Deficiencies (last 4 years)
Deficiencies (over 4 years)
8.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
120% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Routine
Deficiencies: 12
Date: Oct 25, 2024
Visit Reason
Routine inspection of Brookside Healthcare Center to assess compliance with healthcare regulations and standards.
Findings
The facility had multiple deficiencies including failure to develop individualized care plans for residents, inadequate infection control practices, incomplete documentation, failure to follow physician orders, and food service sanitation issues.
Deficiencies (12)
F 0655: The facility failed to develop a nutritional risk care plan upon readmission for Resident 46, risking unmet nutritional needs.
F 0656: The facility failed to develop an individualized care plan addressing Resident 69's ongoing constipation issue.
F 0679: The facility failed to provide an ongoing activity program meeting Resident 83's preferences for music, news, and outdoor time.
F 0684: The facility failed to ensure coordination with hospice agency; Resident 10 had no hospice plan of care available to staff.
F 0695: The facility failed to follow physician orders for oxygen therapy for Residents 10 and 36, risking respiratory status.
F 0726: LVN 7 failed to demonstrate competency by pushing medication through Resident 62's G-tube instead of allowing gravity flow.
F 0745: The facility failed to ensure Social Services followed up on a hospice evaluation order for Resident 30, risking delayed hospice care.
F 0757: The facility failed to monitor antibiotic therapy for Resident 46, including lack of adverse reaction monitoring and unclear antibiotic indication.
F 0812: The facility failed to maintain food service safety; food crumbs, grime, and wet utensils were found in the kitchen, risking foodborne illness.
F 0836: Physician 1 did not complete Resident 341's history and physical exam within the facility's required timeframe.
F 0842: The facility failed to ensure complete and accurate documentation; Resident 36's treatment record had multiple missed entries and POLST forms for Residents 10, 36, and 82 had missing information.
F 0880: The facility failed to implement infection prevention and control measures including improper PPE use, failure to change oxygen tubing weekly, failure to test symptomatic staff for COVID-19, and inadequate hand hygiene by multiple staff.
Report Facts
Residents sampled: 21
Residents affected: 78
Medication order duration: 7
Oxygen flow rate: 3
Oxygen flow rate: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 7 | Licensed Vocational Nurse | Failed to administer medication correctly through G-tube for Resident 62 |
| LVN 5 | Licensed Vocational Nurse | Presented with COVID-19 symptoms but was not tested before returning to work |
| CNA 2 | Certified Nursing Assistant | Did not wear gloves or perform hand hygiene while feeding Resident 83 on Enhanced Barrier Precautions |
| CNA 3 | Certified Nursing Assistant | Fed Resident 83 without gloves despite Enhanced Barrier Precautions |
| CNA 4 | Certified Nursing Assistant | Handled soiled linens improperly and did not perform hand hygiene |
| LVN 4 | Licensed Vocational Nurse | Did not perform hand hygiene between vital signs and medication administration |
| RNS 1 | Registered Nurse Supervisor | Reviewed and confirmed oxygen therapy orders were not followed for Residents 10 and 36 |
| Director of Nursing | Director of Nursing | Provided multiple statements on expectations for care plan development, infection control, and documentation |
| Infection Preventionist | Infection Preventionist | Provided infection control guidance and confirmed failures in PPE use and documentation |
| Social Service Director | Social Service Director | Acknowledged incomplete POLST form reviews and hospice follow-up failures |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Sep 4, 2024
Visit Reason
The inspection was conducted to evaluate compliance with wound measurement policies and procedures following admission of residents, specifically focusing on wound assessments and documentation.
Findings
The facility failed to follow its policy for wound measurements on admission for one of three sampled residents. Wound measurements were not documented until four days after admission, contrary to the facility's policy requiring measurements within 24 hours.
Deficiencies (1)
F 0684: The facility failed to provide appropriate treatment and care according to orders and resident preferences by not measuring a left trochanter wound within 24 hours of admission. Wound measurements were delayed until four days after admission, placing the resident's health and safety at risk.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Reviewed and verified medical records and wound assessment policies. | |
| Treatment Nurse (TXT Nurse 1) | Admitted failure to document wound measurements on admission. | |
| Registered Nurse (RN 1) | Described wound measurement procedures and documentation practices. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 11, 2024
Visit Reason
The inspection was conducted due to complaints regarding delayed response times to call lights by nursing staff, potentially affecting resident care and safety.
