Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Brodie Ranch Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe dementia, a history of falls, and dependence for transfers had bed rails installed without a bed rail safety assessment, physician order, or inclusion of bed rail use and entrapment risk in the care plan, despite a signed consent outlining potential dangers. The care plan only addressed ADL assistance and bed mobility support, omitting any interventions related to bed rails. Maintenance installed 1/3 bed rails on a bed with a low air loss mattress based on a nurse’s request, without documented IDT involvement or verification that required clinical steps were completed. The resident was later found unresponsive, partially out of bed with her head and neck between the rail and mattress, and was pronounced deceased after CPR and EMS response; the medical examiner noted neck injuries consistent with entrapment between the mattress and bed rails and indicated a likely cause of death of strangulation or asphyxiation.
A resident with multiple comorbidities and a history of falls experienced an unwitnessed fall resulting in injury. The LPN assessed the resident and notified the NP and ADON, but did not inform the resident's emergency contact. The family member only learned of the incident from the resident the next day. Staff interviews and policy review confirmed that notification of the resident's representative was required, but this was not done.
Staff failed to consistently knock on resident doors before entering, as observed with three residents who had varying levels of cognitive impairment and complex medical conditions. Two residents reported irritation and a desire for staff to respect their privacy by knocking, while interviews with staff and management confirmed awareness of the policy but could not explain the lapse in practice.
Food was prepared hours in advance and held uncovered, resulting in meals being served at low temperatures and lacking flavor. Multiple residents consistently reported cold, bland, and repetitive food, with pureed meals containing lumps that required chewing. Staff interviews and facility records confirmed ongoing complaints about food quality and temperature, which were not effectively addressed.
A medication cart on one hall was left unattended and unlocked for about 10 minutes, allowing medications to be accessible to residents. Multiple staff passed by without securing the cart, despite facility policy requiring medication carts to be locked at all times when unattended. Interviews with the MA, RN, DON, and ADM confirmed the expectation and importance of keeping the cart locked to prevent unauthorized access.
A resident with severe cognitive impairment and a history of falls was found on the floor in the dining room and remained there for over an hour and a half without being assessed by nursing staff. Despite being at risk for falls, the resident was not evaluated, and no documentation or incident report was created. The resident's family eventually assisted him to bed without staff intervention, and he passed away approximately eight hours later. The facility's policies on fall management and incident reporting were not followed, leading to an Immediate Jeopardy situation.
A resident with multiple health issues, including schizophrenia and moderate cognitive impairment, eloped from a facility through an unsecured emergency exit door. The resident was later found at a gas station and tested positive for cocaine at the hospital. The facility failed to provide adequate supervision and secure the emergency exit, placing the resident at risk.
A facility failed to investigate a verbal abuse allegation between two residents, where one resident accused another of making sexual comments, leading to a physical altercation. Despite documentation by an LPN, the incident was not reported to the DON or ADM, preventing an investigation. The facility's policy requires immediate reporting of all ANE allegations, which was not followed, potentially placing residents at risk.
A resident with intact cognition and multiple medical conditions expressed a desire to transfer to another facility, but the LTC facility failed to develop and implement an effective discharge plan. The social worker did not document efforts in the EMR and was unsure about the resident's decision-making status, leading to a lack of progress in the discharge process. The facility's policy on involving residents in discharge planning was not followed, placing the resident at risk of unmet post-discharge needs.
