Brookside Care Center

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. R14's electronic medical record (EMR) did not include a skin assessment when R14 readmitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents received care consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 (R67 and R133) of 4 residents reviewed for pressure injuries.*R67's pressure injuries were not assess upon admission or upon 2 subsequent readmissions. In addition, multiple open areas were measured as one wound with no characteristics documented of what the wound looked like. *R133 had moisture associated skin damage to the coccyx that developed into an Unstageable pressure injury. The wound was documented as scattered full-thickness wounds with no documentation of how many wounds or how big the wounds were.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure adequate supervision and safety to prevent accidents from occurring for 1 of 6 residents (R90) reviewed for falls. R90 was care planned to have a floor mat alongside the bed. Observations were made of R90 lying in bed without the floor mat in place.

Inspectors wroteBased on interview and record review, the facility did not ensure the attending physician addressed the identified irregularity noted by the pharmacist for 1 (R5) of 5 residents reviewed for unnecessary medications.*R5 had an order for olanzapine, an antipsychotic medication, that was ordered for skin picking disorder/excoriation. The pharmacist documented that was not an approved diagnosis for the use of the medication. The physician did not address the diagnosis for use.

Inspectors wroteBased 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). This failure resulted in the R1’s becoming lethargic, requiring hospitalization.

Inspectors wroteBased on interview and record review the facility did not report 1 (R12) of 3 reportable incidents to the State survey agency and/or Law Enforcement within the required timeframe. *On 02/12/2025, The facility was made aware of R12's missing narcotic medication. The facility did not notify the State Agency at any point, and did not notify Law Enforcement until 02/28/2025.

Inspectors wroteBased on interview and record review the facility did not ensure that 2 (R9, R12) of 3 allegations of mistreatment involving residents were investigated or thoroughly investigated timely. * R9 reported her engagement and wedding ring as missing, and the facility completed a self-report. There was no documentation of other residents on R9's unit being interviewed for missing items. R9's family reported to the facility that they suspected a newer staff member to be involved, and the facility did not submit this to the state agency nor complete an addendum to the original facility self-report. * The facility was made aware by staff that R12 had missing medications, and did not submit the allegations of potential misappropriation to the state agency.

Inspectors wroteBased in interview and record review, the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 1 (R8) of 4 residents reviewed. * On 12/4/2025 at 9:00 AM R8 did not have a comprehensive assessment completed when R8 yelled and cried out stated stated R8's foot hurt. Licensed practical nurse (LPN) assessed R8's leg instead of R8's foot and noted no pain. There was no documentation of an assessment or pain assessment completed at that time for R8. On 12/4/2025 in the evening R8 was noted to have pain in the left foot, LPN noted R8 left toes were swollen and painful to touch. An order for x-ray was obtained and R8 was noted to have a 3rd, 4th, and 5th, metatarsal (toe) fractures on the left foot. [...]

Inspectors wroteBased 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.

Inspectors wroteBased on record review, and interview, the facility failed to ensure two of two sampled discharged residents (R)393 and R140) had discharge summaries completed prior to discharge to ensure continuity of care.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure ongoing communication and collaboration with the dialysis facility and failed to ensure a medication was administered on dialysis days for one of one residents (Resident (R) 5) reviewed for dialysis out of a sample of 32.

Inspectors wroteBased on interviews, personnel files review, and policy review the facility failed to ensure a performance review was completed for three of five Certified Nurse Aides (CNA) 4, CNA1, and CNA 5) once every 12 months.