Inspection Reports for
Brookside Inn
1297 S PERRY ST, CASTLE ROCK, CO, 80104-1977
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
3.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
27% better than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 6, 2025
Visit Reason
The inspection was conducted due to allegations of resident abuse and failure to prevent physical restraints at the facility.
Complaint Details
The complaint investigation was substantiated with findings of physical abuse to Resident #2 by CNA #1 and to Resident #1 by LPN #1. The facility failed to initiate timely investigations and report to the state agency. The investigation led to suspension of CNA #1 and police involvement.
Findings
The facility failed to protect residents from physical abuse by staff and failed to prevent the use of physical restraints for convenience rather than medical necessity. Investigations revealed incidents of abuse involving two residents and staff, with inadequate facility response and reporting.
Deficiencies (2)
F 0600: The facility failed to protect Resident #2 from physical abuse by a certified nurse aide who forcefully pushed the resident causing pain and distress. The facility also failed to protect Resident #1 from abuse by a licensed practical nurse who grabbed and twisted the resident's arm.
F 0604: The facility failed to ensure Resident #2 was free from physical restraints imposed for staff convenience, as evidenced by a recliner chair pushed against the resident's bed restricting movement.
Report Facts
Residents Affected: 2
BIMS score: 5
BIMS score: 3
Incident date: Jan 21, 2025
Incident date: Apr 12, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide (CNA) #1 | Named as the staff member who physically abused Resident #2 and was suspended following investigation. | |
| Licensed Practical Nurse (LPN) #1 | Named as the staff member who physically abused Resident #1 by grabbing and twisting the resident's arm. | |
| Certified Nurse Aide (CNA) #2 | Observed LPN #1 grabbing Resident #1's arm and intervened during the incident. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 8, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding resident-to-resident abuse and failure to maintain infection prevention and control measures.
Complaint Details
The complaint investigation substantiated that the facility failed to prevent resident-to-resident abuse between Resident #120 and Resident #18, both with histories of aggressive behavior. The facility also failed to maintain an adequate infection control program and proper COVID-19 vaccination tracking.
Findings
The facility failed to prevent resident-to-resident abuse between two residents with known aggressive behaviors and did not update care plans accordingly. The infection control program was inadequate, lacking a facility-specific water management plan for Legionella, inconsistent housekeeping hygiene practices, and incomplete COVID-19 vaccination tracking and administration.
Deficiencies (2)
F 0600: The facility failed to protect residents from abuse by not preventing a resident-to-resident altercation on 12/16/23 and not updating care plans to separate residents with aggressive behaviors.
F 0880: The facility failed to maintain an effective infection prevention and control program, including inadequate hand hygiene and glove use by housekeeping staff, improper use of disinfectants, and incomplete COVID-19 vaccination tracking and administration.
Report Facts
Residents reviewed for abuse: 39
Residents affected by abuse: 2
Scratch size: 4
Scratch size: 1
BIMS score Resident #120: 10
BIMS score Resident #18: 3
Handwashing duration observed: 7
Hand hygiene duration recommended: 15
Hand hygiene duration recommended by housekeeping supervisor: 20
COVID-19 booster clinic date: Nov 10, 2023
Inspection Report
Complaint Investigation
Deficiencies: 10
Date: Nov 3, 2022
Visit Reason
The inspection was conducted due to complaints and allegations regarding resident dignity, abuse, neglect, and care concerns at the facility.
Complaint Details
The complaint investigation substantiated multiple deficiencies including dignity concerns, abuse incidents, failure to report and investigate abuse, inadequate activity and hydration services, fall management failures, food safety violations, and lack of behavioral health training for staff.
Findings
The facility failed to maintain resident dignity by removing toilets from shower rooms, failed to prevent and investigate resident-to-resident and staff-to-resident abuse, failed to provide adequate activities and hydration, failed to ensure proper fall assessments and interventions, failed to maintain sanitary food preparation practices, and failed to provide adequate behavioral health training for staff.
Deficiencies (10)
F0550: The facility failed to ensure residents experienced a dignified living experience when toilets were removed from shower rooms, causing residents to urinate or defecate in the shower.
F0600: The facility failed to ensure two residents were kept free from physical abuse, including failure to ensure personalized behavioral interventions for Resident #104.
F0609: The facility failed to timely report alleged abuse to proper authorities and failed to conduct thorough investigations for abuse allegations.
F0679: The facility failed to provide activities to meet all resident needs, including failure to invite Resident #26 to group activities and insufficient one-to-one visits.
F0689: The facility failed to ensure residents were assessed by a registered nurse after falls and failed to implement effective person-centered fall prevention interventions.
F0730: The facility failed to conduct annual certified nurse aide performance evaluations and provide training based on reviews.
F0744: The facility failed to ensure personalized behavioral interventions were in place for Resident #104 with a history of confusion, delusions, hallucinations, and aggressive behaviors.
F0807: The facility failed to ensure residents #2 and #29 were offered beverages throughout the day to maintain hydration.
F0812: The facility failed to store, prepare, distribute, and serve food in a sanitary manner, including failure to label and date food, improper hand hygiene and glove use, failure to clean the ice machine timely, and lack of monitoring of cooked food cooling.
F0949: The facility failed to provide behavioral health training to a male activity assistant working on the memory care unit regarding resident-specific trauma and triggers.
Report Facts
Residents affected: 43
Residents independent with bathing: 79
Residents assisted with bathing: 44
Residents dependent with bathing: 39
Days since last ice machine cleaning: 132
One to one activity visits for Resident #24: 12
Fall incidents Resident #39: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| AA #1 | Activity Assistant | Worked on memory care unit without trauma-informed training for residents with sexual abuse history |
| LPN #1 | Licensed Practical Nurse | Failed to notify NHA of reported abuse immediately |
| NHA | Nursing Home Administrator | Interviewed multiple times regarding abuse, fall management, and staff training |
| DD | Dietary Director | Interviewed regarding food safety and sanitation failures |
| ESD | Environmental Services Director | Interviewed regarding ice machine cleaning |
| CNA #3 | Certified Nurse Aide | Interviewed regarding fall interventions and hydration |
| DON | Director of Nursing | Interviewed regarding fall assessments and interventions |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 15, 2021
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to promote and facilitate a resident's right to make choices about their care, specifically related to bathing preferences.
Complaint Details
The complaint was substantiated. Resident #37 was cognitively intact and required assistance with bathing. The resident was not offered or provided a bath for nine days after returning to the facility on 7/5/21 while on isolation precautions. Staff interviews revealed miscommunication about bathing responsibility.
Findings
The facility failed to ensure Resident #37 received showers according to their preference. There was miscommunication between staff regarding responsibility for bathing the resident, resulting in the resident not receiving a bath for nine days after readmission while on isolation precautions.
Deficiencies (1)
F 0561: The facility failed to promote and facilitate Resident #37's right to self-determination by not providing showers according to the resident's preference. The resident did not receive a bath for nine days after readmission despite preferring two showers per week.
Report Facts
Residents Affected: 2
Resident Bath Frequency Preference: 2
Days without Bath: 9
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