Brookside Inn

Inspectors wroteBased 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 residents' fall interventions were appropriate or if new fall interventions were needed. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on record review and interviews, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented in order to facilitate improvement in the lives of nursing home residents through continuous attention to quality of care, quality of life, and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to quality of life and quality of care.

Inspectors wroteBased on record review and interviews, the facility failed to provide response, action and rationale to residents involved in group grievances. Specifically, the facility failed to effectively address, resolve and follow up with residents on the outcomes and resolutions of grievances expressed.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure proper storage of medications for one of one medication storage room and three of five medication storage carts. Specifically, the facility failed to:-Ensure eye drops, insulin vials, tuberculin (TB) serum vials and nebulizer medications were dated with the dates they were opened;-Ensure expired medications were discarded; and,-Ensure expired medical supplies were discarded.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure meals were served according to the resident's preferences for residents on five of six units. Specifically, the facility failed to offer substantive menu alternatives and honor residents' food preferences.

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases on two of three units. Specifically, the facility failed to:-Ensure housekeepers cleaned and disinfected the residents' rooms in a hygienic manner; -Ensure housekeepers cleaned high touch areas; -Ensure hand hygiene was completed during room cleaning; -Ensure dwell times for disinfectants were followed per manufacturer's recommendations:-Ensure staff followed appropriate hand hygiene practices;-Ensure staff donned (put on) appropriate personal protective equipment (PPE) when providing care for residents on enhanced barrier precautions (EBP); [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#53) of four residents reviewed for abuse out of 42 sample residents were kept free from abuse. Specifically, the facility failed to protect Resident #53 from verbal abuse by Resident #37.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to ensure that residents were free from involuntary seclusion for two (#85 and #29) of three residents reviewed for proper placement out of 42 of sample residents. Specifically, the facility failed to accurately and timely re-evaluate the appropriateness of Resident #85 and Resident #29's placement in the secure unit.

Inspectors wroteBased on record review and interviews, the facility failed to adequately monitor residents for unnecessary psychotropic medications needed to provide effective and person-centered care for one (#85) of five residents reviewed for use of psychotropic medications out of 42 sample residents. Specifically, the facility failed to ensure the physician's order for Resident #85's as needed (PRN) lorazepam (antianxiety medication) was reevaluated and a rationale was provided by the physician to justify the continued use of the psychotropic medication beyond the 14-day limit.

Inspectors wroteBased on record review and interviews, the facility failed to report alleged violations of potentialabuse to the State Survey and Certification Agency in accordance with state law for one (#53) of four residents reviewed for abuse out of 42 sample residents. Specifically, the facility failed to report an incident of potential verbal abuse towards Resident #53 by Resident #37 to the State Agency.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide necessary services consistent with professional standards of practice to promote healing of pressure injuries and prevention of additional pressure injuries for two (#85 and #91) of three residents reviewed for pressure injuries out of 42 sample residents. Specifically, the facility failed to:-Ensure Resident #85, who was at high risk for skin break due to immobility was repositioned and provided incontinence care in a timely manner; and,-Ensure staff consistently implemented care planned pressure injury prevention interventions for Resident #85; and,-Ensure Resident #91, who had a stage 4 pressure injury, was repositioned in a timely manner.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure staff provided respiratory care consistent with professional standards of practice for two (#42 and #16) of three residents reviewed for oxygen services out of 42 sample residents. Specifically, the facility failed to:-Ensure staff adequately maintained and cleaned Resident #42's continuous positive airway pressure (CPAP) machine; and,-Ensure staff administered oxygen to Resident #42 and Resident #16 per physician's order.

Inspectors wroteBased 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. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents were free from physical restraints imposed for staff convenience and not required to treat medical symptoms for one (#2) of three residents reviewed for restraints out of three sample residents. Specifically, the facility failed to ensure Resident #2, who had a history of getting up out of bed unassisted, was kept free from physical restraints.

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to: -Ensure the facility had a water monitoring program to prevent the potential spread of Legionella and other waterborne pathogen infections; -Ensure housekeeping staff changed gloves and performed hand hygiene consistently when appropriate; -Ensure housekeeping staff performed hand hygiene appropriately when performed; -Ensure housekeeping staff used a disinfectant chemical when cleaning resident bathrooms; and, -Ensure tracking, offering and administration of the COVID-19 vaccination.

Inspectors wroteBased on record review and interviews, the facility failed to ensure two (#120 and #18) of five residents reviewed for abuse out of the 39 sample residents were kept free from abuse. Specifically, the facility failed to prevent a resident-to-resident altercation, on 12/16/23, between Resident #120 and Resident #18, who had a history of aggressive behaviors toward each other.