The facility failed to post the most recent survey results in a place readily available to residents, family members, and legal representatives. A binder labeled 'Survey Results' was found to contain outdated information, missing the latest full recertification survey results. Residents expressed a desire to see these results to make informed decisions and understand issues within the facility.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Care Plan Bed Rail Use Leading to Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan addressing the use of bed rails and the risk of entrapment for a resident with severe cognitive impairment. The resident was an elderly female with diagnoses including a left femoral neck fracture, severe dementia, repeated falls, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan, focused on ADL self-care performance deficit related to unspecified dementia, only specified staff assistance for bed mobility and encouragement to participate, and did not mention bed rails or any risk of entrapment. The facility obtained a signed bed rail consent form from the resident’s family member, which detailed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment between the rails and mattress or bed components. However, from the time of admission through the period reviewed, there was no documented assessment for bed rail safety, no physician order for bed rails, and no addition of bed rail use or entrapment risk to the resident’s care plan. Maintenance staff reported that bed rails were installed on the resident’s bed at the request of a charge nurse, without a documented work order date and under the assumption that all clinical steps had been completed. The facility’s policy required that alternatives be attempted first, that the IDT assess the resident for entrapment risk, obtain informed consent, verify equipment compatibility, and update the care plan, but these steps were not carried out for this resident prior to installation. The resident was later found unresponsive in the early morning hours, seated on the floor on the right side of the bed with her head and neck positioned between the side rail and the mattress. A CNA reported that the resident had been resting calmly during an earlier round and was later observed partially out of bed with her head pinned between the assist bar and the mattress. The LVN responding to the CNA’s report observed the resident in a sitting position off the mattress with her head resting between the side rail and mattress, and CPR was initiated before EMS arrived and pronounced her deceased. The county medical examiner reported bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress that, while initially leaving little space between the mattress and rails, could be compressed enough to create significant space between the mattress and rails.
Failure to Notify Resident Representative After Fall
Penalty
Summary
The facility failed to immediately notify a resident's representative after the resident experienced an unwitnessed fall that resulted in injury and had the potential for requiring physician intervention. The resident, an elderly male with diagnoses including unspecified dementia, hypertension, congestive heart failure, and metastatic prostate cancer, had a history of falls and was assessed as having moderately impaired cognition. On the day of the incident, the resident was found on the floor of his restroom after standing up from the toilet and experiencing weakness in his legs, leading to a fall. The nurse on duty assessed the resident, noted multiple skin tears, and initiated fall protocol and neurochecks. The nurse notified the on-call nurse practitioner and the assistant director of nursing but did not notify the resident's family member or representative. The resident's family member, who was listed as the emergency contact, was not informed of the fall by the facility. Instead, the family member learned of the incident directly from the resident the following morning, who described the fall and his pain. When the family member contacted the facility, the nurse confirmed the fall had occurred the previous day. Interviews with facility staff, including the LVN, RN, DON, ADON, and administrator, revealed that the expectation was for the family or emergency contact to be notified of any significant change, such as a fall, regardless of the resident's status as their own responsible party. The staff member involved stated she did not notify the family because she believed the resident was his own responsible party. Review of facility policies and in-service training materials confirmed that both the provider and the resident's representative should be notified of a fall, with documentation of the date and time of notification. The failure to notify the resident's representative was inconsistent with facility policy and staff training, as well as the expectations of facility leadership.
Failure to Knock on Resident Doors Before Entry
Penalty
Summary
The facility failed to ensure that staff consistently honored residents' rights to privacy and dignity by not knocking on residents' doors before entering their rooms. During observations, a CNA was seen entering the rooms of three residents without knocking. Interviews with two of these residents confirmed that staff did not always knock before entering, and both expressed irritation and a desire for staff to knock consistently, especially when their doors were closed or when they were changing. The residents involved had significant medical histories, including heart disease, cognitive communication deficits, dementia, muscle wasting, and other chronic conditions. Their cognitive abilities ranged from moderate to severe impairment, as indicated by their BIMS scores. Despite these challenges, the residents were aware of and affected by the lack of respect for their privacy. Interviews with the CNA, DON, and ADM revealed that all staff had been trained on the policy requiring staff to knock before entering residents' rooms, regardless of the residents' cognitive status, except in emergencies. The staff acknowledged the importance of this practice for maintaining residents' privacy and dignity, and management reported that compliance was monitored through rounds and in-service training. However, the deficiency occurred because the policy was not consistently followed, and staff could not explain why the required action was omitted.