Complaint Details
The investigation was complaint-driven based on resident reports of delayed call light responses. The complaint was substantiated as the facility failed to meet its policy requirements.
Findings
The facility failed to follow its policy to ensure timely response to call lights for three sampled residents, resulting in delays of up to 3 hours during night shifts. Interviews with residents confirmed these delays, while the Director of Nursing reported no prior complaints.
Deficiencies (1)
F 0684: The facility failed to provide timely responses to call lights for three sampled residents, risking their health and safety. Residents reported waiting between 1 to 3 hours for staff to respond, especially during night shifts.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding call light complaints and stated no prior complaints were received. |
Inspection Report
Deficiencies: 1
Date: Jan 3, 2024
Visit Reason
The inspection was conducted to evaluate compliance with medication storage and labeling requirements, specifically focusing on the proper use and storage of insulin in the facility.
Findings
The facility failed to ensure insulin was used and stored according to manufacturer recommendations and facility policy for two residents. Insulin vials were found past their beyond-use date or without an open date, posing potential risks for inadequate blood sugar control.
Deficiencies (1)
F 0761: The facility failed to ensure insulin was labeled and stored according to accepted professional principles. Resident 4's insulin was used past the manufacturer's beyond-use date, and Resident 5's insulin lacked an open date.
Report Facts
Residents receiving insulin: 14
Residents affected: 2
Insulin open date limit: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding insulin storage and labeling policy noncompliance | |
| Licensed Vocational Nurse 2 | Interviewed during medication cart inspection regarding insulin vial open date | |
| Licensed Vocational Nurse 3 | Interviewed during medication cart inspection regarding unlabeled insulin vial |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 9, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding a fall incident involving Resident 1, who fell from a wheelchair in the front lobby resulting in injury.
Complaint Details
The investigation was triggered by a fall incident involving Resident 1 on August 18, 2023. The fall occurred in the front lobby while Resident 1 was in a wheelchair with an alarm, but without adequate supervision. Staff interviews revealed confusion about monitoring responsibilities and lack of communication about the resident's fall risk status. The fall resulted in a skin tear and hematoma to the forehead, and the resident was sent to the hospital for evaluation.
Findings
The facility failed to provide adequate supervision to prevent avoidable accidents for Resident 1, who sustained an open injury to the forehead after falling from a wheelchair. Interviews and record reviews revealed inconsistent monitoring and unclear staff responsibilities related to fall risk management.
Deficiencies (1)
F 0689: The facility failed to ensure adequate supervision to prevent avoidable accidents, resulting in Resident 1 falling from a wheelchair and sustaining an open injury to the forehead.
Report Facts
Date of fall incident: Aug 18, 2023
Date of survey completion: Nov 9, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding fall incident and supervision policies |
| Occupational Therapist | Occupational Therapist | Interviewed about Resident 1's condition and supervision on day of fall |
| Physical Therapist Assistant | Physical Therapist Assistant | Interviewed about Resident 1 placement and supervision in front lobby |
| Receptionist | Receptionist | Interviewed about supervision and fall incident in front lobby |
Inspection Report
Deficiencies: 1
Date: Sep 30, 2023
Visit Reason
The inspection was conducted to evaluate compliance with care planning and documentation requirements following a resident's fall and to assess monitoring of nutritional intake as per the facility's policies and procedures.
Findings
The facility failed to follow its care plan for Resident 1 by not documenting neuro checks and use of floor mats after a fall, and by missing documentation for monitoring and recording meal intake on multiple dates. The interdisciplinary team did not document an investigation after the fall as required by policy.
Deficiencies (1)
F 0656: The facility failed to develop and implement a complete care plan that meets all the resident's needs with measurable timetables and actions. Specifically, there was no documentation of neuro checks and floor mats for Resident 1 after a fall, and missing documentation for monitoring intake and recording of every meal.
Report Facts
Missing meal documentation dates: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding missing documentation and policy noncompliance related to Resident 1's care plan and fall investigation. | |
| Minimal Data Set Coordinator | Interviewed regarding missing neuro checks and floor mats documentation for Resident 1. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 20, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely assess and notify the physician of a change in condition related to a pressure ulcer for one resident.
