Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Brookside Healthcare Center during CMS and state inspections, most recent first.
The facility failed to maintain food service safety standards, as observed during a survey. Food crumbs, grime, and trash were found under the steam table, and food crumbs and thickener powder residue were present in the preparation area. Additionally, six wet scoops were improperly stored, which could lead to bacterial growth. These deficiencies had the potential to expose residents to foodborne illnesses.
The facility failed to implement proper infection control measures, including not changing a resident's oxygen tubing as per policy, allowing an LPN with COVID-19 symptoms to work without testing, and multiple staff not performing hand hygiene at critical times. These actions risked cross-contamination and infection spread among residents, staff, and visitors.
A facility failed to maintain accurate documentation in a resident's Treatment Administration Record and had incomplete POLST forms for three residents. The TAR showed gaps in catheter care documentation, while the POLST forms lacked essential information like physician signatures and advance directives. Staff acknowledged these omissions, which could lead to miscommunication and care delays.
A resident readmitted to the facility with multiple medical conditions, including end-stage renal disease and recent amputation, did not have a care plan developed to address their high risk for nutritional deficit. Observations noted the resident appeared pale and weak, with untouched food, and interviews confirmed the absence of a care plan despite facility policy requiring one within 24 hours of admission.
A facility failed to create an individualized care plan for a resident with ongoing constipation issues. Despite the resident's cognitive intactness and a documented history of constipation, no care plan was developed to address this condition. The resident reported ongoing constipation problems, and a review confirmed the absence of a specific care plan, contrary to facility policy.
A resident with moderate cognitive impairment was not provided with an individualized activity program that met their preferences for music, news, and outdoor time. Despite these preferences being documented, observations showed the resident often remained in their room without appropriate activities. The activity log indicated infrequent one-on-one activities, and the Activity Director confirmed a lack of documentation regarding the resident's participation or refusal.
A resident admitted for hospice care did not have a hospice plan of care available to facility staff, leading to potential delays in treatment and uncoordinated care. The resident, with multiple medical conditions, was admitted to hospice care, but the plan of care was not provided within the expected timeframe. This oversight was confirmed through staff interviews and record reviews, highlighting a lapse in communication between the hospice agency and the facility.
Two residents in an LTC facility did not receive oxygen therapy as prescribed by their physicians, with one receiving 2.5 LPM instead of the ordered 3 LPM, and another receiving 2.5 LPM instead of 2 LPM. The discrepancies were confirmed by nursing staff, who acknowledged the importance of following physician orders to prevent respiratory distress. Both residents had significant medical histories requiring precise oxygen management.
An LVN failed to demonstrate competency in administering medication through a G-tube for a resident with dysphagia. The LVN pushed Pantoprazole through the G-tube with a syringe instead of allowing it to flow by gravity, as per facility policy. This action was contrary to the prescribed method and acknowledged by the DON.
A facility failed to ensure follow-up on a hospice evaluation order for a resident with dementia, stroke, aphasia, and major depressive disorder. Despite a physician's order and family agreement, there was no documentation of Social Services contacting a hospice company or the family. The absence of follow-up was confirmed by the Case Manager and Social Services Director, and the DON acknowledged the oversight.
A resident's antibiotic regimen was not properly monitored for adverse reactions, and the indication for use was unclear. The facility did not document the required monitoring for adverse reactions or initiate infection surveillance. The resident, with a complex medical history, was prescribed Amoxicillin-Pot Clavulanate without specifying the infection site, contrary to the Physician Discharge Summary's recommendation for a respiratory infection.
A resident admitted with multiple fractures, interstitial pulmonary disease, and depression did not receive a history and physical exam (H&P) within the required timeframe. The facility's policy and state regulations mandate an H&P within 72 hours of admission, but it was completed six days later. The DON confirmed this delay could impact the resident's care.
A resident admitted with a left trochanter wound did not receive timely wound measurements as required by the facility's policy. Despite the resident's medical history, including diabetes and hypertension, the initial assessment and subsequent evaluations failed to document wound measurements until four days post-admission. Interviews with staff confirmed the oversight, highlighting a lapse in following wound management protocols.
