Brookside Inn

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Mar 12, 2026

  Based on observations, record review and interviews, the facility failed to ensure an environment free from risk of accidents and hazards for three (#106, #37 and #10) of six residents reviewed for accident hazards out of 42 sample residents.Specifically, the facility failed to:-Ensure Resident #106 was transported appropriately in the facility transportation vehicle, which resulted in a fall from the resident's wheelchair causing fractures to both of her lower extremities;-Ensure Resident #37's care planned fall interventions were consistently implemented by staff in order to prevent multiple falls for the resident, including one with major injury; and,-Ensure the interdisciplinary team (IDT) reviewed Resident #37 and Resident #10's falls in a timely manner in order to determine if the… […]

• Actual harm, isolatedF600Mar 6, 2025

  Based on interviews and record review, the facility failed to ensure two (#2 and #1) of three residents were kept free from abuse out of three sample residents. Specifically, the facility failed to ensure Resident #2 was free from physical abuse by certified nurse aide (CNA) #1. On 1/21/25, CNA #1 entered Resident #2's room to provide care. CNA #1 roughly repositioned Resident #2 with pillows and forcefully pushed Resident #2 toward the wall, causing a loud thud. Resident #2 cried out in pain multiple times, asking CNA #1 to stop being rough with her. The facility failed to initiate an abuse investigation and make a report to the state agency after Resident #2's family reported CNA #1 was rough toward Resident #2 when providing care. […]

• Actual harm, isolatedF689Nov 3, 2022

  Based on observations, record revise and interviews, the facility failed to ensure four (#39, #90, #86 and #29) of six residents reviewed for accidents out of 43 sample residents received adequate supervision to prevent accidents. Specifically, the facility failed to develop and implement a person-centered care plan that identified Resident #39's fall risk and put effective interventions into place to reduce falls and prevent an injury. Resident #39 was admitted to the facility on [DATE] with a diagnosis of [CONDITION(S)] (disorder of the central nervous system that affects movement), dementia, abnormalities of gait and mobility and restlessness and agitation. On 6/29/22 and 10/11/22 Resident #39 sustained falls. […]

• No harm, potential for more than minimal, widespreadF812Mar 12, 2026

  Based on observations, record review and interviews, the facility failed to ensure food was prepared, distributed and served under sanitary conditions in the main kitchen.Specifically, the facility failed to ensure ready-to-eat foods were handled in a sanitary manner to prevent cross-contamination.Findings include:I. Professional referenceAccording to The Colorado Retail Food Establishment Regulations, (3/16/24), retrieved on 3/18/26, Food employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment. (3-301.11)II. ObservationsDuring a continuous observation of the lunch meal service on 3/11/26, beginning at 10:20 a.m. […]

• No harm, potential for more than minimal, widespreadF838Mar 12, 2026

  Based on record review, and staff interviews, the facility failed to conduct and document a facility-wide assessment to determine and identify what resources are necessary to care for its residents appropriately during both day-to-day operations and emergencies.Specifically, the facility failed to develop a facility assessment that was facility specific to include, resources, training and specifics about the resident population.Findings include:I. Record reviewThe facility assessment was provided by the nursing home administrator (NHA) on 3/12/26 at 11:00 a.m. The facility assessment revealed it was last reviewed on 5/8/25 by the NHA. […]