Inspection Reports for
Brookdale Sylvan Ranch

The complaint investigation was based on allegations that the licensee was not following infection control requirements and was not preventing the spread of scabies. The findings were unfounded, meaning the allegations were false or without reasonable basis.

The investigation found that the facility's infection control plan was up to date, staff were trained yearly on infection control, and no current infectious outbreaks or cases of scabies were present. The allegations were determined to be unfounded.

The complaint included allegations that staff did not meet residents' incontinence care needs, handled a resident roughly causing injury, failed to observe residents for changes in condition, served poor quality food, and spoke inappropriately to a resident. All allegations were investigated and found to be unfounded.

All allegations including inadequate incontinence care, rough handling of a resident, failure to observe changes in condition, poor food quality, and inappropriate staff communication were found to be unfounded after interviews and observations during the investigation.

The Licensing Program Analyst conducted interviews and reviewed relevant documents related to the incidents. No deficiencies were cited at this time.

The facility was found to be clean, safe, sanitary, and in good condition with no observed violations of health, safety, or personal rights. Staff files and resident files were reviewed and found to be in compliance with training and clearance requirements. No deficiencies were observed during the inspection.

The complaint investigation addressed multiple allegations including improper medication administration, lack of care and supervision resulting in falls and pressure injuries, food preparation safety violations, serving expired food, rough handling of residents, failure to provide incontinence care products, and pest issues. All allegations were found to be unsubstantiated or unfounded based on evidence and interviews.

The investigation found all allegations to be unsubstantiated or unfounded after reviewing documentation, conducting interviews, and performing audits. No evidence was found to prove violations related to medication administration, resident care, food safety, or pest control.

Allegation: Resident sustained unexplained bruising while in care. The mark was observed on 06/18/24 but was no longer present by 9:00 AM that day. Interviews indicated the resident has a history of self-inflicted slapping and no evidence of staff abuse was found. The complaint was unsubstantiated.

The investigation included interviews and document reviews. The allegation was found to be unsubstantiated as there was no preponderance of evidence to prove the alleged violation occurred. Staff and residents did not express concerns about abuse or safety.

The complaint alleged that staff did not dispense residents' medications as prescribed. This allegation was substantiated based on medication audits and documentation review. Two other allegations—failure to ensure residents were bathed regularly and failure to prevent resident-to-resident hitting—were investigated and found unsubstantiated.

The investigation substantiated that the facility did not ensure residents were given their medications as prescribed, based on medication audits revealing multiple discrepancies for three residents. Two other allegations regarding bathing and prevention of resident-to-resident hitting were found unsubstantiated.

The visit was triggered by a complaint related to an incident reported on 04/25/2024 involving alleged use of force by Staff #1. The complaint was investigated internally by the facility and discussed with the Licensing Program Analyst. No deficiencies were cited.

During the visit, the Licensing Program Analyst and Executive Director discussed the incident and the facility's internal investigation. The resident involved has since moved to a higher level of care. No deficiencies were cited at this time.

The inspection found the facility to be in good condition with no deficiencies cited. Areas toured included resident rooms, common areas, and safety features were verified. Staff files and resident records were reviewed and found compliant.

Allegation: Staff force resident to eat while in care. The investigation included interviews with the Executive Director, four staff members, and seven residents. It was found that residents are self-fed or assisted privately as needed, and no force feeding was observed or reported.

After extensive interviews with the Executive Director, staff, and residents, the allegation was found to be unfounded, meaning it was false, could not have happened, or was without a reasonable basis.

The complaint included allegations that the facility did not have enough staff to meet residents' needs, staff were inadequately trained, and staff did not provide all resident records to the authorized representative. All allegations were found unsubstantiated after review of staff interviews, training records, physician reports, and communication with the resident's responsible party.

The investigation found all allegations to be unsubstantiated. Staff were found to meet training requirements and provide adequate care to residents, including assistance with activities of daily living. The facility did not provide all incident reports to the resident's authorized representative, but these reports were deemed internal documents and not part of resident records.

The complaint alleged that a resident sustained unexplained injuries. The investigation included interviews with eight staff members and review of resident medical and care documents. The fall was unwitnessed and the facility was unsure when it occurred. The resident was not sent to the hospital but was evaluated by a nurse practitioner who ordered an X-ray. The complaint was found to be unsubstantiated.

The investigation found that the resident (R1) had multiple abrasions and injuries with no documented falls at the facility. Staff were unable to explain how the injuries occurred. After reviewing medical reports and interviewing staff, the Department found no evidence of negligence by the facility. The allegations were determined to be unsubstantiated.

The complaint alleged that staff hit a resident. Interviews revealed conflicting statements, with one staff denying the incident and others overhearing an admission. No physical injuries were observed on the resident. The allegation was determined to be unsubstantiated.

