Brookside Skilled Nursing Hospital

Inspectors wroteBased on observation, interview and record review the facility failed to ensure food were stored and prepared in a sanitary manner when these were observed during kitchen tour:1. The walk-in refrigerator had one grape and one nut on the floor.2. There was ice built up in the freezer on the center support.3. Debris were found under the Freezer: one small potato, one packet of mustard, red onion skin, and debris.4. Five items were found opened but not dated in the cabinet: hot green salsa, food coloring, vanilla extract, cinnamon sticks, browning and seasoning sauce.5. One item found opened with no label and no date: chili oil.6. Three fruit flies were found in the kitchen.7. The interior of two ovens were not cleaned.8. One dirty spatula was stored in the clean utensil drawer.9. Six water pitchers were wet and stored in an enclosed cabinet. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there was an effective pest control program when fruit flies were found in the kitchen. Additionally, three broken window screens and one sliding door screen were observed during tour. These damaged screens are potential entry points for flying pests. These failures did not ensure residents' environment was free from pests.

Inspectors wroteBased on interview and record review, the facility failed to ensure target behaviors for the use of Zyprexa (an anti-psychotic medication that changes brain chemistry to stabilize mood and reduce hallucinations=seeing or hearing things that are not there) were accurate, specific, and individualized for Resident 2, one of five residents on these types of medication. This failure did not ensure staff were monitoring the right target behaviors and/or formulated appropriate interventions for Resident 2 within her care plans.

Inspectors wroteBased on observation, interviews and record review, the facility did not ensure coordination and collaboration with Hospice agency on developing and ongoing communication of plan of care for one of three residents, Resident 11. This failure could delay Hospice service when changes of condition occurs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5%. This failure resulted in a medication administration total error rate of 9% with a total of three errors out of thirty three opportunities for errors. During a concurrent observation and interview on 04/15/2026 at 8:38 AM with Licensed Vocational Nurse 1 (LVN 1) during medication administration preparation for Resident 25, LVN 1 mixed water with the polyethylene glycol 3350 powder (an unflavored powder used to treat occasional constipation) and was unable to state how much water was used to dissolve the polyethylene glycol 3350 powder. Resident 25 was not informed by LVN 1 that polyethylene glycol 3350 solution was being administered until after Resident 25 had already consumed the polyethylene glycol 3350 solution. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure resident rooms accommodated no more than four residents in each room when one room (Rooms 101) had six residents in the room. This failure had the potential to negatively impact the safety and well-being of residents.

Inspectors wroteBased on interviews and record review, the facilty failed to administer the prescribed Morphine Sulfate (a strong pain medication) to one of five sampled residents (Resident 1) as ordered when: Morphine Sulfate was prescribed on 2/13/24, and was given almost 24 hours later on 2/14/24. This failure had the potential to cause Resident 1 to feel discomfort while dying on comfort care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Certified Dietary Manager (CDM), the position responsible for supervision of daily food service operations, was fully qualified when the facility did not have a full-time kitchen manager. This failure had the potential for inadequate supervision of the dietary department for 73 out of 75 residents who received food from the kitchen.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain a medication error rate below five percent (5%). During the medication pass on 10/22/24, four medication errors were observed out of thirty-three opportunities for two out of four residents, resulting in an error rate of 12.12%. This failure had the potential to result in harm in the health and safety of residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were met for food storage in the kitchen when: 1. There were 4 rotten tomatoes with the delivery date of 10/9/24 in the walk-in refrigerator. 2. There were 4 apple pies on a tray with no label/expiration dates, covered with one aluminum tray with black colored old grime in the refrigerator #2. 3. There was a bag of chicken wings with no label/expiration date in the freezer #2. These failures had the potential to put residents at risk for foodborne illnesses.

Inspectors wroteBased on interview and record review, facility did not ensure Hospice services and interventions were addressed for one (Resident 4) of 18 sampled residents, when the care plan did not include specific coordination and communication plan of care between the facility and the hospice agency. This failure had the potential to result in not providing the needed plan of care and specific services to Resident 4.