A long-term care facility failed to respond to call lights in a timely manner, as reported by three residents with significant medical conditions. These residents experienced delays of up to 3 hours, particularly during the night shift, which contradicted the facility's policy of answering call lights within a reasonable time. The DON was unaware of any complaints, despite the residents' reports.
Failure to Maintain Food Service Safety Standards
Penalty
Summary
The facility failed to maintain professional standards for food service safety, as observed during a survey. During an initial observation tour of the kitchen, food crumbs, black grime, and trash were found on the floor under the steam table. The Dietary Services Director (DSD) acknowledged that the kitchen areas should be kept clean and free of debris, but admitted that the dietary staff did not perform regular cleaning. The facility's policy and procedure for general cleaning indicated that floors must be mopped at least once per day, which was not adhered to. Additionally, food crumbs and thickener powder residue were found in the food preparation area. The DSD confirmed that these areas should be kept clean and free of residues, but again noted that regular cleaning was not conducted by the dietary staff. The facility's sanitation policy required all utensils, counters, shelves, and equipment to be kept clean, which was not followed. The Registered Dietitian (RD) also acknowledged that the cook preparation area should be kept clean. Furthermore, six wet scoops were found stored inside a plastic container box, which the DSD stated should have been air-dried before storage to prevent bacterial growth. The facility's sanitation policy required all items to be air-dried with no water droplets present. The RD confirmed that utensils should not be stored wet, as moisture can harbor bacteria. These deficiencies had the potential to expose 78 of 84 highly susceptible residents to foodborne illnesses due to cross-contamination.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection control and prevention measures in several instances, leading to potential cross-contamination and infection spread among residents, staff, and visitors. One deficiency involved Resident 58, whose oxygen tubing was not changed according to the facility's policy, which mandates weekly replacement to prevent odor and dirt accumulation. The tubing was last changed on October 13, 2024, but should have been replaced by October 20, 2024. This oversight was confirmed by LVN 4 and the Infection Preventionist (IP), who acknowledged the importance of adhering to the policy for infection control purposes. Another significant deficiency occurred when LVN 5, who exhibited COVID-19 symptoms, was not tested upon returning to work and before providing care to residents. Despite having a sore throat and other symptoms, LVN 5 continued to work without a documented negative COVID-19 test result. The IP admitted to discarding the test results and failing to document them, which is against the facility's COVID-19 mitigation plan that requires symptomatic staff to be tested and results recorded. This lapse in protocol could have facilitated the spread of infection within the facility. Additionally, multiple staff members, including LVN 4, CNA 1, and RNA 1, failed to perform hand hygiene at critical times, such as before and after resident contact, after handling soiled linens, and when moving between care activities for different residents. These actions were observed during various instances, and staff acknowledged their failure to adhere to the facility's hand hygiene policy. The lack of proper hand hygiene practices, especially in rooms with Enhanced Barrier Precautions, posed a significant risk of cross-contamination and infection spread.
Deficiencies in Documentation and POLST Forms
Penalty
Summary
The facility failed to ensure complete, accurate, and consistent documentation in residents' clinical records, as observed in the Treatment Administration Record (TAR) of one resident and the POLST forms of three residents. Specifically, the TAR for one resident showed multiple gaps in documentation regarding catheter care, monitoring of catheter placement, and signs and symptoms of infection. These omissions were acknowledged by the Registered Nurse Supervisor, who stated that documentation should be completed immediately after care is provided. Additionally, the POLST forms for three residents were found to have missing information, including critical details such as the date the form was prepared, physician signatures, and advance directive information. The Licensed Vocational Nurse and Registered Nurse Supervisor confirmed these omissions, noting that the forms were not filled out completely as expected. The Social Service Director also acknowledged that the POLST forms were not thoroughly reviewed, which could lead to delays in treatment or miscommunication. Interviews with the Director of Nursing and other staff members highlighted the expectation for complete and accurate documentation as part of their job responsibilities. The facility's policies and procedures emphasize the importance of thorough documentation to ensure proper care and communication. However, the observed deficiencies in documentation and incomplete POLST forms indicate a failure to adhere to these standards, potentially impacting the coordination and delivery of care to the residents.
