Brookside Care Center

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

AM, LN 1 he stated that he could not recall the events on 11/17/25. Reviewed LN 1's progress note (a part of a patient's record, documenting their health status, treatment response, and changes during care to track progress, ensure accountability, and facilitate communication among healthcare providers) dated 11/17/25, indicated: .[at] 0755 [AM] CNA and LN noted [Resident 1] feeding stray cats from inside the [Resident 1's] room. [LN 1] took the bag of cat food that was sitting on top of a chair in room. At this time the CNA were present.0800 [AM] DON made aware of this situation and DON walked to [Resident 1's] room.[Resident 1] stated Your nurse there ([Resident 1 was pointing to the direction of myself [LN 1]) hurt me and twisted my left arm.Cops arrived.0823 [AM].LN 1 was then able to recall the events on 11/17/25 and added that CNA 1 was inside Resident 1's room when the incident occurred and could confirm that LN 1 did not touch or hurt Resident 1. LN 1 stated the DON was aware of the accusation from Resident 1, and LN 1 talked to the police when they came to the facility on [DATE REDACTED] to make the police report. LN 1 stated he did not call the police to make a report and clarified that Resident 1 called the police to report he was abused. LN 1 further stated it was important to report abuse allegations for patient's rights and safety and added the risk to the residents for unreported abuse allegations were ongoing or continued abuse. During a concurrent interview and record review on 12/22/25 at 3:21 PM, the DON confirmed she was aware of the allegation of abuse to Resident 1 on 11/17/25. The DON further stated that she did not report the allegation of abuse to the required agencies because the police officer told her Resident 1 recanted (took back) his story and the police officer would not be making a police report on the alleged abuse. When asked if the DON had confirmed this information with Resident 1, or if she made a progress note documenting this information,

she stated, no. The police report dated 11/17/25, report number 25-34636, was reviewed with the DON. The DON was made aware that a police report was completed and there was no mention of Resident 1 recanting his story in the police report. The police report also indicated the events were transcribed from

the body camera worn by the officer at the time the police report was taken. When asked if the DON made any attempt to interview Resident 4, Resident 1's roommate, she stated, no. The DON confirmed the facility did not investigate the allegation or complete the required notifications per their facility policy.During an

interview on 12/22/25 at 4 PM, the Administrator (ADM) stated she was new to the facility and it was her expectation that all staff with knowledge of an alleged abuse report it immediately and make all the required notifications within two hours. The ADM added this allegation of abuse should have been reported to the police by the facility, to the state agency, the Ombudsman, and the facility should have completed their own investigation. The ADM stated the risk to the residents when alleged abuse was not reported could be emotional distress and the potential for abuse to continue. The ADM explained it was important for the residents to trust the facility staff, and for the residents to feel safe.Review of the facility policy and procedure titled, Abuse, Neglect and Exploitation, undated, indicated, .It is the policy of this facility to provided protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse.An immediate investigation is warranted when suspicion of abuse.or report of abuse, neglect or exploitation occur.Reporting of all alleged violations to the Administrator, state agency, adult protective services and all other required agencies.within specified time frames.Immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse.Administrator will follow up with government agencies.to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies.

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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

12/22/2025

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 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 ensure an allegation of employee-to-resident physical abuse was thoroughly investigated by the facility in a timely manner when on 11/17/25, the facility did not fully investigate an allegation of abuse to Resident 1. This failure resulted in a delayed facility abuse investigation and had the potential to affect Resident 1's physical and psychosocial well-being.Findings:

During an interview on 12/22/25 at 1 PM, in Resident 1's room, Resident 1 stated that a few weeks ago he had his cat food taken away and his arm twisted by Licensed Nurse (LN) 1 and that it was witnessed by a Certified Nursing Assistant (CNA). Resident 1 explained he called the police on 11/17/25 and made a police report because LN 1 got angry with him, grabbed and twisted his left arm hard enough to tear off a bandage on Resident 1's elbow while LN 1 took away Resident 1's bag of cat food. Resident 1 stated he bought the cat food with his own money and liked to leave cat food for the stray cats on the patio outside of his room. Resident 1 further stated that in addition to the CNA witnessing the incident, he also told the Director of Nursing (DON) when she came into the room that he was physically hurt by LN 1. Resident 1 explained that he felt like, I'm nothing and a nobody to them, and that he did not feel like the facility cared about him or his rights. Resident 1 further explained that he told the DON that he no longer wanted LN 1 to be his nurse. During an interview on 12/23/25 at 8:55 AM, LN 1 confirmed the Director of Nursing (DON) was aware of the accusation from Resident 1. LN 1 further stated he documented in his progress note dated 11/17/25 at 7:55 AM and indicated that the DON was made aware of the accusations and that Resident 1 called the police to make a report of abuse. During an interview on 12/22/25 at 3:21 PM, the DON confirmed she was aware of the allegation of abuse to Resident 1 on 11/17/25. The DON further stated that she did not conduct a thorough and complete investigation into the allegations because the police officer told her Resident 1 recanted (took back) his story and the police officer would not be making a police report on the alleged abuse. When asked if the DON had confirmed this information with Resident 1, or if she made a progress note documenting this information, she stated, no. When asked if the DON made any attempt to interview Resident 4, Resident 1's roommate, she stated, no. The DON confirmed the facility did not thoroughly investigate the allegation. Review of the facility policy and procedure titled, Abuse, Neglect and Exploitation, undated, indicated, .The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect.b. Establish policies and procedures to investigate any such allegations.V. Investigation of Alleged Abuse.A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse.occur.B. Written procedures for investigations include: 1. Identifying staff responsible for the investigation.4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations.6. Providing complete and thorough documentation of the investigation.

Residents Affected - Few

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

Event ID:

Facility ID:

If continuation sheet