Inspectors wroteIII. Failure to ensure Residents #90, #86 and #29 were assessed by a registered nurse after a fall A. Professional reference Colorado Department of Regulatory Agencies, State Board of Nursing: Practice Act and Laws. 2022. https://dpo.colorado.gov/Nursing/Laws retrieved on 11/8/22 at 3:07 p.m. The practical nursing student is taught to identify normal from abnormal in each of the body systems and to identify changes in the patient's condition, which are then reported to the registered nurse (RN) or medical doctor (MD) for further or 'full' assessment. B. Resident #90 1. Resident status Resident #90, age [AGE], was admitted on [DATE]. According to the October computerized physician orders (CPO), the diagnoses included dementia, delirium, bipolar disorder, anxiety disorder, unspecified pain, and a tremor. [...]

Inspectors wroteBased on observations, interviews and record review the facility failed to store, prepare, distribute, and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to: -Ensure food was labeled and dated; -Ensure appropriate hand washing and glove usage in the main kitchen; -Ensure timely inspection and cleaning of the ice machine; and, -Ensure cooked food items were monitored and cooled properly.

Inspectors wroteBased on observations, record review, and staff and resident interviews, the facility failed to promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality out of 43 sample residents, in three of three shower rooms. Specifically, the facility failed to ensure residents experienced a dignified living experience when; -The facility had three toilets removed from all three facility shower rooms which were called spa rooms. Residents could not use a toilet during their shower time. The residents were expected to go to the bathroom in their rooms before taking a shower or receiving a staff assisted shower. If unable to return to their rooms to use the bathroom during a shower, the residents were expected to urinate or defecate down the shower drain while in the shower. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure that two (#48 and #3) of five out of 43 sample residents were kept free from physical abuse. Specifically, the facility failed to ensure personalized care planned behavioral interventions were in place for Resident #104, who had a history of confusion, delusions and hallucinations and was exhibiting altered mental status behaviors. On 10/18/22, Resident #104 threw a wheelchair pedal towards Resident #48. Resident #48 sustained a laceration on his right forehead that required a computerized tomography (CT) evaluation, neurological monitoring, wound care and steri-strips for wound closure. Additionally, the facility failed to ensure Resident #3 was kept free from physical abuse by Resident #5.

Inspectors wroteBased on record review and interviews, the facility failed to report alleged violations of potential abuse to the proper authority, including the policy and state oversight agency in accordance with state law for one alleged violations; involving two (#40 and #5) of five residents reviewed for allegations of abuse out of 43 sample residents Specifically, the facility failed to report one allegation of resident abuse by staff to the facility administrator, director of nursing, local police, or the Stage Agency, in a timely manner. Cross reference F610: failure to conduct a thorough investigation.

Inspectors wroteBased on staff interviews and record review the facility failed investigate allegations of abuse for one (#40) of five residents reviewed for abuse out of 43 sample residents. Specifically, the facility failed to thoroughly investigate one report of physical abuse that Resident #40 voiced to a licensed nurse. Cross-reference: F609 failure to notify the State agency in a timely manner.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure activities designed to support residents' physical, mental, and psychosocial well-being were provided for one (#26) of two residents out of 43 sample residents. Specifically, the facility failed to ensure Resident #26 was invited to group activities, which was her preference, and developed a comprehensive care plan which addressed the resident's socialization and activity needs.

Inspectors wroteBased on record review and interviews, the facility failed to conduct yearly certified nurse aide (CNA) performance reviews and provide training based on the annual reviews for two (CNA #5 and CNA #7) out of two facility CNAs reviewed for annual reviews and training. Specifically, the facility failed to: -Provide performance evaluation reviews annually; and -Ensure a system was in place to track CNAs to ensure the facility performed performance evaluation reviews annually.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that one (#104) of four out of 43 sample residents had personalized behavioral interventions in place. Specifically, the facility failed to ensure the personalized behavioral interventions were care planned and in place for Resident #104, who had a history of confusion, delusions and hallucinations and was exhibiting aggressive behaviors.

Inspectors wroteBased on observations and interviews, the facility failed to ensure that beverages were provided throughout the day for two (#2 and #29) of two residents sampled for hydration out of 43 sample residents. Specifically, the facility failed to ensure Resident #2 and Resident #29 were offered beverages throughout the day to maintain proper hydration.

Inspectors wroteBased on observations, record review, and interviews the facility failed to provide behavioral health training for a facility staff person who worked on the memory care unit for three (#90, #84 and #107) of six residents reviewed of 43 sample residents. Specifically, the facility failed to: -Develop, evaluate, and provide training to a male activity assistant (AA) #1 who worked on the secured memory care unit for resident specific interventions; -Educate AA #1 about three female residents (#90, #84, #107) with dementias, who each had a history of sexual abuse trauma in their past with males; and, -Educate AA #1 on what behaviors and triggers to look for and respond to when interventions were written in the resident's care plans.