of Discharge or Transfer was sent to the resident's guardian, it did not include the correct name or address of the Ombudsman, and there was no evidence that the Ombudsman received written notification as required. Interviews confirmed that the Ombudsman did not receive a copy of the discharge notification, and the Administrator acknowledged not sending a written notice to the Ombudsman, despite attempting to reach her by phone. The Director of Nursing provided documentation of the relevant CMS policy and stated that the facility was supposed to follow these procedures. However, at the time of the survey, no documentation was available to show that the required written notice had been sent to the Ombudsman.
Food Safety and Sanitation Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food storage, preparation, and sanitation in its kitchen, as observed during a survey. Partially frozen chicken cubes were found in an open, unlabeled, and undated plastic bag on a food prep table, alongside a personal cell phone. The Dietary Manager acknowledged the potential for contamination from flies or bacteria from the cell phone, yet did not sanitize the area after removing the phone. Additionally, the Dietary Manager used potentially contaminated ladles in food preparation without proper sanitation. The facility's dietary staff did not consistently practice proper hand hygiene and glove use. The Dietary Manager was observed touching various surfaces and personal items without washing hands or changing gloves, leading to potential cross-contamination of food. Similarly, Dietary Aide B donned gloves without washing hands and touched clean plates, while Dietary Aide C touched clean silverware with potentially contaminated gloves. These actions were contrary to the facility's policies and procedures, which emphasize the importance of hand hygiene and changing gloves between tasks. Furthermore, the facility did not enforce the use of hair nets and beard nets for all individuals entering the kitchen, including the Regional Maintenance Director, a contractor, and nursing staff. This oversight increased the risk of hair contamination in food preparation areas. The facility's failure to provide requested in-service training records and policies on food safety further highlighted deficiencies in staff training and adherence to food safety protocols.
Deficiencies in Resident Hygiene and Grooming
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for two residents, leading to deficiencies in personal hygiene and grooming. Resident #15, a male with rheumatoid arthritis, muscle weakness, and chronic pain syndrome, was observed with unclean and rough fingernails, and an odor of bowels on his right hand. Despite his inability to clean or trim his nails due to physical limitations, he reported that staff did not file his nails and left them dirty. His care plan indicated a need for assistance with ADLs, but records showed no refusal of nail care, highlighting a lapse in the facility's provision of necessary services. Resident #18, a female with severe cognitive impairment due to dementia, was found with facial hair and unclean nails. Her care plan required staff assistance for all ADLs, yet observations revealed a lack of attention to her grooming needs. The resident was non-verbal and unable to communicate her needs, further emphasizing the facility's responsibility to ensure her hygiene was maintained. Despite no documented refusal of care, the presence of blackish substances under her nails suggested inadequate cleaning. Interviews with facility staff, including the Director of Nursing (DON), Licensed Vocational Nurse (LVN), and Certified Nursing Assistant (CNA), revealed inconsistencies in the execution of nail care responsibilities. The DON acknowledged the potential health risks associated with poor nail hygiene but did not view facial hair on female residents as a dignity issue. Staff admitted to being too busy to perform comprehensive nail care outside of scheduled shower days, indicating systemic issues in meeting residents' hygiene needs. The facility's policy on ADLs emphasized the importance of maintaining residents' abilities and hygiene, yet the observed deficiencies demonstrated a failure to adhere to these standards.
Inadequate Supervision and Policy Non-Compliance in Resident Transfer
Penalty
Summary
The facility failed to ensure adequate supervision and adherence to care plans for a resident requiring mechanical lift transfers. A certified nursing assistant (CNA) did not follow the care plan for a resident with cerebral palsy, anxiety disorder, abnormal posture, and contractures, which required a two-person assist using a Hoyer lift for transfers. Instead, the CNA attempted the transfer alone, without locking the wheels of the mechanical lift, which is against both the facility's policy and the manufacturer's instructions. The resident, who was cognitively intact and dependent on staff for transfers, was not injured during the incident but reported that sometimes only one person assisted with transfers. The Director of Nursing (DON) confirmed the expectation for two-person assistance for safety. The facility's policy and the Hoyer lift manufacturer's manual both specify the need for two caregivers and the importance of locking the wheels during transfers, which were not adhered to in this instance.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically psychotropic drugs, unless necessary to treat a specific condition as diagnosed and documented in the clinical record. A resident, who had not previously used psychotropic drugs, was prescribed antidepressants Fluoxetine and Trazodone, and the antipsychotic medication Abilify. The facility did not conduct behavior and side effect monitoring for these medications as required. The resident, diagnosed with Alzheimer's Disease, Dementia, and Major Depressive Disorder, was at risk of adverse consequences due to the lack of monitoring. The facility's records showed multiple instances where behavior and side effect monitoring for the prescribed medications were not completed over a period of time. Interviews with staff revealed that monitoring was sometimes missed, and the Director of Nursing acknowledged the expectation for staff to document and check for side effects and behaviors related to psychotropic medications. The facility's policy on medication management emphasized the need to evaluate, assess, monitor, and document the effectiveness of medication regimens, which was not adhered to in this case.
