Brookside Care Center
Inspection Findings
F-Tag F0607
F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
not familiar with the incident and had no recollection of being notified, despite the progress notes indicating
the DON, ADON, and Social Services were notified. The DON acknowledged the event was an alleged abuse incident and no investigation was completed for Resident 1 and Resident 2. The DON stated that there was a potential risk for abuse, and Resident 1 and Resident 2 could have potentially gotten hurt.During a joint interview and policy review on 11/21/25 at 1:57 p.m. with the Administrator (ADM) and DON, the facility's undated policy titled, Compliance with Reporting Allegations of Abuse/Neglect/Exploitation was reviewed. The policy indicated, .all allegations of abuse/neglect/exploitation. must be reported to the Administrator of the facility. 6. Investigation: The facility will investigate all allegations and types of incidents. The ADM and DON verified that the facility's abuse policy was not followed for the alleged resident-to-resident abuse incident involving Resident 1 and Resident 2. The DON acknowledged that the IDT was unable to follow-up with either residents or conduct
an investigation because the incident was not reported to them and did not come to their attention until the Department surveyor informed them during the investigation.
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
11/21/2025
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-Tag F0610
F 0610
Respond appropriately to all alleged violations.
Level of Harm - Minimal harm or potential for actual harm
Based on interview and record review, the facility failed to report an allegation of resident-to-resident abuse incident to the Department within the required timeframe when Resident 1 reported that Resident 2 was throwing objects, including cups and utensils toward Resident 1. This failure left Resident 1 and Resident 2 without required protective interventions and placed them at risk for psychosocial (internal cognitive aspects of a person's life and how they interact with those around them) harm. During a review of Resident 1's clinical record titled, admission RECORD, the record indicated Resident 1 was admitted to the facility with multiple diagnoses which included generalized anxiety disorder (a mental health condition that causes fear, a constant feeling of being overwhelmed and excessive worry about everyday things) and depression (mood disorder that causes a persistent feeling of sadness and loss of interest).Review of Resident 2's clinical record titled, admission RECORD, the record indicated Resident 2 was admitted to the facility with multiple diagnoses which included dementia, (the loss of cognitive functioning - thinking, remembering, and reasoning), anxiety, and metabolic encephalopathy (a brain dysfunction caused by a chemical imbalance in
the body that can cause confusion, memory problems, and changes in behavior).During an interview on 11/20/25 at 1:36 p.m. with Resident 1, Resident 1 stated she had a problem with Resident 2 about a month ago when Resident 2 urinated on the floor and threw a butter knife and fork at her. Resident 1 stated that
the objects did not hit her. Resident 1 also stated that she told the activities director and the Director of Nursing (DON) of the incidents.During a concurrent interview and record review on 11/20/25 at 3:20 p.m. with the Assistant Director of Nursing (ADON), Resident 1 and Resident 2's progress notes were reviewed.
The ADON acknowledged that the Department was not notified of the event between Resident 1 and Resident 2 involving the throwing of a knife and fork. The ADON also stated that as a mandatory reporter for alleged abuse cases, the event needed to be reported to the Department within two hours. The ADON stated that it put Resident 1 and Resident 2 at risk for harm especially when the intradisciplinary team (IDT - group of health care professionals with various areas of expertise who work together toward the goals of residents) was not aware of the incident. During a concurrent interview and record review on 11/20/25 at 3:46 p.m. with the DON, Resident 1 and Resident 2's progress notes were reviewed. The DON acknowledged the event was an alleged abuse incident and should have been reported to the Department within two hours. The DON stated that there was a potential risk for harm for both Resident 1 and Resident
- 2. During a joint interview and policy review on 11/21/25 at 1:57 p.m. with the Administrator (ADM) and
DON, the facility's undated policy titled, Compliance with Reporting Allegations of Abuse/Neglect/Exploitation was reviewed. The Policy indicated, .all allegations of abuse/neglect/exploitation. must be reported to the Administrator of the facility and to other appropriate agencies. Procedure for Response and Reporting Allegations of Abuse. 2. A. Notify the appropriate agencies immediately: as soon as possible, but no later than 24 hours after discovery of the incident. The ADM and DON agreed that the facility's reporting process was not followed for the alleged resident-to-resident abuse incident involving Resident 1 and Resident 2. The ADM and DON acknowledged that the Department was not notified about the incident. The DON stated that the IDT was unable to follow-up because they were not aware of the allegation until the Department surveyor informed them.
Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
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.