Inspectors wroteBased on observations, interviews, and record reviews, it was determined that two separate vials of incorrectly labeled eye drop medications lacked proper labels for prescription medications for a resident. This is an issue because the absence of labels can lead to confusion in medication administration, increasing the risk of administering the wrong medication or dosage, which could adversely affect the resident's health and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident rooms accommodated no more than four residents in each room when room [ROOM NUMBER] had six residents in the room. This failure had the potential to negatively impact the safety and well-being of residents.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of resident to resident abuse and injury of unknown source within the required 2-hour timeframe to the State Survey Agency (SSA- where state law provides for jurisdiction in long-term care facilities) for three (3) of six sampled residents (Resident 1, Resident 2, and Resident 3). The deficient practice had the potential for delayed provision of care and the potential to compromise the protection of the residents in the facility which could affect the resident's wellbeing.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, and distribute food in a safe and sanitary manner. 1. Opened food items were not properly dated and stored. 2. Fresh produce in the refrigerator had mold-like substance. 3. Thawed, uncooked poultry in the refrigerator was not properly dated and stored. 4. [NAME] (C) 2 did not follow proper sanitation and food handling practices during tray line service and did not perform hand hygiene after removing gloves. 5. Temperature and storage conditions for emergency food kits were not monitored. 6. Food Service Manager (FSM) wore jewelry in the kitchen. 7. Kitchen tools and patient food trays were not maintained in good condition. 8. Coffee mugs belonging to facility staff were stored in the kitchen cabinets. These deficient practices had the potential to put residents at risk for foodborne illnesses.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an effective pest control program. 1. [NAME] 1 did not report sighting of a roach in the kitchen counter. 2. Recommendations made by the pest control company were not followed. These failure had the potential to not eradicate and contain common household pests in the facility to prevent contamination, transmission or spread of disease to patients.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices when: 1. One staff did not perform hand hygiene in between resident care activities. 2. One staff was not wearing personal protective equipment (PPE- protective clothing, helmets, gloves, face shields, goggles, facemasks and/or respirators or other equipment designed to protect the wearer from injury or the spread of infection or illness) properly. 3. One of 16 sampled residents (Resident 16) was using a nasal cannula (NC - a flexible tubing that sits inside the nostrils and delivers oxygen) that was not changed weekly. 4. One of 16 sampled residents (Resident 32) was using an unlabeled NC. These failures had the potential for cross-contamination and spread of infectious diseases that could jeopardize the health of the residents, staff, and visitors.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a care plan with appropriate nursing interventions for one of four sampled residents (Resident 28) when: There was no care plan for Resident 28's oxygen therapy. This deficient practice had the potential to prevent Resident 28 from receiving appropriate, and individualized care and services consistent with her needs, based upon assessment and physician order.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services according to professional standards of quality for one of four sampled residents when: The oxygen order for Resident 28 was not specified whether continuous or as needed basis. This failure had the potential to not deliver oxygen correctly and ensure safe and effective oxygen therapy, which can result to negative consequences to the resident.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of 16 sampled residents (Resident 29) had weekly assessments and documentation of the pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence) on the left buttock. This failure had the potential to result in delayed healing, and ineffective plan of care and treatment of the resident's pressure ulcer.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of 16 sampled residents (Resident 165) was provided treatment, supervision and appropriate equipment and supplies to prevent accidents related to oral suctioning (a procedure to clear secretions such as mucus from the mouth). 1. There was no assessment and documentation to identify Resident 165's individual risk of an accident, including the need for supervision prior to performing oral suction on her own. 2. Resident 165's care plans did not incorporate oral suctioning procedures consistent with the resident's needs, goals, and facility standards of practice, policies and procedures. 3. There was no physician's order for Resident 165 to self-administer an oral suctioning procedure. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident rooms accommodated no more than four residents in each room when two rooms (rooms [ROOM NUMBERS]) had six residents in each room. This failure had the potential to negatively impact the safety and well-being of residents.