Failure to Prepare and Serve Palatable, Safe, and Appetizing Food
Penalty
Summary
The facility failed to prepare and serve food in a manner that conserved nutritive value, flavor, and appearance for the majority of its residents. Observations revealed that food, including vegetables for various diets, was prepared as early as 2 hours and 45 minutes before meal service and held in shallow, uncovered pans on the stove for extended periods. Test trays for both regular and pureed diets were found to be at low temperatures and described as bland in flavor. Pureed foods were served with visible lumps, requiring chewing, which is inconsistent with prescribed dietary guidelines. Food temperatures recorded during meal service were often below recommended serving temperatures, with some items as low as 88 to 99 degrees Fahrenheit. Multiple residents reported dissatisfaction with the food, citing issues such as cold temperatures, lack of flavor, and insufficient variety. Interviews with residents and a confidential group interview indicated that complaints about cold and unappetizing food were consistent and ongoing. Staff interviews confirmed that food preparation often began several hours before service, and that food was sometimes left sitting in hallways before being served, contributing to the temperature issues. Despite repeated complaints documented in Resident Council meeting minutes and grievance logs, the facility did not address the concerns effectively, and the same issues persisted over several months. The facility's own Diet and Nutrition Care Manual specified that pureed foods should not contain visible lumps and should not require chewing, yet observations and test trays contradicted these standards. Staff interviews revealed a lack of clear communication and follow-through regarding resident complaints, with dietary management unaware of the extent of dissatisfaction. The ongoing failure to prepare and serve food at safe and appetizing temperatures, with appropriate flavor and texture, was directly observed and corroborated by resident and staff interviews, as well as facility documentation.
Unattended and Unlocked Medication Cart
Penalty
Summary
A medication cart located on the 200 hall, assigned to a medication aide (MA-A), was observed to be unattended and unlocked for approximately 10 minutes, making medications accessible to residents. Multiple staff members walked past the unlocked cart without securing it. The facility's policy requires medication carts to be locked at all times when unattended, and this was confirmed in interviews with the medication aide, a registered nurse (RN-C), the Director of Nursing (DON), and the administrator (ADM). Each staff member acknowledged the importance of keeping the cart locked to prevent unauthorized access to medications. The facility's policy, as reviewed, states that medications and biologicals must be stored safely, securely, and properly, with access limited to authorized personnel. The failure to lock the medication cart resulted in medications being accessible to residents and others, contrary to facility policy and accepted professional standards. No specific residents were identified as having accessed the medications during the incident.
Failure to Assess and Document Resident Fall
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. The incident involved a male resident with a history of age-related physical debility, repeated falls, muscle wasting, and a history of stroke and heart attack. The resident was found on the ground in the dining room and remained there for over an hour and a half without being assessed by a nurse. There was no nursing documentation or incident report created by the responsible RN. The resident had a severely impaired cognition as indicated by a BIMS score of 00 and required substantial assistance with mobility. Despite being at risk for falls, the resident was not assessed after being found on the floor, and no vital signs or neuro checks were conducted. The resident's family members eventually arrived and assisted him to bed without any staff intervention or assessment. The RN claimed the resident was combative, which prevented an assessment, but this was contradicted by family members who stated the resident was not aggressive. The lack of assessment and documentation was a significant oversight, as the resident passed away approximately eight hours later. The facility's policies on fall management and incident reporting were not followed, as no physical assessment was completed, and no incident report was filed. This failure resulted in the identification of an Immediate Jeopardy situation, highlighting the risk of residents not receiving necessary medical care.
Resident Elopes Through Unsecured Emergency Exit
Penalty
Summary
The facility failed to ensure a safe environment for Resident #1, who was able to elope from the facility through an emergency exit door. This incident occurred after CNA C used the exit code to the emergency door, which was not supposed to be used except in emergencies. The door was not properly latched, allowing Resident #1 to leave the facility unnoticed. The resident was later found at a gas station by LVN B, who did not stay with him until assistance from the facility arrived. The resident was eventually taken to the hospital, where he tested positive for cocaine. Resident #1 was a male with multiple diagnoses, including type II diabetes, schizophrenia, and acute kidney failure. He had a moderate cognitive impairment and used a wheelchair. Despite being assessed as a low risk for elopement, he had expressed a desire to leave the facility on several occasions. His care plan included monitoring for behavior episodes, but there was no indication of exit-seeking behavior prior to the incident. The facility's failure to secure the emergency exit and provide adequate supervision placed Resident #1 at risk for unsafe elopement, dehydration, and hospitalization. The incident highlighted lapses in staff adherence to protocols regarding emergency exits and supervision of residents, particularly those with a history of leaving facilities against medical advice.
