Inspection Reports for Brodie Ranch Nursing and Rehabilitation Center

The complaint investigation found that the facility failed to notify Resident #1's representative after an unwitnessed fall on 09/16/25. The resident's family member stated they were not notified by the facility until the resident himself called on 09/17/25. Interviews with staff confirmed the failure to notify the family, which did not meet facility policy or expectations.

The facility failed to notify Resident #1's representative after an unwitnessed fall on 09/16/25, which could result in the family or representative not being aware of conditions requiring medical decisions. Interviews and record reviews confirmed the lack of timely notification despite policies requiring notification of the resident's physician and representative.

The complaint investigation was triggered by reports of staff not knocking before entering resident rooms, unsecured medication carts, and poor food quality including cold temperatures and lack of flavor. Resident interviews and observations confirmed these issues.

The facility failed to ensure staff knocked before entering residents' rooms, compromising privacy for 3 residents. One medication cart was found unlocked and unattended, risking resident safety. The kitchen failed to prepare and serve food at safe temperatures and with adequate flavor, leading to multiple resident complaints about cold, bland, and improperly prepared meals.

The complaint investigation revealed that Resident #2 was found on the floor in the dining room and left unattended for over an hour and a half without nursing assessment or documentation, resulting in immediate jeopardy. Resident #2 later passed away. Resident #1 eloped from the facility through an emergency exit door due to staff misuse of the door code and lack of supervision, resulting in hospitalization with positive cocaine findings. Immediate jeopardy was identified but later removed after corrective actions.

The facility failed to ensure Resident #2 was assessed and cared for after being found on the floor for over an hour and a half, resulting in immediate jeopardy. Additionally, the facility failed to prevent Resident #1 from eloping through an emergency exit door, leading to hospitalization. Corrective actions and staff in-services were implemented to address these issues.

The complaint involved an allegation of verbal abuse by Resident #1 against Resident #2 during an incident on 05/27/2024 where Resident #1 threw a cup of cold water at Resident #2 due to alleged sexual talk. The facility failed to investigate this allegation properly. Interviews with staff and residents confirmed the incident and the failure to report it to the Administrator. The allegation was not substantiated as Resident #1 did not recall the event and psychological assessment showed no negative effects.

The facility failed to properly investigate an allegation of verbal abuse made by Resident #1 against Resident #2 during a resident-to-resident incident on 05/27/2024. Staff documented the incident but did not report it appropriately to the Administrator, resulting in a lack of investigation and corrective action. The facility's policy requires immediate reporting of such events to the Administrator, which was not followed.

The complaint investigation revealed that Resident #1 wanted to move to another facility, but discharge planning was not initiated or documented properly. The social worker had not documented efforts in the EMR, and there was confusion about the resident's decision-making capacity and family involvement. The Administrator on Duty confirmed the discharge planning should have been initiated and documented.

The facility failed to ensure Resident #1 had a discharge plan in place, despite the resident expressing a desire to move to another nursing facility. Documentation and communication regarding discharge planning were lacking, and staff had not properly documented or initiated the discharge process, placing residents at risk of unmet post-discharge needs.

The facility failed to have the results of the most recent full recertification survey (02/06/24 to 02/08/24) posted in the Survey Results binder at the entrance, placing residents at risk of not having necessary information to make decisions about living at the facility. Interviews with residents confirmed the importance of having survey results accessible. The administrator acknowledged responsibility and recent efforts to obtain the survey results.

The facility was found deficient in multiple areas including failure to accommodate residents' needs for call lights, lack of private space for resident council meetings, failure to post required contact information, inadequate privacy for telephone use, delayed mail delivery on weekends, failure to provide scheduled bathing for a resident, inadequate supervision during smoking resulting in a burn injury, improper respiratory care equipment maintenance, and food safety violations in the kitchen.

The complaint involved Resident #22's family expressing concern that a check sent to the resident was deposited into the facility trust fund without the resident's knowledge or consent. Resident #22 confirmed she did not approve the deposit and had not received the check. The investigation also included Resident #28's burn injury due to inadequate supervision while smoking.

The facility failed to allow Resident #22 to manage her own personal funds, depositing a check into her trust fund without her consent. Additionally, the facility failed to provide adequate supervision to Resident #28 while smoking, resulting in a burn injury and scar.

The facility failed to develop and implement a comprehensive person-centered care plan addressing Resident #1's central line and failed to provide appropriate care and monitoring of the central line site, resulting in an Immediate Jeopardy that was later removed. The facility implemented corrective actions including dressing changes, staff education, and ongoing monitoring.

The complaint investigation revealed failures in timely reporting of abuse and theft, inadequate investigation of allegations, care plan deficiencies, respiratory care issues, insufficient RN coverage, failure to post nurse staffing, insufficient dietary staffing, improper food storage, and infection control lapses including COVID-19 precautions.

The facility failed to timely report and investigate alleged abuse and misappropriation of resident property, failed to update care plans to reflect current dietary orders, did not provide appropriate respiratory care, lacked sufficient RN coverage and failed to post nurse staffing daily, had insufficient dietary staff causing delayed meal service, failed to label and date food properly, and failed to maintain an effective infection prevention and control program including proper COVID-19 precautions.