Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Skilled Nursing Hospital during CMS and state inspections, most recent first.
Food was observed stored and prepared in an unsanitary manner during a kitchen tour. Surveyors found food debris in the walk-in refrigerator and under the freezer, ice buildup on the freezer support, and a dim refrigerator light that made cleaning and inspection difficult, according to the DS. Several opened items in storage were not dated, one opened container of chili oil had no label or date, and three fruit flies were present in the kitchen. Surveyors also observed dirty oven interiors, a dirty spatula stored in a clean utensil drawer, and wet water pitchers stored in an enclosed cabinet.
The facility failed to maintain an effective pest control program when fruit flies were seen in the kitchen and damaged screens were found during a tour. A Dietary supervisor confirmed the fruit flies, and a MAS confirmed a sliding door screen with a hole, one window screen with a hole, and two window screens with damaged or bent frames that left gaps for flying pests. The facility policy required monthly pest control inspections and keeping screens on doors and windows, but it did not direct staff to regularly check, maintain, or repair screens.
Inaccurate and nonindividualized target behaviors were documented for a resident receiving Zyprexa. The resident had bipolar disorder, depression, hopelessness, panic attacks, and a history of suicide attempts, but the MDS, physician order, and care plan did not align on the medication’s purpose. Staff gave inconsistent reports about whether they were monitoring for hallucinations or paranoia, and a CNA said she had not been told what behaviors to watch for.
A resident with hemiplegia, dementia, and palliative care needs had an order for hospice services, but the care plan did not show ongoing coordination or communication with the hospice agency. The plan listed hospice-related needs and nursing approaches, yet it did not identify the hospice agency, a point of contact, or a process for communication when the resident's condition changed or when transfer was needed.
A resident with bipolar disorder, depression, panic attacks, and a history of suicide attempts received Zyprexa, but staff did not provide accurate monitoring of the target behavior tied to the medication. The MDS nurse, CNA, and RN gave inconsistent explanations for why the antipsychotic was being used, and the resident’s records contained conflicting documentation about whether it was for hallucinations, paranoia, mood swings, or depression.
Medication Administration Error Rate Exceeded Threshold: The facility had a 9% med error rate, with three errors in 33 opportunities. An LVN mixed polyethylene glycol 3350 powder with water for a resident but could not state the amount of water used, and the resident was not told about the medication until after it was consumed. In a separate observation, an RN gave a resident Metformin outside the scheduled time and administered an inhalation powder for COPD without instructing the resident to rinse the mouth, despite MAR directions and prescribing information to do so.
Overcrowded Resident Room: A room contained six residents, with two beds in one section and four beds in another, while sharing a common entrance door and bathroom. Surveyors observed the room and later measured it at 581 square feet, and the ADM was informed of the finding.
A resident with severe cognitive impairment and multiple diagnoses did not receive prescribed Morphine Sulfate as ordered, resulting in a delay of almost 24 hours. The medication was unavailable, and the facility's policy of administering medications within 60 minutes was not followed. The order was received by the DON, but the emergency kit was accessed only after a verbal prescription was obtained the next day.
The facility failed to maintain a full-time kitchen manager, resulting in inadequate supervision of the dietary department for 73 out of 75 residents. The previous manager resigned, and a part-time contractor was overseeing operations twice a week. Interviews with staff confirmed the absence of a full-time manager, with a new hire expected in early November. This arrangement did not comply with state requirements for dietetic service supervision.
A medication error rate of 12.12% was observed in an LTC facility due to improper administration techniques. Errors included a staff member not wearing gloves for eye drops, incorrect Victoza injection technique, improper self-administration of Advair by a resident, and incorrect Lovenox injection technique. Staff acknowledged their lack of awareness of proper procedures.
The facility failed to ensure safe food storage and labeling practices, with rotten tomatoes found in the refrigerator, apple pies without labels covered in grime, and unlabeled chicken wings in the freezer. These issues were contrary to the facility's policies on food safety and sanitation.
