Brookside Care Center
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
(9/25/25), CNA 1 assisted him with changing his brief (a disposable product used by people who cannot control their bladder and/or bowels). Resident 1 stated CNA 1 instructed him to turn to his left side but when he did so, the air mattress deflated on the left side, causing him to fall onto the floor. Resident 1 stated that only CNA 1 was present during the incident. Resident 1 further stated he can turn by himself, but since the fall, two staff members have now assisted him during care. Resident 1 stated the air mattress was removed on 9/25/25 after his fall. During an interview with the Director of Staff Development (DSD) on 10/21/25 at 2:09 PM, the DSD stated that the facility's protocol for a newly installed air mattress included verifying that the mattress settings were appropriate for the resident's weight and checking the overall firmness of the bed. Additionally, nurses were trained to ensure that the mattress remains properly inflated and is not flat. The DSD further stated that both he and the Director of Rehabilitation (DOR) trained staff on proper air mattress repositioning. They emphasized that residents who were immobile or morbidly obese should be turned with the assistance of two CNAs at a time. Regarding Resident 1, CNA 1 was the only staff member assisting him during the incident and was subsequently written up for not following the protocol. A review of the facility's memo titled, CORRECTIVE ACTION MEMO dated 9/25/25 indicated, .Type of Violation: Violation of Safety Rules.employee [CNA 1].failure to follow company protocol regarding repositioning or doing ADL's care for morbid obesity patients have to be 2 people assist to prevent fall.During a concurrent interview and record review with the Administrator (ADM) and the assistant director of nursing (ADON) on 10/30/25 at 12:15 PM, the air mattress invoices were reviewed. The ADM stated that
an air mattress was ordered from their vendor on 9/19/25 for another resident (Resident 3). When Resident 3 was discharged from the facility, facility staff switched Resident 3's bed, including the air mattress, with Resident 1's bed. The ADON confirmed the settings for Resident 1's air mattress were never added to Resident 1's treatment or medication administration record so the nurses could verify the mattress settings every shift. During a concurrent interview and record review of Resident 1's medical record with the ADON
on 10/30/25 at 2:15 PM, the ADON stated she was unsure who decided to move Resident 3's bed to Resident 1's room, as there was no physician order for an air mattress for Resident 1.During a phone
interview with the ADON on 11/3/25 at 10:35 AM, the ADON stated that if an air mattress was applied to a resident's bed without a physician's order, there would be a risk of injury to the resident using the mattress.A review of the facility's Policy titled, Sufficient Staffing revised 10/2024 indicated, .Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based
on each resident's plan of care. A review of the facility's undated Certified Nursing Assistant - Job Description indicated, .Major Duties and Responsibilities.Assist resident with or performs activities of daily living for resident in accordance with the care plans and established policies and procedures.Additional Assigned Tasks.Establish a culture of compliance by adhering to all facility policies and procedures.A
review of the facility's policy titled, Assistive Devices and Equipment revised 10/2024 indicated, .Devices and equipment that assist with resident mobility safety and independence are provided for residents. These include.Specialty mattresses.The following factors will be addressed to the extent possible to decrease the risk of avoidable accidents associated with devices and equipment.Personal fit.equipment or device will be used according to its intended purpose and will be measured to.the resident's size and weight as much as possible.Requests or the need for special equipment should be referred to the appropriate Department.
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BROOKSIDE CARE CENTER in STOCKTON, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in STOCKTON, CA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from BROOKSIDE CARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.