Brodie Ranch Nursing and Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible for 3 of 5 residents (Residents #11, #73 and 103) reviewed for accidents.1. The facility failed to prevent Resident #11 from sustaining a head injury requiring lacerations during an unwitnessed fall on 04/15/2026.2. The facility failed to conduct a smoking safety evaluation for Residents #73 and 103 prior to survey entrance on 05/19/2026. The facility failed to address smoking in the care plan for Resident #73. These failures placed residents at risk of smoking-related and fall-related injuries. 1. Review of Resident #11s face sheet, dated 05/21/26, revealed an [AGE] year-old female admitted [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident was treated with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 4 of 4 residents (Resident #10, Resident #12, Resident #55, and Resident #84) reviewed for resident rights. The facility failed to ensure that HS knocked on the doors of Resident #12, Resident #55, and Resident #84 when entering their rooms. The facility failed to ensure the privacy of Residents #12, #55, and #84 by not knocking before entering. The facility failed to ensure Resident #10 was dressed in his own clothing on 05/19/2026, 05/20/2026, and 05/21/2026. These failures placed residents at risk of poor self-esteem and feeling that their privacy was invaded. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for one of eight residents (Resident #11) reviewed for ??.The facility failed to report to Health and [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to refer all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 2 (Residents #113 and 87) of 6 residents reviewed for PASARR.The facility failed to perform a new PASRR assessment on Resident #113 when he was newly diagnosed with bipolar disorder. The facility failed to refer Resident #87 for a level II PASRR evaluation despite her qualifying diagnosis of paranoid personality disorder. This failure could place residents at risk of not receiving the services and support needed. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 11 residents (Resident #73) reviewed for comprehensive care plans. The facility failed to ensure Resident #73 was care planned for smoking and for compromised oral/dental status. This failure placed residents at risk of accident injury and not having nutritional needs met. Record review of the undated face sheet for Resident #73 reflected a [AGE] year-old male admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assist residents in obtaining routine dental care for 1 of 11 residents (Resident #73) reviewed for dental needs. The facility failed to offer Resident #73 dental services or refer him to be seen by a dentist. This failure placed residents at risk of pain and poor nutrition. Review of the undated face sheet for Resident #73 reflected a [AGE] year-old male admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 1of 3 residents (Resident #125) reviewed for incontinence care. The facility failed to ensure that :CNA C and CNA D handled personal care items with clean gloves while providing incontinent care for Resident #125. This failure could place the residents at the facility at risk of transmission of disease and infection.

Inspectors wroteBased 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. This failure placed residents at risk of injury or death from entrapment in bed rails.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights for 1 of 25 (Resident #1) residents reviewed for care plans. 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 #1 prior to installation. She became entrapped in the 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 non-compliance began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the survey began. This failure placed residents at risk of injury or death from entrapment in bed rails.

Inspectors wroteBased on interviews and record reviews, the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention for 1 (Resident #1) of 4 residents reviewed for notification of changes. The facility failed to ensure Resident #1's representative was notified after Resident #1 had an unwitnessed fall on 09/16/25. This failure could result in the family or representative not being aware of conditions that may require them to make medical decisions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 3 of 10 residents (Resident #31, Resident #71, and Resident #76) reviewed for rights. The facility failed to ensure CNA B knocked on Resident #31, Resident #71, and Resident #76's doors when going into the residents' rooms. The deficient practice could place residents at risk of feeling like their privacy was being invaded or the facility was not their home.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare foods by methods that conserve nutritive value, flavor, and appearance in the facility's only kitchen for 20 of 21 residents (Resident #42, Resident #47, Resident #63, Resident #19, Resident #361, and confidential group interview (15 of 16 residents)). The [NAME] prepared food as early as 2 hours and 45 minutes prior to meal service as observed on 03/24/2025 at 9:15 a.m. and 03/25/2025 at 9:35 a.m. The [NAME] held food in shallow pans uncovered on top of the stove for more than 2 hours and 45 minutes prior to meal service. Regular test tray rendered a low temperature and bland flavor. Pureed test tray rendered a low temperature and bland flavor. Food lacked seasoning and was unacceptable to residents. Food was prepared and held at low temperatures for hours prior to meal service. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that drugs and biologicals used in the facility were stored properly for 1 (Hall 200-MA Cart) of 7 Medication carts reviewed for drug storage. The facility failed to ensure one medication cart (Hall 200-MA Cart) was locked and that medications were securely stored. This failure could place residents at risk to obtain and take medications not prescribed for them which could result in resident's harm due to adverse medication reactions.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. He was later taken to the hospital where he tested positive for cocaine. This deficient practice placed residents at risk for unsafe elopements, falls, injuries, dehydration, and hospitalization. An Immediate Jeopardy (IJ) existed from 08/03/24 - 08/04/24. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure a verbal abuse alleged violation was thoroughly investigated with Resident #1 and Resident #2. The facility failed to investigate an allegation made by Resident #1 during a separate facility reported incident. The facility failed to investigate Resident #1's allegation of verbal abuse, in a facility reported incident that involved Resident #1 and another resident. Resident #1 made an allegation of verbal abuse against Resident #2. This failure could place residents at risk to prevent further abuse, neglect, and exploitation; and it potentially prevents the facility to take corrective actions to prevent abuse, neglect, and exploitation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement an effective discharge planning process that focused on the resident's discharge goals and included regular re-evaluation of residents to identify changes that require modification of the discharge plan and to reflect these changes in the discharge plan for one of one resident (Resident #1) reviewed for discharge planning. The facility failed to ensure Resident #1 had a discharge plan in place. This failure placed residents at risk of not having a plan in place to address residents post discharge needs.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and observation, the facility failed to provide a private space for residents' monthly council meetings and the confidential resident group meeting during survey for 9 of 9 confidential residents reviewed for resident council. The facility did not provide a private space for resident council meetings. This failure could place residents, who attended resident council meetings, at risk of not being able to exercise their rights of being able to voice their grievances in a private space without uninvited staff being present. Findings Included: Observation and interview on 02/07/24 at 03:15 PM, during a confidential resident group meeting held in the dining room with 9 residents revealed at various times during the resident group meeting 2 dietary staff entered the dining room while the residents were answering questions and voicing their opinions/concerns. [...]