A resident with cerebrovascular dementia was admitted to two hospice agencies, but the facility failed to include a specific coordination and communication plan in the care plan. The DON acknowledged the absence of a coordinated care plan, and communication with the hospice agency was limited to quarterly IDT meetings. Facility policies required a coordinated plan of care developed by the interdisciplinary team and hospice coordinator.
Two vials of prescription eye drop medications were found unlabeled, making it unclear to which resident they were prescribed. The facility's policy requires proper labeling, but a staff member failed to label them correctly, as acknowledged by a nurse during an interview.
The facility was found non-compliant with regulations limiting resident room capacity, as room [ROOM NUMBER] contained six beds instead of the allowed four. Initially observed with six beds, the room was later used as a PT Room. The Administrator had requested a waiver from CMS for this configuration.
The facility failed to report incidents of resident-to-resident abuse and an injury of unknown source within the required timeframe. A resident with no cognitive impairment was hit by another resident with severe cognitive impairment, and the incident was reported to the police immediately, but the Ombudsman and CDPH were notified the following day. Another resident, who was non-verbal and dependent on staff, was found with a fracture and dislocation, but the report was delayed. The facility did not adhere to its policy of immediate reporting, potentially compromising resident protection.
Unsanitary Food Storage and Kitchen Conditions
Penalty
Summary
Food was not stored and prepared in a sanitary manner during the kitchen tour. In the walk-in refrigerator, surveyors observed one grape and one nut on the floor, and the Dietary Supervisor acknowledged the light bulb in the refrigerator was very dim, making it difficult for staff to properly clean the area and for supervisors to check cleanliness. In the freezer, there was ice built up on the center support near the door, and debris was found under the freezer, including one small potato, one packet of mustard, red onion skin, and other debris. The Dietary Supervisor stated maintenance would be asked to look at the freezer door to determine the cause of the ice buildup.
Pest Control and Screen Maintenance Deficiencies
Penalty
Summary
The facility failed to ensure an effective pest control program when fruit flies were observed in the kitchen during a concurrent observation and interview with the Dietary supervisor. In addition, during a later tour of the courtyard, three damaged screens were identified: a sliding door screen with a hole, one window screen with a hole, and two window screens with damaged or bent frames that left gaps for flying pests. These observations were confirmed with the Maintenance Assistance, who stated he checks screens daily but could not explain how the damaged screens were not detected. Review of the facility policy titled SANITATION AND INFECTION CONTROL stated the facility would maintain a pest control prevention program with monthly inspections, treatment, and prevention of vermin and insect infestation and keep screens on all doors and windows, but the policy contained no language directing staff to check, maintain, or repair screens on a regular basis.
Inaccurate and Nonindividualized Zyprexa Target Behaviors
Penalty
Summary
The facility failed to ensure that the target behaviors for the use of Zyprexa were accurate, specific, and individualized for a resident with bipolar disorder who was receiving the medication. Review of the resident’s mental health record showed she had depression, was bedridden, felt hopeless, had a history of three suicide attempts, reported panic attacks, and was taking low-dose Zyprexa for mental health issues. However, the resident’s MDS documented normal memory and reasoning, no mood or behavior issues, and an active diagnosis of bipolar disorder, while the physician order listed the target behaviors for Zyprexa as auditory and visual hallucinations. During interview and record review, the MDS nurse stated he thought the resident had auditory hallucinations but could not describe specifics such as whether the voice was familiar, a stranger’s, or telling her to harm herself. He also stated the care plan interventions for Zyprexa were generic and not individualized. A CNA stated she had not been told what behaviors to monitor for, and an RN stated staff were supposed to monitor for paranoia, showing inconsistent understanding of the medication’s target behaviors. The administrator acknowledged the documentation incorrectly identified visual and auditory hallucinations as target behaviors, while mental health records from 2024 indicated Zyprexa had been prescribed for mood swings and depression.
