Brookside Care Center

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Assessment (a comprehensive evaluation of a facility's ability to provide skilled nursing care, rehabilitation services, and other related health services to residents), dated 8/8/24, was reviewed with the Administrator (ADM). The ADM stated the facility had not met the facility assessment staffing plan which indicated .Based

on the facility's resident population and their needs for care and support, the facility's general approach to staffing is to ensure that it has sufficient staff members with the appropriate competencies and skill sets to meet the needs of the residents. The ADM explained his expectations were whenever there was a resident

in the facility with a tracheostomy the facility would have an RN in the building 24 hours a day to provide tracheostomy care, and that the staff would have the required competencies. The ADM also explained the risk to the residents with tracheostomies could have been a negative clinical outcome (an undesirable or unfavorable result for a patient receiving medical care).

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Brookside Care Center

1221 Rosemarie Lane Stockton, CA 95207

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Based on observation, interview, and record review, the facility failed to ensure medications were administered within professional standards of practice, to one resident (Resident 4) in a sample of four, when Resident 4's medications were left at her bedside.This failure had the potential for Resident 4 not taking her medications and/or another resident taking Resident 4's medication, negatively impacting the resident's health and well-being.Findings:During a concurrent interview and observation, on 8/6/25, at 12:50 PM, Resident 4 was in her room and two liquid medications were observed to be on her bedside table. Resident 4 explained the medications were her protein and her lactulose.A review of Resident 4's clinical document titled, Medication Administration Record (MAR), dated 8/1/25 through 8/31/25, the document indicated, .Lactulose [promotes bowel movements] . and, .[brand name liquid protein] .During an

interview with Licensed Nurse (LN) 1, on 8/6/25, at 1:05 PM, LN 1 confirmed he had left Resident 4's liquid protein and lactulose on her bedside table. LN 1 stated he should not have left the medications there. LN 1 explained he should have watched Resident 4 take her medications. LN 1 further explained there was a risk for another resident taking Resident 4's medication and there was a risk Resident 4 would not have taken her medication that was left on her bedside table.During an interview with the Assistant Director of Nursing (ADON), on 8/6/25, at 1:35 PM, the ADON stated the importance of not leaving medications at the residents bedside was another resident could take the medication, placing that resident at risk.A review of

the facility policy titled, Medication Administration, dated 2025, the document indicated, .Medications are administered by licensed nurses . in accordance with professional standards of practice . Observe resident consumption of medication .

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Brookside Care Center

1221 Rosemarie Lane Stockton, CA 95207

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or potential for actual harm

Based on observation and interview, the facility failed to ensure one of four sampled residents (Resident 4) received food that was safe and at an appetizing temperature when Resident 4's lunch meal on 8/7/25 was served cold and Resident 4's cold drink was served warm.This failure had the potential for Resident 4 to not obtain her nutritional requirements due to unpalatable food, negatively affecting Resident 4's health and well-being. Findings:During an interview with Resident 4, on 8/6/25, at 12:50 PM, Resident 4 stated the food was always cold and the drinks were always warm.During a concurrent observation and interview with Dietary Aide/Cook (DA/Cook) 1, on 8/6/25, at 12:56 PM, in Resident 4's room, the DA/Cook 1 took the temperatures of the food items on Resident 4's lunch tray that had been delivered at 12:52 PM. The temperatures were as follows: Taco Casserole 115 degrees Fahrenheit (F - a unit of measure); Mixed Vegetables 102 degrees F; Cranberry Juice 60 degrees F. During an interview with the Registered Dietitian (RD), on 8/12/25, at 1:59PM, the RD stated the above food items were in the danger zone for food safety with the danger zone (temperatures that allow for rapid bacteria growth) being 40 degrees F to 140 degrees F for hot foods and above 40 degrees F for cold drinks. The RD explained the safe holding temperature for food was > 140 degrees F. The RD further explained foods in the danger zone could cause foodborne illness when consumed. According to the Food Safety and Inspection Service U.S. Department of Agricultures website, .Danger Zone (40 F - 140 F) .Leaving food out too long at room temperature can cause bacteria (such as Staphylococcus aureus, Salmonella Enteritidis, Escherichia coli O157:H7, and Campylobacter) to grow to dangerous levels that can cause illness. Bacteria grow most rapidly in the range of temperatures between 40 F and 140 F, doubling in number in as little as 20 minutes. This range of temperatures is often called the Danger Zone . https://www.fsis.usda.gov/food-safety/safe-food-handling-and-preparation/food-safety-basics/danger-zone-40f-140f

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Brookside Care Center

1221 Rosemarie Lane Stockton, CA 95207

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

open can of coconut water, no name no date;Three staff lunch bags one green, one red, one black;One medium container with a red lid containing cooked beans, no name no date;One medium sized container with a red lid containing vegetable looking items, pineapple chunk looking items, tapioca looking items and

a pink pudding substance with a black plastic spoon in the container, undated and unlabeled;One bag, dated 8/8/24, room [ROOM NUMBER]A, with a container of rice and a cake with use by date of 8/12/24;One medium sized, opaque container, with a blue edging on the lid, containing food items, unlabeled and undated; One white container with an opaque lid containing food items, undated and unlabeled;One bag of grapes undated and unlabeled;One bag, containing lunch meat, undated for room [ROOM NUMBER]B;The top rack in refrigerator contained unidentifiable debris, a caked on red sticky red substance, and a moderate amount of clean liquid.The freezer contained loose debris, with stains and a brownish substance on the left side and bottom of the freezer. The food items in the freezer were as follows:One piece of cake between two paper plates undated and unlabeled; Ice cream bars undated and unlabeled;One bottle of brand named water undated and unlabeled;An opaque container with a blue lid containing food items undated and unlabeled;CNA 1 confirmed the above items and lack of cleanliness of

the refrigerator and freezer.The red signage on refrigerator door, undated, indicated NOTIFICATION This is

a Resident Only Refrigerator All food placed in the Refrigerator must have residents name and a date. Food has a shelf life of 72 hours and then the food must be removed from the Refrigerator and thrown away