Failure to Develop Nutritional Care Plan for Resident
Penalty
Summary
The facility failed to develop a care plan addressing the nutritional needs of a resident upon readmission, which was necessary due to the resident's high risk for nutritional deficit. This deficiency was identified during an observation and interview with the resident, who appeared pale and weak, and had not eaten their lunch. The resident expressed that the food was unappetizing following a recent hospital stay. The resident's brother provided additional context, noting that the resident was undergoing dialysis three times a week and had recently undergone a below-the-knee amputation due to gangrene. A review of the resident's records revealed multiple medical diagnoses, including systemic lupus erythematosus, dysphagia, end-stage renal disease, and dependence on renal dialysis, all of which contributed to the resident's high risk for nutritional deficit. Despite these conditions, no care plan was developed to address the resident's nutritional status. Interviews with the Registered Nurse Supervisor and the Director of Nursing confirmed the absence of a care plan and emphasized the importance of such a plan in preventing weight loss and monitoring the resident's nutritional status. The facility's policy required care plans to be initiated within 24 hours of admission based on identified problems and changes in medical condition, which was not adhered to in this case.
Failure to Develop Individualized Care Plan for Constipation
Penalty
Summary
The facility failed to develop an individualized care plan for a resident to address ongoing constipation issues. The resident, who was admitted to the facility with a history of constipation, was found to be cognitively intact according to the Minimum Data Set assessment. Despite the physician's documentation of constipation in the resident's History and Physical, and the prescription of a bowel regimen including medications like Senna, Colace, Miralax, Dulcolax, and Fleet Enema, there was no care plan developed to address this issue. During an interview, the resident reported having a bowel movement three days prior and expressed ongoing problems with constipation. A review of the resident's care plans revealed that while baseline and comprehensive care plans were developed, there was no documented evidence of a care plan specifically addressing constipation. A Licensed Vocational Nurse confirmed the absence of a care plan for constipation, despite the issue being present upon admission. The facility's policy requires care plans to be initiated within 24 hours of admission and completed within seven days, but this was not adhered to in this case.
Failure to Provide Individualized Activity Program
Penalty
Summary
The facility failed to provide an ongoing activity program tailored to meet the needs and interests of a resident, identified as Resident 83, who was part of a sample of 21 residents. Resident 83, who had moderate cognitive impairment, expressed preferences for listening to music, keeping up with the news, and going outside for fresh air. Despite these preferences being documented in the resident's care plan, the facility did not consistently offer activities that aligned with these interests. Observations revealed that Resident 83 was often found awake in his room, staring at a turned-off TV, with no stereo or sensory stimulation present. Interviews with the resident and staff indicated that while the resident preferred staying in his room, he also expressed a desire to go outside and listen to music. The activity log for October showed that one-on-one activities were only offered three times during the month, with music being offered only once, and there was no documented evidence of the resident's preferences being consistently addressed during these visits. The Activity Director acknowledged that while activities were offered based on Resident 83's preferences, there was a lack of documentation regarding the resident's participation or refusal of activities. The facility's policy emphasized the importance of implementing a resident-centered activities program, yet the documentation and execution did not reflect the resident's stated preferences, leading to a deficiency in providing individualized care.
Lack of Hospice Plan of Care for Resident
Penalty
Summary
The facility failed to ensure proper coordination and collaboration with a contracted hospice agency for a resident admitted for hospice care. During an initial observation, it was noted that the resident, who was receiving oxygen therapy, did not have a hospice plan of care available to the facility staff. This oversight was confirmed during interviews and record reviews with various staff members, including a Licensed Vocational Nurse and a Minimum Data Set Nurse, who both verified the absence of the hospice plan of care in the resident's hospice binder. The resident, identified as having multiple medical conditions including hemiplegia, hemiparesis, aphasia, and chronic embolism, was admitted to hospice care on October 18, 2024. However, the hospice plan of care, which is crucial for ensuring coordinated care, was not provided to the facility staff within the expected timeframe. The Social Service Director received the hospice plan of care only on October 24, 2024, several days after the resident's admission to hospice care, indicating a lapse in communication and documentation between the hospice agency and the facility. Interviews with the Hospice Director of Patient Care Services and the Director of Nursing revealed that the hospice plan of care should have been available within 48-72 hours of hospice admission. The absence of this plan was acknowledged as a failure by the hospice agency, which did not meet the expected standards of timely communication and documentation. This deficiency had the potential to cause delays in treatment and uncoordinated care for the resident, as the facility staff were not informed of the specific care and services required for the resident's condition.