Hospice Coordination and Communication Not Reflected in Care Plan
Penalty
Summary
The facility did not ensure coordination and collaboration with the Hospice agency in developing and maintaining an ongoing plan of care for Resident 11. Resident 11 was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, dementia, and encounter for palliative care, and had an order for Hospice services with Pathways Home Health and Hospice Services. During observation on 4/13/26 at 11 AM, the resident was in bed with both eyes closed and was not responsive to name call. Review of the care plan, started 12/18/25, showed hospice-related needs including cerebral atherosclerosis, vascular dementia, limited food intake and expected weight loss, high risk for pressure ulcers, pain management, special wound care, and respiratory support for shortness of breath and anxiety. The approaches listed were limited to nursing actions such as assisting with positioning, honoring advanced directive wishes, hospice referral, managing pain, providing food and fluids of choice, and oxygen per MD order. No ongoing process for communication with the hospice agency was found, including who to contact, what to do when changes occur, or when to transfer. During interviews, MDS 1 confirmed the care plan did not indicate ongoing coordination of care with the hospice agency, and the SSD stated the care plan did not identify which hospice agency and had no information about the hospice agency. The facility policy stated the facility and hospice agency will develop systems of communication and a coordinated plan of care, but the resident's care plan did not reflect this.
Unnecessary Antipsychotic Medication Due to Inaccurate Behavior Monitoring
Penalty
Summary
The facility failed to ensure Resident 2’s drug regimen was free from an unnecessary drug when staff did not provide accurate monitoring of the target behavior for Zyprexa. Resident 2 had a history of bipolar disorder, depression, panic attacks, and three suicide attempts, and a mental health note stated she was on low-dose Zyprexa for mental health issues, with the dose recently reduced from 5 mg to 2.5 mg daily. The MDS dated 3/21/26 showed normal memory and reasoning, no mood or behavior issues, and an active diagnosis of bipolar disorder while the resident was receiving an antipsychotic medication. During record review and interviews, staff gave inconsistent explanations for why Zyprexa was being used and what behaviors were being monitored. The MDS nurse found an order dated 1/11/26 documenting Zyprexa for bipolar disorder with target behaviors of auditory and visual hallucinations, but he could not provide specifics about those hallucinations. A CNA stated no one told her what behaviors to monitor, and an RN stated the medication was for paranoia and staff were supposed to monitor for paranoia. The Administrator was informed that the MDS nurse thought the medication was for hallucinations, the CNA was unaware of specific behaviors to monitor, the RN thought it was for paranoia, current documentation incorrectly identified hallucinations as target behaviors, and mental health records from 2024 indicated Zyprexa had been prescribed for mood swings and depression.
Medication Administration Error Rate Exceeded Threshold
Penalty
Summary
The facility failed to ensure a medication error rate of less than 5%, with a total medication administration error rate of 9% based on three errors out of 33 opportunities. During a concurrent observation and interview on 04/15/2026 at 8:38 AM, LVN 1 prepared polyethylene glycol 3350 powder for Resident 25 by mixing it with water but was unable to state how much water was used to dissolve the powder. Resident 25 was not informed that the polyethylene glycol 3350 solution was being administered until after the resident had already consumed it. During a separate observation on 04/15/2026 at 9:31 AM, RN 1 administered eight medications to Resident 22, including Metformin 1000 mg, which was scheduled for 8:00 AM on 04/15/2026. RN 1 also administered an inhalation powder containing fluticasone furoate 100 mcg and vilanterol 25 mcg per actuation for COPD and did not ask Resident 22 to rinse the mouth after administration, despite the MAR instruction to rinse mouth well after use. The prescribing information for the inhalation powder also directed rinsing the mouth with water without swallowing after inhalation, and the facility policy stated medications are to be administered as prescribed and residents are to be told the type of medication being given and the procedure.
