Brodie Ranch Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Brodie Ranch Nursing and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, patternF694May 8, 2023

  Based on interview and record review, the facility failed to provide care according to professional standard of practice and in accordance with physician order for one (Resident #1) of two residents reviewed for quality of care in that, in that: The facility failed to ensure the transparent dressing covering Resident #1's central line site to her right chest was changed after returning from the hospital on 03/30/23. Resident #1's dressing had not been changed in approximately 37 days. There were no physician orders in place for the permcath, dressing changes for the permcath, or monitoring the site for signs and symptoms of infection . This failure resulted in an identification of an Immediate Jeopardy (IJ) on 05/06/23 at 3:45 PM. […]

• Immediate jeopardy, isolatedF700Mar 31, 2026

  Based on observation, interview, and record review, the facility failed to attempt to use appropriate alternatives prior to installing a side or bed rail or to ensure correct installation, use, and maintenance of bed rails for 1 of 25 residents (Resident #1) reviewed for bed rails. The facility failed to ensure an assessment was conducted for risk of entrapment and that the use of bed rails was added to the care plan for Resident #1prior to installation. Resident #1 became entrapped in her bed rails on [DATE] and found deceased with her head and neck between the rails and her mattress. The noncompliance was identified as Past Noncompliance. The IJ began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the survey began. […]

• Immediate jeopardy, isolatedF684Aug 8, 2024

  Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #2) of four residents reviewed for quality of care. The facility failed ensure Resident #2 was assessed by a nurse after he was found on the ground in the dining room on [DATE]. He laid on the ground for over an hour and a half until family members arrived and assisted him to bed. There was no nursing documentation or incident report created by RN H. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE] at 5:22 PM. […]

• Immediate jeopardy, isolatedF689Aug 8, 2024

  Based on interview and record review, the facility failed to ensure the residents environment remained as free of accident hazards as is possible and ensure each resident received adequate supervision for one (Resident #1) of three residents reviewed for accidents and hazards. The facility failed to ensure Resident #1 did not elope from the facility from an emergency exit door after CNA C utilized the exit code to the emergency door. LVN B observed the resident at a gas station after leaving work and did not stay with him until someone from the facility could assist. The temperature outside was a high of 95 degrees. […]

• No harm, potential for more than minimal, widespreadF577Mar 29, 2024

  Based on observation, interview, and record review the facility failed to have the results of the most recent survey of the facility posted in a place readily available to residents, family members and legal representatives for 1 of 1 survey results books. The facility failed to ensure a binder placed on a table at the entrance of the facility and titled Survey Results contained the results of the most recent full recertification survey. This failure placed residents at risk of not having all the information necessary to make decisions about living at the facility. Findings included: Observation on 03/29/24 at 12:50 PM revealed a white three-ring binder on a console table just inside the entrance doors to the facility. The binder had Survey Results printed on the front. […]