Brookside Inn

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Administration Deficiencies

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Resident Rights Deficiencies

Honor the resident's right to organize and participate in resident/family groups in the facility.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Emergency Preparedness Deficiencies

Provide emergency officials' contact information.

Emergency Preparedness Deficiencies

Establish emergency prep training and testing.

Emergency Preparedness Deficiencies

Establish staff and initial training requirements.

Emergency Preparedness Deficiencies

Conduct testing and exercise requirements.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Nursing and Physician Services Deficiencies

Observe each nurse aide's job performance and give regular training.

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.

Administration Deficiencies

Provide behavior health training consistent with the requirements and as determined by a facility assessment.

A complaint survey, prompted by #CO39288, Incident #38119, Incident #39193 and Incident #39283 was conducted on 3/5/25 to 3/6/25. One deficiency was cited. Based 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. Findings include:I. Facility policy and procedureThe Restraint Free Environment policy and procedure, undated, was provided by the nursing home administrator (NHA) on 3/6/25 at 1:55 p.m. It revealed in pertinent part, "It is the policy of [the facility] that each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints."Physical restraint refers to any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident' s body that the individual cannot remove easily which restricts freedom of movement or normal access to one' s body."Discipline means any action taken by the facility for the purpose of punishing or penalizing residents."Convenience refers to any action taken by the facility to control.. Based 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.The rough care provided by CNA #1 toward Resident #2 caused Resident #2 physical pain and mental anguish as evidenced by her crying out and asking CNA #1 repeatedly to stop and not treat her that way.Additionally, the facility failed to protect Resident #1 from abuse from licensed practical nurse (LPN) #1.Findings include:I. Facility policy and procedureThe Abuse Prevention policy and procedure, undated, was provided by the nursing home administrator (NHA) on 3/6/25 at 1:55 p.m. It read in pertinent part, "Our residents have the right to be free from abuse, neglect, exploitation, misappropriation of resident property, mistreatment, corporal pu..

A complaint survey, prompted by #CO39551 was completed on 3/5/25 to 3/6/25. One deficiency was cited. Based 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.The rough care provided by CNA #1 toward Resident #2 caused Resident #2 physical pain and mental anguish as evidenced by her crying out and asking CNA #1 repeatedly to stop and not treat her that way.Additionally, the facility failed to protect Resident #1 from abuse from licensed practical nurse (LPN) #1.Findings include:I. Facility policy and procedureThe Abuse Prevention policy and procedure, undated, was provided by the nursing home administrator (NHA) on 3/6/25 at 1:55 p.m. It read in pertinent part, "Our residents have the right to be free from abuse, neglect, exploitation, misappropriation of resident property, mistreatment, corporal punishment and involuntary seclusion."Our facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individuals."The Abuse Investigations policy and procedure, undated, was provided by the NHA on 3/6/25 at 1:55 p.m. It read in pertinent part, "All reports of alleged or suspected abuse, neglect, exploitation, misappropriation of resident property, mistreatment of residents and injuries of unknown source shall be promptly a..