Overcrowded Resident Room
Penalty
Summary
The facility failed to ensure resident rooms accommodated no more than four residents in each room when Room 101 had six residents. During an observation on 4/13/26 at 10:30 AM, the room was divided into two sections, with two beds in the right section and four beds in the left section. The room had a common entrance door and a shared bathroom, and there were a total of six residents in the room. On 4/14/26 at 10:00 AM, Room 101 was measured at 581 square feet. During an interview on 4/16/26 at 3:15 PM, the Administrator was made aware of the finding.
Failure to Administer Prescribed Morphine Timely
Penalty
Summary
The facility failed to administer the prescribed Morphine Sulfate to a resident as ordered, resulting in a delay of almost 24 hours. The Morphine was prescribed on February 13, 2024, but was not administered until February 14, 2024. This delay occurred because the medication was unavailable, as noted in the nurses' notes, which stated that the drug was not administered due to being unavailable and awaiting delivery. The facility's policy requires medications to be administered within 60 minutes of the scheduled time, which was not adhered to in this case. The resident involved had a severe cognitive impairment with a BIMS score of 7 and was admitted with diagnoses including low back pain, declining cognitive function, mixed hyperlipidemia, and dysphagia. The Director of Nursing received the doctor's order for Morphine on February 13, 2024, at 3:34 PM, but the medication was not available in the facility's emergency kit until the following day. The Pharmacist Consultant confirmed that the order was received on February 13, 2024, and the facility was authorized to access the emergency kit on February 14, 2024, after contacting the doctor for a verbal prescription.
Deficiency in Dietary Management Due to Lack of Full-Time Kitchen Manager
Penalty
Summary
The facility failed to ensure that the Certified Dietary Manager (CDM), responsible for supervising daily food service operations, was fully qualified due to the absence of a full-time kitchen manager. This deficiency was identified through observations, interviews, and record reviews, revealing that the facility did not have a kitchen manager present on a full-time basis. Instead, a part-time contractor, who began working in mid-September 2024, was overseeing the kitchen operations twice a week. The absence of a full-time kitchen manager had the potential to impact the dietary department's supervision for 73 out of 75 residents receiving food from the kitchen. Interviews with various staff members, including the Director of Nursing (DON), Administrator (ADM), and Registered Dietitians (RDs), confirmed the lack of a full-time kitchen manager. The previous kitchen manager had resigned about a month prior, and the facility was in the process of hiring a new manager, expected to start in early November 2024. The facility's organizational chart and job descriptions indicated that the dietary manager was supposed to report to the administrator and ensure the delivery of healthful meals. However, the current arrangement did not meet the requirements outlined in the State of California Health and Safety Code, which mandates a full-time dietetic services supervisor if a registered dietitian is employed less than full-time.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a 12.12% error rate during a medication pass. This was observed during the administration of medications to two residents. The errors included improper administration techniques for eye drops, subcutaneous injections, and inhalers, which deviated from both facility policies and manufacturer instructions. One resident received eye drops without the administering staff member wearing gloves, and the resident's head was not positioned correctly. The staff member did not create a pouch in the lower eyelid or instruct the resident to look upward, nor did they hold the inner canthus after administration. Another error involved the administration of Victoza, where the nurse did not hold the needle in place for the recommended six seconds post-injection, potentially affecting medication absorption. Additionally, a resident self-administered Advair without proper guidance, failing to exhale before inhaling and not holding their breath as required. The resident also swallowed water instead of rinsing and spitting, increasing the risk of complications. Furthermore, Lovenox was administered without maintaining a pinch on the injection site throughout the injection, contrary to manufacturer recommendations. These errors were acknowledged by the staff involved, who were unaware of the correct procedures.
Deficiency in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to maintain safe and sanitary conditions for food storage in the kitchen, as observed during a survey. There were four rotten tomatoes found in the walk-in refrigerator, which were past their seven-day shelf life from the delivery date. The staff member acknowledged the tomatoes were expired and discarded them. Additionally, the facility's policy did not specifically list tomatoes in their refrigerated storage guidelines, but they were considered fruit and expected to be stored for seven days. Further observations revealed four apple pies in refrigerator #2 without labels or expiration dates, covered with an aluminum tray that had black grime. The staff member confirmed the absence of labels and identified the grime. Additionally, a bag of chicken wings in freezer #2 was found without a label or expiration date. The facility's policies required all perishable food items to be properly stored, labeled, and dated to ensure food safety and prevent foodborne illnesses.