The investigation included interviews with staff and review of relevant documents. The allegation that staff hit a resident was found to be unsubstantiated due to lack of preponderance of evidence, despite some staff statements indicating an admission. The facility conducted an internal investigation and terminated the involved staff.

The inspection found the facility to be in compliance with no deficiencies cited. Areas toured and reviewed included resident apartments, common areas, staff and resident files, medication storage, and safety equipment. All observed conditions met regulatory requirements.

The complaint alleged wrongful eviction of resident R1. The investigation revealed that R1's responsible party had submitted a 30-day notice, but later requested to stop it. The facility initially insisted on removal by 02/04/2023 but agreed to extend relocation time until 02/10/2023. The facility did not submit a 30-day notice to the Department and worked with the responsible party. The allegation was found unsubstantiated due to lack of preponderance of evidence.

The investigation found that although the allegation of wrongful eviction may have occurred, there was insufficient evidence to substantiate the claim. The facility worked with the resident's responsible party to allow additional time for relocation, and the resident moved out on 2023-02-11.

The inspection found that COVID-19 infection control policies were implemented, including signage, visitor screening, and adequate PPE supplies and staffing. Recommendations were made for fit testing, vital sign monitoring, staff training, hand hygiene, cleaning supplies calibration, and food service protocols. No deficiencies were cited during the visit.

The facility failed to properly supervise six residents with dementia who left the premises, posing an immediate health, safety, and personal rights risk. A deficiency was cited for inadequate care and supervision of residents with dementia.

No immediate health, safety, or personal rights violations were observed during the facility tour. No deficiencies were cited in the infection control domain.

The follow-up was related to a previous non-compliance conference triggered by 4 Type A citations and 12 substantiated complaint allegations since 2018.

The facility is making efforts to achieve continued and substantial compliance by implementing plans to address fall risks, conducting regular staff training including medication technicians, and performing regular audits of residents' medications.

The facility had 12 substantiated complaint allegations since 2018.

The facility has a history of 14 Type A citations and 12 substantiated complaint allegations since 2018, with repeat violations related to medication errors and shortages of trained and qualified staff. The facility committed to actions to achieve continued compliance, including regular medication audits and maintaining updated staff training records.

The visit was complaint-related, investigating medication errors reported in incident reports for 5/12/2021 and 5/19/2021. The complaint was substantiated as deficiencies were cited and a civil penalty issued.

Two medication errors were identified: resident R1 received the wrong medication on 5/12/2021, and resident R2 received an incorrect dosage on 5/19/2021. Both incidents were corrected, residents monitored with no adverse reactions, and staff received additional medication management training. A civil penalty was issued due to repeated citation of the regulation within 12 months.

The visit was triggered by an incident report regarding a resident who left the facility and was found at a nearby store. The incident was investigated and found to be managed properly with no adverse effects to the resident.

The facility responded appropriately to the incident by monitoring the resident, providing staff training on elopement, conducting regular elopement drills, routing the back gate alarm to staff pagers, and initiating regular gate checks. No deficiencies were cited during this visit.

The facility was found to be in substantial compliance with no immediate health, safety, or personal rights violations observed, and no deficiencies were cited as a result of the inspection.

The complaint investigation was substantiated for allegations of medication mismanagement, unmet hygienic care needs, incomplete records, lack of activities, and inadequate staffing. The allegation of staff falsifying medical records was unsubstantiated. The allegation of residents sustaining multiple fractures due to falls was unfounded except for one confirmed fracture.

The investigation substantiated multiple allegations including medication errors, insufficient staffing leading to unmet resident care needs, incomplete resident records, and lack of planned activities. One allegation regarding staff falsifying medical records was unsubstantiated, and another regarding residents sustaining multiple fractures due to falls was unfounded with only one fracture confirmed.

The inspection found multiple medication errors including missed administration of fentanyl patches and Norco, missing medication in the cart, and lack of communication with hospice regarding medication reorders. Deficiencies were cited related to medication errors posing immediate health and safety risks.

The Licensing Program Analyst delivered an exclusion order to the facility administrator for a staff member who is excluded from the facility due to reasons unrelated to this facility.

The complaint investigation was substantiated for allegations that facility staff failed to provide identified care and supervision, failed to seek timely medical care, and violated resident personal rights. The allegation that the facility had insufficient staff was unsubstantiated.

The investigation substantiated allegations that facility staff did not provide identified care and supervision, did not seek timely medical care for a resident, and violated resident personal rights. Specific deficiencies included delayed 9-1-1 response for a resident with chest pain, inadequate incontinent care, and improper administration and documentation of PRN medication without hospice approval. Another allegation of insufficient staffing was found unsubstantiated.