Brookside Healthcare Center

Inspectors wroteBased on interview and record review, the facility failed to ensure medications that were discontinued, expired, or no longer needed were destroyed in accordance with facility policy and procedures (P&P) and regulatory requirements for non-controlled medications logs (a non-controlled medication is a medication that is not classified as a controlled substance or narcotic but still requires proper handling and disposal), when the non-controlled medication disposition logs (document used to record the destruction of a medication for tracking purposes) revealed 163 medications were destroyed with only one licensed nurse signature, and an additional 20 medications were destroyed without any licensed nurse signature. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure received a new Preadmission Screening and Resident Review evaluation (PASRR- a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) was conducted for one (1) of three (3) sampled residents (Resident 63) reviewed for PASRR requirements, when the facility failed to complete a PASRR Level I screening and refer for further PASRR evaluation after Resident 63 was diagnosed with unspecified psychosis (a mental health disorder involving a loss of contact with reality, such as hallucinations or delusions, not caused by substance use or a known medical condition) on May 8, 2020, and bipolar disorder (a mental health disorder characterized by significant changes in mood, energy, and activity levels) on March 1, 2023. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free of medication errors for one (1) of fourteen (14) sampled residents (Resident 53) when Insulin Aspart (NovoLog, a rapid-acting insulin used to control blood high blood sugar) was administered one hour and twenty five minutes before Resident 53 received a meal. This failure had the potential to affect Resident 53's blood glucose levels and place Resident 53 at risk for a hypoglycemic event (low blood sugar).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen were followed when: 1. Chipped paint was found in the kitchen dry storage room. 2. A cutting board was found to be worn, with scoring, areas of chipping, and visible discoloration. These failures resulted in an unsanitary kitchen environment and had the potential to cause foodborne illness (stomach illness acquired from ingesting contaminated food) for 78 of 78 sampled residents who received their meals from the kitchen.1. During an observation on June 15, 2026, at 8:55 AM, in the dry storage room, the wall behind where food is stored was found to have chipped paint. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure used and contaminated materials were handled in a manner that prevented the spread of infection for one (1) of four (4) sampled residents (Resident 40) when a soiled utility cart (a mobile cart with two compartments cart - one for soiled linens, and one for trash, used in nursing homes to store, and transport contaminated materials without spreading germs) was improperly positioned inside Resident 40's room during direct resident care. This failure had the potential to expose Resident 40 to a risk of cross-contamination (the physical transfer of harmful bacteria, viruses, or allergens from one surface, object, or food to another) which could result in negative health outcomes for Resident 40.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light (a device that allows patients to communicate with nursing staff when they need assistance) was within residents' reach for two (2) of six (6) sampled residents (Residents 36 and 41) when: 1. For Resident 36, the call light was located on the floor on Resident 36's right side of the bed and unreachable. 2. For Resident 41, the call light was wrapped around the bed's left upper side rail, behind Resident 41, with the call button pointing towards the floor and unreachable. This failure prevented Residents 36 and 41 from being able to access their call lights to request assistance, which had the potential for delayed medical care, increased risk for falls, and placed their safety and well-being at risk.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain professional standards for food service safety when: 1. Food crumbs, black grime, and trash were found on the floor under the steam table. 2. Food crumbs and thickener powder residue were present in the food preparation area. 3. Six wet scoops (dishers) were found stored inside the plastic container box. These failures had the potential to expose 78 of 84 highly susceptible residents who receives food from the kitchen to foodborne illnesses (illness caused by ingestion of contaminated food or beverages) due to cross-contamination (the transfer of harmful substances or disease- causing microorganisms to food).