Lack of Coordinated Hospice Care Plan for Resident
Penalty
Summary
The facility failed to ensure that hospice services and interventions were properly addressed for a resident with cerebrovascular dementia. The resident was admitted to two different hospice agencies, but the care plan did not include a specific coordination and communication plan between the facility and the hospice agency. During interviews, the Director of Nursing acknowledged the absence of a coordinated care plan and mentioned that care conferences were held quarterly without a formal contract agreement, only a one-time letter agreement. The Director of Social Services stated that communication with the hospice agency was limited to the Interdisciplinary Team meetings held quarterly or as needed. A review of the facility's hospice policies indicated that a coordinated plan of care should be developed by the facility's interdisciplinary team and the hospice coordinator, with the hospice nurse coordinating the implementation and attending resident care conferences.
Improper Labeling of Eye Drop Medications
Penalty
Summary
Two vials of prescription eye drop medications were found without proper prescription labels during an inspection of medication storage. This deficiency was identified as it was unclear to which resident the medications were prescribed, posing a risk of medication administration errors. The facility's Section 7.1 Medication Administration Policy requires all medications to have proper labeling and organization. During an interview, a licensed staff member acknowledged that the medications should have included the resident's name and the date they were opened. The nurse admitted that the staff member responsible for these medications failed to label them correctly.
Non-compliance with Resident Room Capacity
Penalty
Summary
The facility failed to comply with the regulation that limits the number of residents per room to a maximum of four. During an observation, it was found that room [ROOM NUMBER] was divided into two sections, with the right section containing two beds and the left section containing four beds, totaling six beds in one room. This configuration was observed during a survey, although at a later time, the room was noted to be unoccupied and used as a Physical Therapy (PT) Room. The Administrator acknowledged the situation and mentioned having requested a waiver from the Centers for Medicare & Medicaid Services (CMS) for the room configuration. The waiver form indicated that room [ROOM NUMBER] had a total of 581 square feet.
Delayed Reporting of Abuse and Injury Incidents
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse and an injury of unknown source within the required 2-hour timeframe to the State Survey Agency for three of six sampled residents. Resident 1, who had no cognitive impairment, was hit by Resident 2, who had severe cognitive impairment, on the right knee. The incident was reported to the police immediately, but the Nursing Home Administrator (NHA) only left a voicemail for the Ombudsman and faxed the SOC 341 to the Ombudsman and the California Department of Public Health (CDPH) the following day, which was outside the required timeframe. Resident 3, who was non-verbal and totally dependent on staff for activities of daily living, was found to have a right displaced humeral mid-shaft fracture and right anterior shoulder dislocation. The Director of Nursing was notified by a hospital representative about the fracture, and the resident returned to the facility with new medications and paperwork. The facility's fax cover indicated that the incident was identified on a previous date, but the report was not received by CDPH until several days later, indicating a delay in reporting. The facility's policy requires that all incidents of alleged or suspected abuse and injuries of unknown origin be reported immediately or within 2 hours to the appropriate authorities. However, the facility did not adhere to this policy, resulting in delayed reporting of the incidents involving Residents 1, 2, and 3. This deficiency had the potential to delay the provision of care and compromise the protection of the residents in the facility.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 838 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near San Mateo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| San Mateo Medical Center D/p Snf | 1 mi | ★★★★★ | 4 | 0 |
| Belmont Healthcare Center | 2.6 mi | ★★★★★ | 1 | 0 |
| Peninsula Post-acute | 5.2 mi | ★★★★★ | 12 | 0 |
| Millbrae Care Center | 6.1 mi | ★★★★★ | 24 | 0 |
| Devonshire Oaks Nursing Center | 6.3 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Brookside Skilled Nursing Hospital.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.