Brookside Village Inc

In the surveyor’s words

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

• Actual harm, isolatedF686Dec 2, 2021

  Based on observation, interview, and record review, the facility failed to prevent pressure ulcers to develop, and failed to identify and monitor the pressure ulcers until they were at an advanced stage, resulting in the development of Stage 3 pressure ulcers, for 2 of 3 residents reviewed for impaired skin. (Residents C and D) Findings include: 1. On 12/2/21 at 9:15 A.M., during the initial tour, the Director of Nursing (DON) indicated Resident C had skin impairments on her right lower leg. The DON indicated she thought the areas were possibly stasis areas due to circulation. Resident C was observed lying in bed with the covers over her feet at that time. On 12/2/21 at 9:45 A.M., the DON provided a CNA assignment sheet. […]

• Actual harm, isolatedF689Jun 7, 2021

  Based on observation, record review, and interview, the facility failed to adequately supervise and implement effective interventions for 2 of 3 residents who were fall risks. Resident 11 and Resident 23 acquired fractured nasal bones related to a fall, after having had multiple falls with interventions that were not effective with their cognitive status. (Resident 11, Resident 23) Findings include: 1. On 6/7/21 at 1:23 P.M., Resident 23 was observed to be propelling herself in a wheelchair in the hallway. On 6/3/21 at 1:22 P.M., Resident 23's clinical record was reviewed. Resident 23's diagnoses included, but were not limited to, 2-part nondisplaced fracture of surgical neck of left humerus. […]

• No harm, potential for more than minimal, patternF550May 12, 2026

  Based on observation, interview, and record review, the facility failed to ensure resident's were treated with dignity and respect for 4 of 4 residents reviewed for call light response times. A resident was observed waiting on staff to answer her call light while she was in the bathroom and resident call light logs revealed long wait times. (Resident C, Resident G, Resident H, Resident F)Findings include: 1. During an observation on 5/8/26 at 5:36 A.M., Registered Nurse (RN) 20 was walking toward the medication cart from the nurse's station. A call light sounded. RN 20 went from the medication cart to look at the call light screen by the nurse's station which indicated room [ROOM NUMBER] was in the bathroom. […]

• No harm, potential for more than minimal, patternF580Feb 26, 2024

  Based on interview and record review, the facility failed to notify appropriate parties of a resident's significant change of status for 2 of 5 residents reviewed for nutrition. The Medical Doctor (MD) or Registered Dietician were not notified of a significant weight loss, and the Doctor was not notified of a five pound weight gain as indicated in a weight order. (Resident 3, Resident 9) Findings include: 1. On 2/19/24 at 11:14 A.M., Resident 3's clinical record was reviewed. Diagnosis included, but were not limited to, anxiety and depression. The most recent quarterly MDS (minimum data set) assessment, dated 12/8/23, indicated a mild cognitive impairment, and no weight loss or gain. […]

• No harm, potential for more than minimal, patternF804Jun 7, 2021

  Based on observation, interview, and record review, the facility failed to ensure food was served at an appropriate temperature for 2 of 7 residents interviewed, and 1 of 1 lunch trays tested . (Resident 8, Resident 24) Findings include: On 6/2/21 at 10:39 A.M., Resident 8 indicated the hot food was cold sometimes, and cold foods were sometimes warm. On 6/2/21 at 10:50 A.M., Resident 24 indicated the hot food was sometimes cold. On 6/4/21 at 12:02 P.M., a food cart was observed in the hall by the nurses' station. The cart was open and held 6 residents' food trays. […]