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control and prevention measures when: 1. Resident 58's oxygen tubing was not changed in accordance with facility policy. 2. A Licensed Vocational Nurse (LVN) 5 presenting with Covid-19 (an illness that spread from person to person when an infected person coughs, sneezes, or talks) symptoms (fever or chills, cough, shortness of breath, sore throat, runny nose) was not tested upon return to work and prior to providing care to residents. 3. LVN 4 did not perform hand hygiene after checking the vital signs and before administering medications to Resident 76. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure complete, accurate and consistent documentations in residents clinical records when: 1. One of 21 sampled residents (Resident 36's) Treatment Administration Record (TAR-a document that tracks the time and type of treatments administered to a patient) had multiple gaps/ missed documentations. 2. The POLST (Physician Orders for Life-Sustaining Treatment) Form for three of 21 sampled residents (Resident 10, 36, and 82) had missing information. These failures had the potential for residents to receive inconsistent care coordination and unmet care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a risk on nutritional deficit care plan upon readmission to the facility for one of 21 sampled residents (Resident 46). This failure had the potential for not meeting nutritional goals, treatments, and services related to resident's medical, physical, mental, and psychosocial needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure an individualized care plan (a plan showing specific interventions to provide effective and person-centered care to meet the resident's needs) was developed for one of 21 sampled residents (Resident 69) to address the resident's ongoing issue of constipation. This failure had the potential to increase the risk of health complications which can lead to Resident 69's chronic discomfort and reduced quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an ongoing activity program to meet the needs and interests of one of 21 sampled residents (Resident 83). The facility failed to provide Resident 83 with an individualized activity program which met his identified preferences of listening to music, keeping up with the news, and going outside for fresh air. This failure created the risk of not providing appropriate and individualized care to Resident 83 which can lead to cognitive and emotional decline as well as increased feelings of isolation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure coordination and collaboration were practiced with contracted hospice agency when one of one resident admitted for hospice had no hospice plan of care available to facility staff. These failures had the potential to cause delay in treatment, miscommunication, and uncoordinated care for Resident 10.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary respiratory care and services in accordance with professional standards of practice and the resident's plan of care when two of 21 sampled residents (Resident 10 and 36) oxygen therapies were not followed as prescribed by his physician. These failures had the potential to cause changes in Resident 10 and 36's respiratory status and affect their overall health and well-being.

Inspectors wroteBased on observation, interview, and record review, one of five Licensed Vocational Nurses (LVN 7) failed to demonstrate competency in medication administration for one of nineteen sampled residents (Resident 62). LVN 7 did not follow facility procedure when administering medication through the Gastrostomy tube (G-tube- a tube inserted into the stomach for the purpose of providing nutrition) for Resident 62. This failure had the potential to cause G-tube complications for Resident 62.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the Social Services Department followed up on a physician's order for a hospice evaluation for one of 21 sampled residents (Resident 30). This failure had the potential to delay hospice services for Resident 30.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from unnecessary drugs when: 1. The adverse reactions for antibiotic medication were not monitored for one of 21 sampled residents (Resident 46). 2. Indication for an antibiotic medication was not clear and clarified with the doctor for one of 21 sampled residents (Resident 46). These failures had the potential to put the resident at risk of receiving unnecessary medications that could result in serious harm.

Inspectors wroteBased on interview and record review, the facility failed to provide services in compliance with state requirements when Physician 1 did not complete a history and physical exam (H&P- a formal assessment of a resident done by a physician that includes a medical history, physical exam, and a summary of any tests) within the timeframe specified in the facility's policy for one of three sampled residents (Resident 341). This failure had the potential to prevent Resident 341 from receiving appropriate and timely care and services.

Inspectors wroteBased on interview and record review the facility failed to follow their policy for one of three sampled residents (Resident 1), wound measurements on admission. This failure placed a clinically compromised Residents (Resident 1) health and safety at risk. When the left trochanter wound was not measured four days from admission.

Inspectors wroteBased on interview and record review the facility failed to follow their policy and procedure to ensure call lights were answered in timely manner to provide care and services for three of three sampled residents (Resident 1,2, 3). This failure had the potential to place a clinically compromised Residents (Resident 1,2, 3) health and safety at risk. When resident's needs were not met in a timely manner.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure insulin (drug used to lower blood sugar) was used in accordance with facility ' s manufacturer ' s recommendations and direction for storage, use, and disposal for two of 14 residents receiving insulin (Residents 4, and 5). 1. Resident 4 insulin was actively in use and available past the manufacturer ' s beyond-use date (BUD- last date a product can be safely used after it has been altered for resident use). 2. Resident 5 insulin was actively in use and available without an open date. These failures had the potential for Residents 4, and 5 to receive insulin with reduced potency which could cause inadequate blood sugar control. These may result in the physician increasing insulin doses based on the blood sugar results placing the residents at risk for harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate supervision was provided to prevent avoidable accidents for one of three sampled residents (Resident1). When Resident 1 fell out of wheelchair while sitting in front lobby. This failure contributed to Resident 1 sustaining an open injury to forehead and being set out to hospital for further evaluation.

Inspectors wroteBased on interview and closed record review, the facility failed to ensure a care plan was followed according to the facility's policies and procedures (P&P) for one of three sampled Residents (Resident 1) when: 1. There were no documentation of neuro checks and floor mats. 2. There were missing documentation for monitoring intake and recording of every meal. These failures had the potential to adversely affect the health and safety of one resident, Resident 1, by placing Resident 1 at risk of increased malnutrition (not enough nutrients in the body) and further potential injuries from another fall.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1. There were fifteen water pitchers and eight plastic containers stored wet. The blender was stored with water at the bottom of it. 2. There were crumbs and black grime on the floor under the freezer, sticky residues under the crate in the dry storage room, and crumbs and trash under the stove. These failures had the potential to attract pests, contaminate residents' food and/or cause foodborne illnesses, to a population of 83 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure their recyclable dumpster was covered and closed completely. This failure had the potential to attract pests and rodents in the facility with medically compromised population of 84 residents.