Failure to Follow Prescribed Oxygen Therapy for Residents
Penalty
Summary
The facility failed to provide necessary respiratory care and services in accordance with professional standards of practice and the residents' plans of care for two residents. Resident 10 was observed receiving oxygen therapy at a rate of 2.5 LPM, despite a physician's order for 3 LPM to maintain oxygen saturation at or above 90%. This discrepancy was noted during multiple observations over several days. The Licensed Vocational Nurse (LVN) and Registered Nurse Supervisor (RNS) confirmed that the oxygen therapy order was not followed, acknowledging the importance of adhering to the physician's order to prevent compromising the resident's respiratory status. Similarly, Resident 36 was observed receiving oxygen at 2.5 LPM, contrary to the physician's order of 2 LPM. This was also confirmed by the LVN and RNS, who reiterated the necessity of following the prescribed oxygen therapy to ensure patient safety. The Director of Nursing (DON) emphasized the expectation for nurses to adhere to doctor's orders to avoid respiratory distress in residents. Both residents had specific medical histories that necessitated precise oxygen therapy management. Resident 10 had a history of hemiplegia, hemiparesis following a stroke, and other conditions, while Resident 36 had diagnoses including essential hypertension and non-Hodgkin's lymphoma. The facility's policies and procedures, as well as job descriptions for nursing staff, highlighted the importance of following physician orders and maintaining resident safety, which were not adhered to in these instances.
LVN Fails to Follow G-tube Medication Administration Procedure
Penalty
Summary
A Licensed Vocational Nurse (LVN 7) at the facility failed to demonstrate competency in medication administration for a resident with a Gastrostomy tube (G-tube). The resident, identified as Resident 62, was admitted with diagnoses including dysphagia and Gastrostomy status. During a medication pass, LVN 7 was observed administering Pantoprazole, a medication intended to reduce stomach acid, by pushing it through the G-tube with a syringe, contrary to the prescribed method. The facility's policy and procedure for enteral tube medication administration clearly stated that medications should be allowed to flow down the tube via gravity and not be pushed through. This was confirmed during an interview with the Director of Nursing (DON), who reviewed the resident's Order Summary Report and acknowledged that LVN 7 did not follow the correct procedure. The failure to adhere to the facility's medication administration policy had the potential to cause complications for Resident 62.
Failure to Follow Up on Hospice Evaluation Order
Penalty
Summary
The facility failed to ensure that the Social Services Department followed up on a physician's order for a hospice evaluation for a resident, identified as Resident 30. The resident, who was admitted on an unspecified date, had a history of dementia, stroke, aphasia, and major depressive disorder, and lacked the capacity to understand and make decisions. A hospice evaluation was ordered on July 8, 2024, and the resident's family was aware and agreeable to the physician's recommendation. However, the Progress Notes from July 8, 2024, to October 23, 2024, did not indicate any follow-up by Social Services with a hospice company or the resident's family regarding the evaluation. During a review of Resident 30's medical record on October 24, 2024, the Case Manager and Social Services Director confirmed the absence of documentation showing follow-up actions. The Director of Nursing later stated that Social Services should have communicated with the family and hospice company to follow up on the hospice order. The job description for the Social Worker, revised in 2016, included duties to refer residents and families to appropriate social service agencies when necessary, which was not fulfilled in this case.
