Brookside Inn: Illegal Restraint Used on Resident - CO
The resident, identified in federal inspection records only as Resident #2, had dementia-related impulsivity and hallucinations. She frequently tried to get out of bed without assistance. Her bed was positioned against the wall on the right side, and a recliner chair sat in her room. On the day in question, a certified nursing assistant pushed that chair against the open side of the bed, boxing the resident in. With the chair in that position, she could not get out.
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See the Derila PillowWhen inspectors arrived at Brookside Inn on March 6, 2025, they interviewed the nursing home administrator, the director of nursing, the social services director, a social worker, and the nurse educator together. All five said they had no idea care conferences involving Resident #2 had been recorded. The social worker acknowledged she knew some residents at the facility had cameras in their rooms.
All five confirmed what the footage showed. They confirmed the chair placement. They confirmed that with the recliner pushed against the bed, Resident #2 could not exit. They confirmed it met the definition of a physical restraint.
The director of nursing described a resident who was impulsive, sometimes hallucinating, and prone to attempting to get out of bed on her own. Staff had occasionally brought her to the nursing station to keep an eye on her. They could not do that all the time, the director said.
The nursing home administrator, interviewed separately at 12:10 p.m. that same day, was direct about what the aide had done wrong. The CNA should never have pushed the recliner against the bed, she said. She said that in the context of the aide telling Resident #2 "We need you to stay in bed so you don't fall," the chair placement was a physical restraint, full stop.
The resident's history during the weeks around this incident makes clear how vulnerable she was. On January 5, 2025, an interdisciplinary progress note recorded that she had sustained multiple abrasions from a fall, including injuries to her left ankle, right great toe, right inner foot, and right inner ankle. Two days later, a nurse practitioner noted she had moments of impulsivity. By January 14, a nursing note described her as agitated and anxious, found tangled in her blankets with her gown and brief removed.
Her family, according to the social services director, was deeply involved in her care. They were willing to come in and sit with her during episodes of agitation and hallucinations.
The inspection classified the violation as causing minimal harm or potential for actual harm, affecting few residents. That classification reflects the regulatory language, not the full picture of what it means to be trapped in a bed by a piece of furniture while experiencing hallucinations, while agitated, while someone in a position of authority tells you to stay put.
The aide said the words out loud. We need you to stay in bed so you don't fall. The chair was already against the bed when those words were spoken. The resident continued to try to rise anyway.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Brookside Inn from 2025-03-06 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Last verified: November 12, 2026 · Our methodology
BROOKSIDE INN in CASTLE ROCK, CO was cited for violations during a health inspection on March 6, 2025.
The resident, identified in federal inspection records only as Resident #2, had dementia-related impulsivity and hallucinations.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.