CASTLE ROCK, CO - Federal inspectors documented multiple serious violations at Brookside Inn, including two separate abuse incidents and the improper use of physical restraints on residents with dementia, according to a March 2025 inspection report.
Staff Members Forcefully Handled Vulnerable Residents
The most serious violations involved staff members using excessive force on residents who were unable to defend themselves or fully understand what was happening. In one incident captured on hidden camera, a certified nursing assistant was recorded roughly handling a 65-year-old resident with severe dementia while positioning pillows and a recliner chair to keep the resident confined to bed.
The family had installed the hidden camera due to concerns about their loved one's treatment. The video, recorded on January 21, 2025, showed the CNA forcefully pushing the resident toward the wall while the resident cried out "Ow, I don't want to be touched like that! It hurts!" and "Why are you being rough on me?" The staff member responded by saying "Because I need you to stay in bed!"
According to the inspection report, when the resident asked if the CNA was going to touch her again, the staff member replied "nope, I'm going to touch you again" before continuing the rough handling. The incident concluded with the CNA pushing a recliner chair directly against the resident's bed, creating a physical barrier that prevented the resident from getting out.
Medical research shows that rough handling of elderly residents, particularly those with dementia, can cause serious physical injuries including bruising, fractures, and soft tissue damage. The psychological trauma can also worsen confusion and agitation in residents who already struggle with cognitive impairment.
Agency Nurse Physically Grabbed Resident in Medication Area
In a separate incident from April 2024, an agency licensed practical nurse grabbed a resident's arm after becoming frustrated with the resident's behavior near the medication cart. The incident occurred when the nurse was trying to prevent residents from entering the nurse's station by using the medication cart as a barrier.
According to witness testimony from another staff member, the nurse grabbed the resident by the forearm and twisted it while telling the resident to go away. When the resident became more agitated and combative, the witnessing staff member asked the nurse to let go, but the nurse refused and continued yelling at the resident.
A skin assessment performed after the incident revealed multiple bruises on the resident's arms, including round bruising on the left wrist and both elbows. Photographs documented the injuries, which were consistent with forceful gripping.
The facility's investigation concluded the abuse could not be substantiated because the pattern of bruising didn't match the nurse's description of only grabbing the resident's hand. However, inspectors determined that abuse had occurred based on the direct witness testimony of the staff member who observed the nurse willfully grabbing the resident's arm.
Medical Risks of Physical Force Against Dementia Residents
Residents with dementia are particularly vulnerable to abuse because their cognitive impairment prevents them from understanding what is happening or effectively communicating their distress. Both residents involved in these incidents had severe cognitive impairments, with assessment scores indicating significant memory loss, confusion, and decision-making difficulties.
Physical force against elderly residents can result in serious injuries due to their fragile skin, brittle bones, and increased bleeding risk from common medications. Even minor grabbing or rough positioning can cause bruising, tears in the skin, or fractures. The psychological impact can be equally damaging, as residents with dementia may not understand why they are being hurt, leading to increased anxiety, agitation, and combative behaviors.
Proper dementia care requires patience, gentle redirection, and understanding of each resident's triggers and needs. Staff should use de-escalation techniques, provide consistent caregivers when possible, and create calm environments to reduce agitation.
Improper Use of Furniture as Physical Restraint
Inspectors also found that staff improperly used a recliner chair as a physical restraint to prevent a resident from getting out of bed. The resident's family documented multiple occasions when they found the chair pushed directly against their loved one's bed, creating a barrier that the resident could not move.
Federal regulations define physical restraints as any device or equipment that restricts a resident's freedom of movement and cannot be easily removed by the resident. Using furniture to block a resident's movement constitutes a physical restraint under these regulations.
The facility's own policy stated that restraints could not be used for staff convenience and must only be implemented to treat specific medical symptoms. In this case, the chair barrier appeared to be used primarily for staff convenience to prevent the resident from attempting to get out of bed unassisted, rather than being medically necessary.
Physical restraints pose significant health risks including increased fall risk when residents attempt to overcome the restraint, circulation problems, muscle weakness from immobility, and psychological distress. Restraints can also worsen confusion and agitation in residents with dementia.
Facility's Response and Investigation Failures
The inspection revealed significant failures in the facility's response to these incidents. When the family reported concerns about rough treatment during a care conference in January 2025, facility leadership failed to conduct an immediate investigation or report the allegations to state authorities as required.
The nursing home administrator later acknowledged that the word "rough" reported by the family should have triggered an abuse investigation and been reported to the state agency. Only after the inspection began did facility leadership suspend the staff member involved and contact police.
In the April 2024 incident involving the agency nurse, facility management concluded they could not substantiate the abuse despite having a direct witness and photographic evidence of injuries. The nurse was removed from returning to the facility but no further action was documented.
Additional Issues Identified
Inspectors documented several other concerning patterns during the investigation. Staff interviews revealed inconsistencies in understanding reporting requirements for suspected abuse. Some staff members indicated they would report abuse to multiple supervisors and document incidents, while facility leadership demonstrated gaps in following their own investigation protocols.
The facility's handling of care conferences was also problematic, with leadership stating they were unaware that families were recording the meetings. This lack of awareness about family concerns and monitoring efforts suggests communication breakdowns between staff and families.
Documentation reviews showed that proper behavioral interventions and de-escalation techniques were not consistently implemented before resorting to physical interventions. The facility's care plans included appropriate strategies for managing residents with dementia, but the actual care delivery fell short of these standards.
Federal nursing home regulations require facilities to ensure all residents are treated with dignity and respect, free from abuse and improper restraints. Facilities must maintain comprehensive policies, provide proper staff training, conduct thorough investigations of allegations, and report incidents to appropriate authorities. The violations at Brookside Inn represent serious breakdowns in these fundamental protections for vulnerable residents.
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.
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