Failure to Monitor and Clarify Antibiotic Use
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, specifically concerning the administration of antibiotics. For one resident, adverse reactions to the antibiotic Amoxicillin-Pot Clavulanate were not monitored as required. The Infection Preventionist (IP) and the Director of Nursing (DON) confirmed that there was no documentation of monitoring for adverse reactions, which should have been conducted every shift for three days. Additionally, infection surveillance was not initiated at the start of the antibiotic therapy, which is crucial for identifying signs and symptoms of infections and determining the appropriate treatment. Furthermore, the indication for the antibiotic medication was unclear and not clarified with the doctor. The resident's medical records indicated a prescription for Amoxicillin-Pot Clavulanate without specifying the site of the bacterial infection. The Physician Discharge Summary recommended a seven-day course of Augmentin for a respiratory bacterial infection, but this was not reflected in the medication order. The DON verified that the infection surveillance contained incorrect information and that the indication for the antibiotic therapy was incomplete. The resident involved had a complex medical history, including Systemic Lupus Erythematosus, Dysphagia, End Stage Renal Disease, and dependence on renal dialysis. The resident had recently undergone a below-the-knee amputation due to a gangrene infection and was readmitted to the facility. Despite these significant health issues, the facility did not adhere to its policy on antibiotic stewardship, which requires monitoring of antibiotic use and infection surveillance.
Delayed History and Physical Exam for Resident
Penalty
Summary
The facility failed to comply with state requirements when Physician 1 did not complete a history and physical exam (H&P) within the timeframe specified in the facility's policy for a resident. The resident, who was admitted with multiple fractures, interstitial pulmonary disease, and depression, did not receive the required H&P until six days after admission. This delay was contrary to the facility's policy, which mandates that an H&P be completed within 72 hours following admission. During an interview, the Director of Nursing (DON) confirmed that the physician's assessment, documented in the H&P, is crucial for determining a resident's comprehensive medical condition. The facility's policy and the California Code of Regulations both require that a physical examination be conducted within 72 hours of admission. The DON acknowledged that the delay in completing the H&P could prevent the resident from receiving appropriate care and services.
Failure to Measure Wound on Admission
Penalty
Summary
The facility failed to adhere to its policy for wound management for a resident who was admitted with a left trochanter wound. Upon admission, the resident had a history of a fracture of the right fibula, difficulty walking, diabetes type II, and hypertension. The initial assessment on March 9, 2024, noted an open area from a popped blister on the left hip, but no wound measurements were documented. Subsequent assessments on March 10 and March 13 also failed to document the necessary wound measurements until four days after admission. Interviews with the Treatment Nurse and the Registered Nurse revealed that the initial skin assessment should have included wound measurements, which were not performed as required. The Director of Nursing confirmed that the facility's policy mandates wound assessments, including measurements, within 24 hours of admission. The lack of timely wound measurements placed the resident's health and safety at risk, as the facility did not follow its established procedures for wound management.
Delayed Response to Call Lights in LTC Facility
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the timely response to call lights, which is crucial for providing care and services to residents. This deficiency was identified through interviews and record reviews involving three residents. Resident 1, who was admitted with conditions such as hemiplegia, intracerebral hemorrhage, and aphasia, reported that the night shift often did not respond to call lights for 1 to 2 hours. Similarly, Resident 2, with diagnoses including a wedge compression fracture and quadriplegia, stated that call lights could take 1 to 3 hours to be answered, which they found unacceptable. Resident 3, suffering from conditions like traumatic subdural hemorrhage and chronic kidney disease, also experienced delays of up to 1 hour, particularly during the night shift. The Director of Nursing (DON) was interviewed and stated that there had been no complaints from residents or family members regarding call light response times. However, the facility's policy clearly mandates that call lights should be answered within a reasonable time to ensure effective communication between residents and nursing staff. The failure to meet this policy potentially placed the health and safety of clinically compromised residents at risk, as their needs were not met promptly.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Redlands
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Madison Grove Post Acute | 0.7 mi | ★★★★★ | 17 | 0 |
| Redlands Healthcare Center | 0.7 mi | ★★★★★ | 6 | 0 |
| Redlands Comm Hosp D/p Snf | 0.7 mi | ★★★★★ | 8 | 0 |
| Asistencia Villa Healthcare Center | 1.2 mi | ★★★★★ | 18 | 0 |
| Plymouth Village | 2.3 mi | ★★★★★ | 1 | 0 |
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