Complaint Details
The complaint investigation found that the facility did not provide an initial skin assessment on admission for Resident 1 and delayed notifying the physician about the worsening pressure injury. The wound progressed from callous to necrotic, and the resident was eventually sent to the hospital for further evaluation. The facility acknowledged communication issues and protocol adherence concerns.
Findings
The facility failed to provide appropriate pressure ulcer care and timely physician notification for Resident 1, resulting in a worsening pressure injury that required hospital transfer. Documentation and communication deficiencies were noted, including a missing initial skin assessment and delayed wound care interventions.
Deficiencies (1)
F 0686: The facility failed to assess and notify the physician timely of a change in condition to ensure skin care was provided to prevent pressure injury for Resident 1. This failure resulted in a pressure ulcer worsening and transfer to the hospital.
Report Facts
Date of wound assessments: February 22, 2023; March 1, 2023; April 26, 2023
Date of nurse progress note notifying doctor: April 18, 2023
Date of nurse note on persistent pain: May 8, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Interviewed regarding Resident 1's medical records and wound care | |
| Treatment Nurse | Interviewed about wound assessment and notification to doctor | |
| Director of Nursing | Interviewed about pressure injury prevention and resident comorbidities |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 29, 2023
Visit Reason
An unannounced visit was made to investigate a complaint regarding an allegation of resident-to-resident abuse involving Resident 1 and Resident 2.
Complaint Details
The complaint involved an allegation of resident-to-resident abuse where Resident 2 was found naked in Resident 1's room touching her leg. Resident 1 was distressed and did not feel safe. The incident was not reported to the Administrator or appropriate agencies as required by policy. Resident 1 left the facility after the incident and has not returned.
Findings
The facility failed to promptly report an allegation of abuse involving Resident 1 and Resident 2 to the Administrator and appropriate agencies. Additionally, the facility failed to initiate a care plan for Resident 1 after the incident, potentially risking psychosocial decline.
Deficiencies (2)
F 0610: The facility failed to ensure that an allegation of abuse and/or mistreatment was promptly reported to the Administrator and appropriate agencies for Resident 1. This failure increased the risk of uninvestigated and unreported abuse.
F 0656: The facility failed to initiate a care plan with measurable interventions for Resident 1 after an allegation of abuse and/or mistreatment, risking psychosocial decline due to lack of monitoring and intervention.
Report Facts
Residents Affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse (LVN 1) | Licensed Vocational Nurse | Provided interview statements regarding the abuse incident and reporting failures. |
| Director of Staff Development (DSD) | Director of Staff Development | Provided interview statements regarding the abuse incident and lack of reporting and care plan. |
| Assistant Director of Nursing (ADON) | Assistant Director of Nursing | Provided interview statements regarding the lack of care plan and monitoring after the abuse incident. |
| Administrator | Administrator | Admitted that the abuse incident was not reported to appropriate agencies or the ombudsman. |
Inspection Report
Routine
Deficiencies: 12
Date: Apr 22, 2022
Visit Reason
Routine inspection of Brookside Healthcare Center to assess compliance with healthcare regulations and standards.
Findings
The facility had multiple deficiencies including failure to assist residents with advance directives, inadequate follow-up on changes in condition, missed wound treatments, failure to report a major fall, insufficient nursing staff leading to missed IV antibiotic doses, improper dialysis care, medication errors, unsafe medication storage, food preparation and sanitation issues, uncovered waste dumpster, and lapses in infection control practices.
Deficiencies (12)
F 0578: Facility failed to assist one of five residents reviewed to formulate an advance directive as requested, risking delay in treatment or unwanted life-sustaining measures.
F 0684: Facility failed to follow-up with physician after a resident's change in condition for one of two residents reviewed for dialysis, risking delayed medical management.
F 0686: Facility failed to provide prescribed wound care treatments on April 16, 2022, for four residents reviewed, risking delayed healing and increased infection risk.
F 0689: Facility failed to report a fall with major injuries to the state health department for one of six residents reviewed, risking delayed investigation and intervention.
