Brookside Healthcare Center

In the surveyor’s words

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

• Actual harm, isolatedF686Jul 27, 2022

  Based on record review, staff interview, review of information from the National Pressure Injury Advisory Panel (NPIAP), and policy review, the facility failed to assess and monitor a newly applied lower left extremity immobilizer for a pressure area. This resulted in Actual Harm when Resident #57 was readmitted to the facility with a left lower extremity immobilizer on 03/25/22. The immobilizer was not checked for skin breakdown causing a subsequent avoidable unstageable pressure ulcer that was found on 04/06/22. This affected one (Residents #57) of two residents reviewed for pressure ulcer care. The facility census was 93. Findings included: Record review revealed Resident #57 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF803Apr 17, 2025

  Based on observation, record review and interview, the facility failed to ensure portion sizes were served as planned. This had the potential to affect all 94 residents in the facility. Findings include: Review of the dietary spreadsheet for the breakfast meal on 04/17/25 revealed the serving sizes for the scrambled eggs was 1/4 cup, ground ham was a #16 scoop (1/4 cup), pureed ham was a #16 scoop, pureed eggs was a #16 scoop, and pureed muffin was a #16 scoop. During an observation on 04/17/25 at 8:00 A.M., the breakfast tray line revealed [NAME] #24 utilized #8 scoops (1/2 cup) for the ground ham, pureed ham, and pureed eggs and #12 scoops (1/3 cup) were utilized for the scrambled eggs and pureed muffins. […]

• No harm, potential for more than minimal, widespreadF880Jul 27, 2022

  Based on observation, record review and staff interview, the facility failed to ensure infection control precautions were followed and failed to ensure staff wore personal protective equipment (PPE) to prevent the spread of coronavirus (COVID-19). This affected four (Residents #80, #37, #31 and #33) residents and had the potential to affect all residents it the facility. The census was 93. Findings include: 1. Review of the facility's COVID19 line list revealed Resident #80 tested positive for covid on 07/17/22 and had a cough. Resident #37 did not have covid. During observation of the third floor of the facility on 07/18/22 at 4:09 P.M., Resident #80 was walking in the hall wearing a cloth mas. Resident #80 went to the outdoor smoking area and sat next to Resident #37. […]

• No harm, potential for more than minimal, patternF761Jul 27, 2022

  Based on record review, observation, interview and policy review, the facility failed to appropriately secure and store resident medications which had the potential to affect all residents on the 400 West Hall (#2, #3, #5, #12, #17, #18, #19, #20, #32, #35, #36, #40, #41, #43, #46, #47, #52, #53, #54, #61, #63, #75, #81, #87, #88.) The facility also failed to discard expired medication which had the potential to affect all residents receiving medications from the 3 East medication cart (#9, #10, #13, #21, #22, #24, #25, #28, #30, #57, #64, #65, #68, #69, #72, #85, #341, #342) The census was 93. Findings include: 1. Observation on [DATE] at 9:07 A.M. […]

• No harm, potential for more than minimal, patternF802Jul 27, 2022

  Based on observation, interview, and review of facility meal times, the facility failed to ensure resident meals were delivered timely. This had the potential to affect 91 of 93 residents who received meals from the kitchen. The facility identified two residents (#27 and #44) who did not received food from the kitchen. The facility census was 93. Findings include: Observations made on 07/18/22 from 12:30 P.M. to 1:11 P.M. revealed dietary staff delivered meal carts to the 300-Unit at 12:30 P.M., the 400-East Unit at 12:58 P.M., and The 400-West Unit at 1:11 P.M. Observation on 07/20/22 at 1:42 P.M. revealed Dietary staff delivered the meal cart to 400-West Unit. Interviews on 07/18/22 from 10:32 A.M. to 12:16 P.M. […]