Failure to Limit PRN Psychotropic Medication Orders
Penalty
Summary
The facility failed to ensure that PRN orders for psychotropic drugs were limited to 14 days, as required, for a resident who was prescribed Haloperidol for aggression. The resident, who had Alzheimer's Disease, Dementia, and Major Depressive Disorder, received seven doses of Haloperidol beyond the physician-ordered stop date. The medication administration record (MAR) did not reflect the stop date, leading to the continuation of the medication past the intended period. Interviews with facility staff revealed that the order for Haloperidol was initially entered without a stop date, and although it was later clarified to include a stop date, the MAR was not updated to reflect this change. The Director of Nursing (DON) acknowledged that the order was entered into the computer system with the correct stop date, but the facility continued to use paper MARs, which did not reflect the updated information. This oversight resulted in the resident receiving unnecessary medication, placing them at risk for adverse side effects associated with psychotropic drugs.
Dietary Manager Lacks Required Certification
Penalty
Summary
The facility failed to employ staff with the appropriate competencies and skill sets in the food and nutrition services department, specifically concerning the Dietary Manager. The Dietary Manager, who was hired on 03/04/2019, had not completed the certified Dietary Manager course, which is a requirement for the position. During an interview, the Dietary Manager admitted to starting online classes approximately three years ago but did not complete the certification test. She lacked proof of completing the classes or signing up for the course and was not working under a Registered Dietician license or a Certified Dietary Manager License. The only certification she possessed was a food handler certificate. She did not inform anyone about her lack of certification, and it was not requested until the survey. The Registered Dietician Consultant, interviewed via telephone, confirmed that the Dietary Manager was not working under her license and assumed she had the necessary certification. The facility's Administrator, who had been in the position for three weeks, was unaware of the Dietary Manager's lack of certification. He stated that he was initially focusing on the nursing department and planned to address the dietary department subsequently. The Administrator expected all department heads' licenses to be in their personnel records, but a request for the policy on dietary manager qualifications was not fulfilled at the time of the survey exit.
Failure to Follow Puree Food Preparation Protocols
Penalty
Summary
The facility failed to prepare pureed food by methods that conserve nutritive value, flavor, and appearance, as observed in the kitchen. The Dietary Manager was seen pureeing eggs, bacon, and bread without measuring the ingredients or following any recipes. She used water instead of juice or other recommended liquids when pureeing bread, contrary to the facility's policy. The Dietary Manager admitted to not having or using recipes, relying instead on her judgment and experience to determine the amount of food to puree. The Registered Dietician Consultant confirmed that all recipes were available online and that the Dietary Manager had been shown how to access them. The consultant emphasized the importance of using correct measurements to ensure the proper consistency of pureed food and stated that water should not be used as a liquid in the pureeing process. The facility's Administrator acknowledged the Dietary Manager's experience but did not agree with her method of guessing measurements. The facility's policy required that pureed foods be prepared according to recipes, which was not followed in this instance.
Failure to Document Immunization Education and Status
Penalty
Summary
The facility failed to ensure that a resident's medical records included documentation of education on the benefits and potential side effects of influenza and pneumococcal immunizations, as well as documentation of the receipt or refusal of these immunizations. Specifically, for a resident with severe cognitive impairment, there was no record of education provided regarding the influenza vaccine, and the pneumococcal vaccine was not documented in the resident's immunization records. The resident's comprehensive care plan also lacked entries regarding immunization status. Interviews with facility staff revealed that immunizations should be verified upon admission, and education should be provided if consent is not given. However, due to the absence of the MDS coordinator, the immunizations for this resident were missed. The facility's policy requires documentation of education provided to residents or their representatives about the benefits and risks of vaccines, but this was not adhered to in this case.
Failure to Document and Educate on COVID-19 Vaccination
Penalty
Summary
The facility failed to implement its policy regarding COVID-19 immunization education and documentation for a resident. Specifically, the facility did not ensure that Resident #7, or their responsible party, received education on the benefits, risks, and potential side effects of the COVID-19 vaccine. Additionally, there was no documentation in the resident's medical records indicating whether the resident received the vaccine, refused it, or had a medical contraindication. This oversight was identified during a review of the resident's records, which showed no entries regarding immunization status in the comprehensive care plan, physician orders, or immunization records. Resident #7, a male with severe cognitive impairment, was admitted to the facility with diagnoses including anemia, dementia, and a right femur fracture. The facility's policy requires that immunizations be verified upon admission and that education be provided if consent is not given. However, due to the absence of the MDS coordinator, the immunization process for Resident #7 was missed. Interviews with the RNC and DON confirmed that the facility did not follow its policy, resulting in a lack of documentation and education regarding the resident's COVID-19 vaccination status.
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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 Bremond
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Franklin Nursing Home | 14.5 mi | — | 8 | 0 |
| Golden Years Nursing And Rehabilitation Center | 16.2 mi | — | 0 | 0 |
| Heritage House Nursing And Rehabilitation | 18.6 mi | — | 4 | 0 |
| Crossroads Nursing & Rehabilitation | 21.4 mi | — | 9 | 0 |
| Windsor Healthcare Residence | 25.9 mi | — | 0 | 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 August 2026) and official state health department websites.