F 0698: Facility failed to assess and document dialysis access site for one of two residents reviewed, risking infection or complications at the access site.
F 0725: Facility failed to provide sufficient licensed nursing staff on April 15 and 16, 2022, resulting in missed IV antibiotic doses for five residents and missed wound treatments for four residents.
F 0755: Facility failed to ensure controlled drug counts were verified each shift and administered an incorrect dose of acetaminophen to one resident, risking medication diversion and overdose.
F 0761: Facility failed to ensure medications were properly labeled and stored; two unlabeled insulin pens were found in the refrigerator and a loose medication tablet was found in a medication cart drawer.
F 0812: Facility failed to follow proper food portion sizes for puree chicken and vegetarian entrée on April 19, 2022, risking compromised nutrition for residents.
F 0803: Facility failed to maintain sanitary food preparation and storage areas with wet containers, dirty blender, and food debris under equipment, risking contamination and foodborne illness.
F 0814: Facility failed to keep recyclable dumpster covered and closed, risking pest attraction in a medically vulnerable population.
F 0880: Facility failed to implement infection prevention and control program by not disinfecting glucometers between residents, not disinfecting medication vial stoppers, and leaving a CPAP mask uncovered and exposed.
Report Facts
Residents affected: 5
Residents affected: 4
Residents affected: 7
Residents affected: 83
Residents affected: 84
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 1 | Licensed Vocational Nurse | Named in insulin pen storage and glucometer disinfection findings |
| RN 2 | Registered Nurse | Named in medication vial stopper disinfection and glucometer disinfection findings |
| LVN 3 | Licensed Vocational Nurse | Named in wound treatment and CPAP mask findings |
| LVN 4 | Licensed Vocational Nurse | Named in insulin pen disposal and loose medication findings |
| Director of Nursing | Director of Nursing | Named in multiple findings including staffing, medication administration, and infection control |
| Dietary Service Supervisor | Dietary Service Supervisor | Named in food portion and kitchen sanitation findings |
| Registered Dietitian | Registered Dietitian | Named in food portion and kitchen sanitation findings |
| Maintenance Supervisor | Maintenance Supervisor | Named in recyclable dumpster finding |
| Infection Preventionist Nurse | Infection Preventionist Nurse | Named in infection control findings |
Inspection Report
Census: 86
Deficiencies: 3
Date: Jul 18, 2019
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident grievance processes, care planning for refusal of care, and food safety practices in the facility.
Findings
The facility failed to ensure residents were aware of the grievance process and lacked grievance forms for anonymous filing. A care plan was not initiated for a resident who frequently refused care. Food preparation and storage practices were unsanitary, including wet stacked dishes, dirty shelves under the steam table, and a contaminated ice machine.
Deficiencies (3)
F 0585: The facility failed to have a process ensuring residents and staff were aware of the grievance filing process, and grievance forms were not available for anonymous use.
F 0656: The facility failed to develop a care plan for refusal of care for a resident who frequently refused showers and ADLs.
F 0812: The facility failed to ensure safe food preparation and storage practices, including wet stacked bowls, dusty shelves under the steam table, and a yellowish substance buildup in the ice machine.
Report Facts
Residents affected: 86
Grievances filed: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Interim Director (SSID) | Named as assigned Grievance Officer unaware of grievance form location and anonymous filing process | |
| Licensed Vocational Nurse (LVN1) | Interviewed regarding resident refusal of ADLs | |
| Certified Nursing Assistant (CNA1) | Interviewed regarding resident refusal of ADLs | |
| Assistant Director of Nursing (ADON) | Interviewed regarding lack of care plan for refusal of care | |
| Dietary Supervisor Assistant (DSA) | Interviewed about dish storage practices | |
| Dietary Supervisor (DS) | Interviewed about dish storage and cleaning practices | |
| Registered Dietitian (RD) | Interviewed about dish storage expectations | |
| Maintenance Supervisor (MS) | Interviewed about ice machine cleaning schedule |
Report
October 25, 2024
Report
September 4, 2024
Report
July 11, 2024
Report
January 3, 2024
Report
November 9, 2023
Report
September 30, 2023
Report
June 20, 2023
Report
April 5, 2023
Report
April 22, 2022
Report
July 18, 2019
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