Failure to Investigate Verbal Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an alleged verbal abuse incident involving two residents. Resident #1 accused Resident #2 of making sexual comments, which led to Resident #1 throwing a cup of cold water on Resident #2. Despite the incident being documented by LVN A and reported as a resident-to-resident incident, the allegation of verbal abuse was not investigated as required by the facility's policy. Resident #1, who has a moderate cognitive impairment, reported the incident to LVN A, who documented it in the progress notes and completed an incident report. However, the Director of Nursing (DON) and the Administrator (ADM) were not informed of the nature of the incident, specifically the alleged verbal abuse. The DON was unaware of any aggressive behavior or sexual comments, and the ADM was not informed of the incident's details, which prevented the initiation of an investigation. The facility's policy mandates that all abuse, neglect, and exploitation (ANE) allegations be reported immediately to the Administrator. The failure to report and investigate the verbal abuse allegation could place residents at risk and prevent the facility from taking corrective actions to prevent further abuse, neglect, and exploitation. The incident was not discussed in the stand-up meeting, and the Psychologist noted that Resident #1 did not display signs of fear or recall the incident, attributing any paranoia to her dementia.
Failure in Discharge Planning Process
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process for a resident, which focused on the resident's discharge goals and included regular re-evaluation to identify changes requiring modification of the discharge plan. The resident, a male with diagnoses including hemiplegia, hemiparesis, cognitive communication deficit, aphasia following cerebral infarction, and depressive episodes, expressed a desire to move to a specific local nursing facility. Despite having a BIMS score indicating intact cognition and being his own responsible party, the facility did not have a discharge plan in place for him. The social worker (SW) was aware of the resident's wish to transfer but had not documented any efforts in the electronic medical record (EMR). Instead, she kept a notebook with notes on her attempts to contact the desired facility. The SW was under the impression that the resident's family, who were only listed as emergency contacts, might be involved in decision-making, although the resident was his own responsible party. The SW had not reached out to the family or sent any clinical documents to the other facility, as she was waiting for a response from them. The SW's caseload was not considered large, yet she had not documented her efforts or progress in the EMR. The Director of Nursing (DON) and the Administrator (ADM) were aware of the resident's desire to move, but the ADM was unsure about the resident's Medicaid status, which he thought might be delaying the referral process. The facility's policy required the discharge planning process to focus on the resident's goals and involve them as active partners, but this was not adhered to in this case. The lack of documentation and communication regarding the resident's discharge planning placed him at risk of not having a plan to address his post-discharge needs.
Failure to Post Recent Survey Results
Penalty
Summary
The facility failed to have the results of the most recent survey posted in a place readily available to residents, family members, and legal representatives. During an observation, a binder labeled 'Survey Results' was found on a table at the entrance of the facility. This binder contained survey results dating back to 2021 but did not include the results from the most recent full recertification survey conducted from 02/06/24 to 02/08/24. The binder did contain a Notice of Accepted Plan of Correction Form referencing the full recertification survey dated 02/08/24. This omission was confirmed during an interview with the administrator, who had recently started working at the facility and was unsure of the exact date he had requested the survey results. Confidential interviews with four residents revealed that they were interested in knowing the results of State Agency investigations. One resident expressed a desire to see the results before entering the facility to determine if it was a safe place to live. Another resident felt that knowing the survey results was important to understand what was happening in their home and to see if others were experiencing similar issues. The administrator acknowledged that making the survey results available was his responsibility and recognized that residents might be more outspoken about their problems if they could see that others had similar issues documented in the survey results.
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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 Austin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Marbridge Villa | 1.3 mi | ★★★★★ | 0 | 0 |
| West Oaks Nursing And Rehabilitation Center | 2.2 mi | ★★★★★ | 13 | 0 |
| Southpark Meadows Nursing And Rehabilitation Cente | 2.6 mi | ★★★★★ | 5 | 0 |
| Onion Creek Nursing And Rehabilitation Center | 2.8 mi | ★★★★★ | 2 | 0 |
| Brush Country Nursing And Rehabilitation | 5.2 mi | ★★★★★ | 23 | 1 |
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