Before throwing the food away notify the Resident that the food had been stored for 72 hours and must be thrown away Refrigerator will be cleaned every Friday by EVS/housekeepingAn observation of the signage

on the front of the refrigerator titled, Fridge/Freezer Temperature Log, dated 7/2025, indicated the refrigerator temperature was taken one time in July, on July 23rd, with a note stating no thermometer for freezer. An observation in the freezer revealed there was no thermometer in the freezer.During a concurrent

observation and interview with the Director of Nursing (DON), on 8/13/25, at 1:14PM, the DON stated there was one resident refrigerator in the East Wing. The DON confirmed the contents and lack of cleanliness of

the refrigerator and freezer. The DON stated the temperature log on the refrigerator was not sufficient as there was only one recorded temperature for the month of July, 2025. The DON explained the temperature should be taken daily to ensure the food in the refrigerator was safe to eat. The DON explained the importance of maintaining a clean refrigerator, ensuring items were not outdated, and only contained resident food was to ensure residents did not get sick from eating outdated, contaminated food. The DON stated staff items should not be kept in the resident refrigerator/freezer due to potential cross contamination that could cause foodborne illness to residents. The DON confirmed there was not a thermometer in the freezer and stated there should have beenA review of the facility policy titled, Use and Storage of Food Brought in by Family or Visitors, dated 2025, indicated, . It is the right of the residents of this facility to have food brought in by family or other visitors .food must be handled in a way to ensure the safety of the resident .Refrigerate labeled and dated prepared items .If not consumed within 3 days, food will be thrown away .

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Brookside Care Center

1221 Rosemarie Lane Stockton, CA 95207

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0814

Dispose of garbage and refuse properly.

Level of Harm - Minimal harm or potential for actual harm

Based on observation and interview the facility failed to ensure outside garbage bins were kept covered.This failure could have been a contributing factor in the facility harboring pests (cockroaches, flies, ants) with the potential to negatively impact the health and well-being of residents residing in the facility.

Findings

During observations made on 8/6/25 at 10:38 AM, 8/7/25 at 11 AM, and 8/13/25 at 10 AM., the lids of the outside garbage bins were noted to be open. During a concurrent observation and interview on 8/13/25 at 10:11 AM, with the Director of Nursing (DON), the DON confirmed the presence of one cockroach on the wall in the conference room. During a concurrent observation and interview on 8/6/25 at 11:45 AM, with the Dietary Manager (DM), the DM confirmed the outside garbage bin lids were left open.

The DM explained the outside garbage bin lids should have been kept closed so pests were not attracted to

the kitchen. The DM stated the residents could become ill because pests carry germs (a very small virus or bacteria that can make a person ill).During an interview with the Registered Dietitian (RD), on 8/15/25, at 11:47 AM, the RD stated she and the DM were aware of the pests. The RD explained pests should not be

in the kitchen. The RD further explained that cockroaches opened up the opportunity for food contamination and the residents would be at risk for foodborne illness (nausea, vomiting, and/or diarrhea caused by eating contaminated food).

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Brookside Care Center

1221 Rosemarie Lane Stockton, CA 95207

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908

Keep all essential equipment working safely.

Level of Harm - Minimal harm or potential for actual harm

Based on observation, interview, and record review, the facility failed to ensure that the kitchen oven was in good working order when the right oven door was hanging open and could not be closed.This failure had

the potential to delay meal service and have hot foods not maintained at a safe food temperature (Hot food should be kept at 140 degrees Fahrenheit ( F - unit of measurement) or above to avoid rapid bacteria (germs) growth, which could negatively affect the health of 87 residents who received food from the kitchen.

During an observation on 8/6/25, at 11:40 AM, in the kitchen, the right-side door of a double oven was hanging open and the right-side door of the oven was not attached to the oven.During a concurrent

observation and interview with Dietary Aide/Cook (DA/Cook) 1, on 8/6/25, at 11:45 AM, the DA/Cook 1 stated the right-hand oven door had been broken for three to four months. During an interview on 8/12/25, at 1:59 PM, with the Registered Dietitian (RD), the RD stated a kitchen audit was completed on 5/21/25.

The RD stated that the Dietary Manager (DM) and herself were aware the right-hand oven door was broken and had informed the Administrator (ADM). The RD explained the oven was a crucial part of the kitchen and there were food safety concerns when it was broken. The RD further explained she was worried about foods cooked in the oven obtaining and maintaining food safe temperatures (temperatures where rapid bacteria growth is minimal).During an interview on 8/15/25, at 1:12 PM, with the Administrator (ADM), the ADM confirmed the right-hand oven door had been broken from at least 5/21/25 through 8/13/25. The ADM explained the oven should not be broken for three months. The ADM further explained the importance of keeping the oven in good working order was food safety.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet