Brookside Care Center

In the surveyor’s words

From the most serious findings on record at Brookside Care Center, in the surveyor’s own words.

• Actual harm, isolatedF760Jul 11, 2025

  Based on observation, record review, interview, document review and facility policy review, the facility failed to ensure one of four residents reviewed for medication administration (Resident (R)1) out of eight sampled residents was free from significant medication errors when R1 was administered R8’s medications which included amiodarone (cardiac antiarrhythmic), bumetanide (diuretic), carvedilol (blood pressure), clozapine (antipsychotic), divalproex (anticonvulsant), Jardiance (diabetic), and lamotrigine (anticonvulsant). […]

• Actual harm, isolatedF686Jan 31, 2025

  Based on interviews, record review, and review of facility policy, the facility failed to ensure that one of three residents (Resident (R)1) reviewed for pressure ulcers out of a total sample of five did not develop a pressure ulcer, unless their clinical condition showed that it was unavoidable. R1, who entered the facility without any skin issues to his right heel, developed a facility-acquired deep tissue injury (DTI) pressure ulcer that deteriorated to an unstageable ulcer. There was no documentation the facility monitored R1's skin and implemented interventions as ordered by the physician and identified in the resident's plan of care. Findings include: Review of the facility's policy titled Prevention of Pressure Ulcers dated 01/06/23, revealed, . […]

• No harm, potential for more than minimal, patternF880Jun 18, 2026

  Based on observation, interview, and record review, the facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection for 6 (R26, R96, R133, R67, R55, and R106) of 28 residents reviewed for Infection control practices. *Staff did not implement Enhanced Barrier Precautions (EPB) for R26, R96, and R133 despite each meeting the criteria to require such precautions. *R67 was observed during wound care to the sacrum to have stool present at the rectum and was not provided with incontinence care prior to completing the treatment creating an unsanitary environment.*Staff were observed to handle R55, and R106's medications with bare hands. […]

• No harm, potential for more than minimal, isolatedF628Jun 18, 2026

  Based on interview and record review, the facility did not provide a notice of discharge to the Office of the State Long-Term Care Ombudsman for 2 of 4 residents (R1 and R67) reviewed for discharge from the facility. R1 was transferred to the hospital 6 times between 2/7/26 and 5/17/26. No notice was provided to the Ombudsman. R67 was transferred to the hospital 2 times between 3/31/26 and 4/20/26. No notice was provided to the Ombudsman. Findings include: 1) R1 was admitted to the facility on [DATE]. R1 was transferred to the hospital on 2/7/26, 2/11/26, 3/20/26, 4/2/26, 4/23/26, and 5/17/26. On 6/16/26 at 3:00 PM, Surveyor asked Nursing Home Administrator (NHA)-A who sends notification to the Ombudsman of resident transfers. […]

• No harm, potential for more than minimal, isolatedF684Jun 18, 2026

  Based on interview and record review, the facility did not ensure 1 (R14) of 3 residents received treatment and care in accordance with professional standards of practice.R14 returned to the facility on 4/9/26. There is no evidence a skin assessment, including R14's vascular wounds, was completed. Findings Include:The Facility policy titled, Skin care management, initiated 12/21/26 documented: policy: each resident will have a skin assessment and treatment plan for the maintenance of skin integrity and wound management if required .R14's significant change minimum data set (MDS) completed on 4/22/26 documented R14 has 3 venous and arterial ulcers present at the time of the MDS assessment.On 4/3/26, R14 was sent to the hospital and returned on 4/9/26. […]