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient licensed nursing staff to ensure residents received nursing care and treatment as ordered by the physician and specified in their care plans (an individualized plan for the medical care of a resident) when: 1. A registered nurse (RN) was not available to administer antibiotics (medications that destroy or slow down the growth of bacteria) intravenously (IV- administered into the veins) to five residents (Residents 45, 65, 230, 231, 235) on April 15, 2022, during the 3:00 PM to 11:00 PM shift (PM shift). This resulted in Residents 45, 65, 230, 231, and 235 to not receive their physician prescribed antibiotics which had the potential for worsening or prolonged infection. 2. Licensed nursing staff were not available to perform wound treatment for four residents (Residents 5, 35, 74, and 281) on April 16, 2022. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement pharmaceutical services procedures to meet the needs of residents when: 1. The on-coming licensed nurses and off going licensed nurses failed to verify and document the controlled medications (medications that are controlled by the government because it may be abused or cause addiction) were counted and verified as being accurate each shift. This failure had the potential for controlled drugs to be diverted to people they were not prescribed for, and to result in unnecessary pain or anxiety for the residents for which they were prescribed. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their daily menu for lunch on April 19, 2022, when: 1. [NAME] 1 did not use the proper scoop size for the puree (food that is blended until it is a thick, smooth, lump-free consistency) chicken for seven of 83 residents. (Cook 1 used a number 10 scoop. The menu indicated to use a number 8 scoop.) 2. [NAME] 1 did not use the proper scoop size for the vegetarian (a diet that does not include any meat, poultry, or seafood) diet entrée for four of 83 residents. (Cook 1 used a number 6 scoop. The menu indicated to use a number 5 scoop.) These failures had the potential compromise the nutritional status of four residents receiving a vegetarian diet and six residents receiving puree diets of 83 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their infection prevention and control program when: 1. Licensed Vocational Nurse (LVN 1) did not clean or disinfect a glucometer (a device used to check blood sugar) in-between use on two residents (Resident 235 and Resident 51). 2. Registered Nurse 2 (RN 2) did not disinfect the rubber stopper (a rubber top on medication vials) of two Vancomycin (an antibiotic) vials during medication administration preparation for Resident 235. 3. Resident 31's CPAP (Continuous Positive Airway Pressure - machine to treat sleep apnea disorders) mask was left exposed and touching Resident 51's nightstand. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of five residents (Residents 230) reviewed for advance directives (written instruction, such as a living will or durable power of attorney for health care, recognized under State law relating to the provision of health care when the individual is incapacitated) was assisted to formulate her advance directive. This failure had the potential to result in a delay of treatment for the Residents 230 as related to advance directives, or for life sustaining measures to be rendered against what she wanted.

Inspectors wroteBased on interview, and record review, the facility failed to follow-up with the physician after a resident's change in condition for one of two residents (Resident 51) reviewed for dialysis (a process of removing waste products and excess fluids from blood). This failure had the potential to result in a delay of management of Resident 51's medical care.

Inspectors wroteBased on interview and record review, the facility failed to ensure four of four residents (Residents 5, 35, 74, and 281) reviewed for pressure ulcers (injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin) were provided wound care treatment as prescribed by their physician on April 16, 2022. This failure had the potential to place Residents 5, 35, 74, and 281 at risk for delayed wound healing and increased risk for infection (establishment of an infective agent in or on a suitable host, producing clinical signs and symptoms).

Inspectors wroteBased on observation, interview, and record review, the facility failed to report a fall with sustained major injuries to California Department of Public Health (CDPH) for one of six residents (Resident 70) reviewed for falls. This failure had the potential to delay investigations of the incident, delay the identification of contributing factors, and delay the implementation of interventions to prevent further injury to Resident 70.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a dialysis (a process of removing waste products and excess fluids from blood) access site was assessed in accordance with the physician's orders and facility policy for one of two residents (Resident 51) reviewed for dialysis. This failure had the potential to increase the risk of infection, bleeding or blood clots at Resident 51's dialysis access site.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were appropriately stored and labeled when: 1. Two unlabeled, opened insulin (a drug used to lower blood sugar) pens were found stored in the medication storage refrigerator after they were obtained by a Licensed Vocational Nurse (LVN 1) from the insulin emergency kit (insulin E-kit - a container where spare insulin is stored for emergent or urgent use). This failure had the potential to result in single resident use insulin pens to be used on multiple residents, 2. One of three nursing station medication carts had a loose single tablet of medication found at the bottom of a drawer. [...]