Based on a record review it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the Life Safety Code Section 9.6 and NFPA 72.1.Annual Fire Alarm inspection report does not show all devices tested2. No 2 year smoke detector sensitivity report availableNFPA 101, Section 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm .. Based on documentation review, it was determined that the facility did not maintain proper electrical practices in accordance with NFPA 99 Health Care Facilities Code (2012). This was evidenced by:1.No written record of the continuity of the grounding circuit, polarity of hot and neutral connections, and retention force of the grounding blade in patient care rooms was conducted annually. NFPA Standard: NFPA 99 Health Care Facilities Code (2012)6.3.3.2 Receptacle Testing in Patient Care Rooms.6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by v.. Based on observation and record review during the survey, it was determined that the facility failed to maintain the back-up emergency generator in accordance with National Fire Protection Association (NFPA) Standard 110. This was evidence by the following: 1.Generator | No monthly conductance testing being conducted2.Load bank test shows that testing missed 1 hour at or above 75 by 15 minutes8.1.1 The routine Maintenance and operational testing program shall be based on all of the following: Manufacturers recommendationsInstruction manualsMinimum r.. Based on observation and staff interview, it was determined that the facility failed to maintain smoke dampers in accordance with Life Safety Code Section NFPA 1051.Fire Damper inspection overdue | last tested in 2019NFPA 105, 6.5.1 Smoke dampers for dedicated and non-dedicated smoke control systems shall be inspected and tested in accordance with NFPA 92A, Standard for Smoke-Control Systems Utilizing Barriers and Pressure Differences.6.5.2* Each damper shall be tested and inspected one year after installation. The test and inspection frequency shall then be eve.. Based on observations and records review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association NFPA 25 and NFPA 1011. No Quarterly reports available for review | 2024 quarterly inspection overdue2. No 5 year internal sprinkler report available for review | Only 5 year FDC hydroNFPA 101: 4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with th.. Based on record review, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Section 19.7.1.6No fire drill recorded 4th Quarter 2nd shiftNFPA 101, 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were disc.. The Colorado Division of Fire Prevention and Control conducted this survey in accordance with the Federal Register at Section 42 CFR 483.70(a). The initial comments, (ID Prefix Tag #K000) are informational only and a representation of the facility' s general characteristics. This facility is a single-story, slab-on-grade, Type II (000) structure. The facility is protected throughout with a full National Fire Protection Association (NFPA) 13 automatic fire sprinkler system. The attic space within the Type II structure has been determined to have limited access and will no..

A recertification survey was conducted from 2/5/24 to 2/8/24. Two deficiencies were cited. An Emergency Preparedness survey was conducted from 2/5/24 to 2/8/24. Four deficiencies were cited. Based on interview and record review, the facility failed to develop a communication plan that included contact information for Federal, State, tribal, regional, local emergency preparedness staff or other sources of assistance. Specifically, the facility failed to update the facility communication plan with the contact information for the correc.. Based 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 prog.. Based on record review and interview, the facility failed to conduct two exercises annually (in the last 12-month cycle) to test the facility' s emergency preparedness (EP) plan; assess each testing activity; thoroughly document the facility' s assessment of each testing activity; document any required revisions of the facility' s EP plan based on the te.. Based on record review and interview, the facility failed to develop and maintain an up-to-date emergency preparedness (EP) training program that aligns with the facility' s specific individualized EP plan, annual risk assessment, facility EP policies and procedures, the facility' s communication plan, that was delivered to all staff upo.. Based on record review and interview, the facility failed to develop and maintain an up-to-date emergency preparedness training and testing program that was based on the facility' s emergency preparedness (EP) program plan, annual risk assessment, facility EP policies and procedures and the communication plan that was delivered to all staf.. Based on record review and interviews, the facility failed to develop and implement emergency preparedness policies and procedures based on the emergency preparedness plan and communication plan to include pre-arranged transfer agreements, in compliance with Federal, State and local laws that were reviewed and those agreements were updat.. Based on record review and interviews, the facility failed to develop and maintain a written emergency communication plan that contained a procedure for how the facility would coordinate patient care within the facility; across healthcare providers; and with State and local health departments in an emergency. Specifically, the facility f.. Based on record review and interviews, the facility failed to ensure notification to the physician and responsible parties for one (#55) out of two residents reviewed for notification out of 39 sample residents. Specifically, the facility failed to notify Resident #55' s representative, hospice provider and the physician regarding the resident pulling out h.. Based 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 aggress.. Based on record review and staff interviews, the facility failed to develop and maintain an emergency preparedness (EP) plan that included a process for cooperation and collaboration with local, tribal, regional, State and Federal emergency preparedness officials efforts to maintain an integrated response during a disaster or emergency. S..