Brookside Inn: Staff Abuse Finding, Investigation Gaps - CO
It was.
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See the Derila PillowFederal inspectors who surveyed Brookside Inn on March 6, 2025, found that the facility had failed to protect Resident #1 from abuse after LPN #1 willfully grabbed her arm to move her out of the way on April 12, 2024. CNA #2 witnessed it directly. That witness account, documented in the inspection record, was not disputed. What the facility disputed was the bruising.
The distinction matters, because the facility's entire response to the incident appeared to rest on a theory that the visible injuries did not match what a nurse's grip would leave behind. The nursing home administrator told inspectors that a police officer had reviewed the case and concluded the bruising showed only one finger's mark, and that a nurse grabbing someone would have left more fingerprints. The administrator said the officer used that reasoning to unsubstantiate the findings.
The administrator also noted she was not present at the facility when the officer and a nurse interviewed Resident #1.
But inspectors reviewed Resident #1's electronic medical record and found no documentation that the bruising on her arms existed before April 12, 2024. None. The facility had no baseline record showing the marks were there before the incident. That absence is not a minor paperwork gap. It means the facility had no evidentiary foundation for the claim that the injuries were pre-existing or unrelated to what CNA #2 saw.
What CNA #2 saw was this: LPN #1 grabbed Resident #1's arm to move her out of the way. Not to help her walk. Not to assist with a transfer. To move her. The inspection record describes it as willful. That word carries weight in abuse determinations. It means the action was intentional, not accidental, not a reflexive grab during a stumble or a fall. LPN #1 chose to grab the resident's arm to reposition her.
The inspection classified the harm level as actual harm. Residents affected: few.
That classification, actual harm, means inspectors concluded Resident #1 was genuinely hurt, not just placed at risk. The bruising on her arms was the physical evidence. The grab was the cause. The witness was the confirmation.
The facility's investigative strategy ran in the opposite direction. Rather than starting from what CNA #2 observed and working outward, Brookside Inn appears to have started from the police officer's fingerprint theory and worked backward. The administrator's account to inspectors centered almost entirely on what the officer believed about the bruising pattern, not on what the eyewitness reported.
That approach left a significant gap. A police officer's assessment of whether a bruise pattern matches a particular grip is not the same as a facility abuse determination. Nursing homes carry an independent obligation to investigate and reach their own findings. A law enforcement decision not to pursue charges, or to unsubstantiate a finding in a criminal context, does not close the question of whether abuse occurred under the standards that govern a federally certified care facility.
Inspectors found that abuse did occur. The CNA's account was the basis.
Brookside Inn is located at 1297 S. Perry Street in Castle Rock, a city of roughly 80,000 people about 30 miles south of Denver. The facility's inspection was completed March 6, 2025.
Resident #1's age, diagnosis, and mobility status do not appear in the portion of the inspection record available. What the record does show is that she was in a situation where a staff member felt entitled to grab her arm to move her out of the way, and that when a coworker reported it, the facility's response was to look at the shape of a bruise instead of the act that caused it.
The nursing home administrator told inspectors she did not know whether LPN #1 was actually the one who caused the injuries on Resident #1's arms. That statement, offered months after the incident, suggests the facility's investigation did not resolve the most basic question it was required to answer. The witness had already answered it. CNA #2 saw LPN #1 grab the resident. The administrator's uncertainty was not a product of conflicting evidence. It was a product of a process that leaned on a police officer's fingerprint theory instead of the account of the person who was in the room.
Inspectors did not accept that uncertainty as a resolution.
The deficiency was cited under the category of abuse, with actual harm to Resident #1. The facility was directed to submit a plan of correction. Under federal rules, facilities cited for abuse findings are required to take immediate corrective action, including removing the staff member from resident contact pending investigation completion, notifying the appropriate state agency, and ensuring the investigation is thorough and documented.
Whether LPN #1 remained on duty during or after the investigation is not stated in the available inspection record. Whether CNA #2 faced any consequences for reporting is also not documented in the record. What is documented is that the person who witnessed the grab reported it, the person who was grabbed showed bruising that had no documented prior existence, and the facility's investigation concluded by deferring to a police officer's read on fingerprint patterns.
The inspection report notes that the bruising looked fresh when inspectors or investigators reviewed it. The administrator said she did not know if LPN #1 caused it. The medical record showed no evidence the bruising was there before April 12.
Resident #1 had bruises on her arms. A coworker saw how they got there. The facility spent its investigation somewhere else.
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.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: November 12, 2026 · Our methodology
BROOKSIDE INN in CASTLE ROCK, CO was cited for abuse-related violations during a health inspection on March 6, 2025.
That witness account, documented in the inspection record, was not disputed.
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.