Inspectors wroteBased on observation , interview, and record review, the facility failed to ensure all residents had a private place for telephone communications without being overheard. The facility failed to ensure there was an area for residents to have private telephone communications. This failure could place residents at risk to lose their ability to communicate privately on the telephone, and could result in a decline in their psychosocial well-being and quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to ensure residents had the right to send and promptly receive mail, and to receive letters, packages, and other materials delivered to the facility for the resident through the means other than a postal service for 9 of 9 confidential residents reviewed for weekend mail delivery in that: The facility failed to ensure residents received their mail on the weekend. These failures could place residents at risk for not receiving mail in a timely manner and could result in a decline in residents' psychosocial well-being and quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice for 3 of 3 residents (Residents #73, #129 and #131) reviewed for oxygen therapy. 1. Resident #73's was receiving oxygen therapy and her oxygen humidifier water bottle was empty. 2. Resident #129 was receiving continuous oxygen therapy and did not have a filter on her oxygen concentrator. 3. Resident #131 had a C-Pap mask lying uncovered on her bedside table. These failures could place residents at risk for ineffective oxygen therapies and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services in that: 1) Dietary staff failed to label and date all food items located in the dry storage. 2) Dietary staff failed to dispose of expired foods items located in the reach-in refrigerator. 3) Dietary staff failed to effectively reseal, label and date items in the walk-in refrigerator. 4) Dietary staff failed to effectively reseal, label and date items in the walk-in freezer. 5) Dietary staff failed to wear hairnets while working in the kitchen. These failures could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents received services in the facility with reasonable accommodation of each resident's needs for 2 of 20 residents (Residents #73 and #126) reviewed for call lights. Residents #73 and #126 were observed in their room with their call lights not in reach. This failure could affect residents who needed assistance with activities of daily living and could result in needs not being met.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that the resident has a right to manage his or her financial affairs The facility failed to ensure Resident #22 was given a check that was sent to her. After Resident #22 was informed, a check was sent to her, the facility failed to allow her to manage her own personal funds. This deficient practice could affect residents and could result in the violation of the rights of residents who choose to manage their own funds and who receive money sent to them by not allowing them to manage their own funds therefore violating their rights and not having preferences honored. Findings Included : [...]

Inspectors wroteBased on observation and interview the facility failed to post, in a form and manner accessible to the residents and resident representatives, the required information for the public and the entire facility for the required contact information (Resident Rights) to include: *HHSC phone number *Contact information for the Ombudsman. *A statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal regulation, including but not limited to reside abuse, neglect, exploitation, misappropriation of property in the facility, and non-compliance with the advances directives requirements (42 CFR part 489 subpart I) requests for information regarding returning to the community. [...]

Inspectors wroteBased on observation, interview and record review, the facility the facility failed to provide the necessary services to maintain grooming and personal care for 1 of 20 residents (#134) reviewed for ADL care. The facility failed to ensure Resident #134 received his bath three times a week as per his shower schedule. These failures could place residents at risk of skin breakdown, infection, and loss of self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance to prevent accidents for one (Resident #28) of eight residents reviewed, in that: The facility failed to follow Resident #28's smoking evaluation requiring 1:1 supervision while she smoked and failed to don her smoking apron in a safe manner which resulted in the resident obtaining a burn to her chest and a subsequent scar. This failure could place residents who smoke at risk for neglect, harm, pain, and injuries.

Inspectors wroteBased on observation, and 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 post the facility's most recent inspection reports. This failure could affect the residents who resided in the facility.