Brookside Inn

F-F600: the facility failed to ensure Resident #2 was kept free from physical abuse by a staff member.

C. Record review

The delusion care plan, initiated on 12/30/24, documented Resident #2 was easily confused at baseline and would make delusional statements to staff. The delusions caused different levels of distress. Resident #2 had intermittent periods of agitation where she tried to get out of bed or her wheelchair.

The cognition care plan, initiated on 7/19/24, documented Resident #2 was easily confused and experienced impaired decision making, memory loss and disorientation. The interventions included adjusting according to

the resident's current cognitive status, communicating with the family and caregivers regarding the resident's capabilities, engaging the resident in simple and structured activities, keeping the resident's routine consistent and trying to provide consistent caregivers as much as possible in order to decrease confusion.

The transfers care plan, initiated on 8/12/24, documented Resident #2 required the use of a mechanical lift for all transfers. The interventions included providing frequent off-loading of the resident when up in the chair, removing the mechanical lift sling when the resident was lying in bed and ensuring two staff member assistance with transfers while using the mechanical lift.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 12 065361 Department of Health & Human Services Printed: 09/05/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065361 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brookside Inn 1297 S Perry St Castle Rock, CO 80104

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 0604 The fall risk care plan, initiated on 7/17/24, documented Resident #2 was at risk for falls related to deconditioning, balance problems, unaware of her safety needs and vision and hearing problems. The Level of Harm - Minimal harm or interventions included anticipating and meeting the resident's needs, putting the bed in the lowest position, potential for actual harm encouraging the resident to participate in activities, following the facility protocol, keeping needed items within reach and maintaining a clear pathway without obstacles. Residents Affected - Few

The 8/26/24 physician progress note documented Resident #2 had become more impulsive in her room, according to staff.

The 1/4/25 nursing progress note documented Resident #2 was found on the floor next to her bed, with her head at the foot of the bed. The resident was extremely confused and continued to voice her desire to ambulate independently. The resident was assisted back to bed and did not sustain any injuries, however continued to attempt to rise out of bed.

The 1/5/25 interdisciplinary fall progress note documented Resident #2 sustained multiple abrasions from the fall. An abrasion to the left ankle, right great toe, right medial (inner) foot and right medial ankle.

The 1/7/25 nurse practitioner progress note documented Resident #2 had moments of impulsivity.

The 1/14/25 nursing progress note documented Resident #2 was agitated and anxious. The resident was tangled in her blankets with her gown and brief taken off.

III. Staff interviews

The NHA, the director of nursing (DON), the social services director (SSD), social worker (SW) #1 and the nurse educator (NE) were interviewed together on 3/6/25 at 11:41 a.m. They all said they were not aware

they were being recorded during Resident #2's care conferences. SW #1 said she was aware some residents at the facility had cameras in their resident rooms.

They all confirmed Resident #2 had a recliner chair in her room and her bed was positioned up against the wall on the right side. The DON said Resident #2 was impulsive, had hallucinations at times and would attempt to get out of bed without assistance often. She said at times, the facility staff would get Resident #2 up in the chair and place her at the nursing station to be watched, but they could not do that all of the time.

The SSD said Resident #2's family was very involved and willing to come in and sit with the resident when

she was having episodes of impulsivity, agitation and hallucinations.

They all confirmed pushing the recliner chair up against the bed was considered a physical restraint because Resident #2 would not be able to exit the bed while the chair was positioned in that way.

The NHA was interviewed on 3/6/25 at 12:10 p.m. The NHA said CNA #1 should never have pushed the recliner chair up against Resident #2's bed. She said in the context of CNA #1 saying We need you to stay in bed so you don' t fall, the recliner chair being pushed up against the bed was considered a physical restraint.

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F-F604 for failure to prevent physical restraints.

B. Record review

The delusion care plan, initiated on 12/30/24, documented Resident #2 was easily confused at baseline and would make delusional statements to staff. The delusions caused different levels of distress. Resident #2 had intermittent periods of agitation where she tried to get out of bed or her wheelchair.

The cognition care plan, initiated on 7/19/24, documented Resident #2 was easily confused and experienced impaired decision making, memory loss and disorientation. The interventions included adjusting questioning according to the resident's current cognitive status, communicating with the family and caregivers regarding

the resident's capabilities, engaging the resident in simple and structured activities, keeping the resident's routine consistent and trying to provide consistent caregivers as much as possible in order to decrease confusion.

The 1/22/25 nursing progress note documented at 5:17 a.m., revealed Resident #2 showed signs of agitation throughout the shift and refused medications at 7:00 p.m., saying Get that out of my face, while waiving her hands back and forth in fighting motions after multiple attempts. Her family arrived at 11:10 p.m. to sit with

the resident.

The 1/23/25 care conference progress note documented the family had concerns regarding customer service, professionalism or being made uncomfortable by staff.

-Review of Resident #2's electronic medical record (EMR) did not reveal any further documentation regarding Resident #2's family concern of rough treatment of the resident by CNA #1.

Staffing documentation for the night shift on 1/21/25 was reviewed on 3/5/25 at 3:00 p.m. CNA #1 was documented as the only CNA working the hallway where Resident #2 resided during the incident on 1/21/25 at 7:32 p.m.

C. Staff interviews

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 12 065361 Department of Health & Human Services Printed: 09/05/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065361 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brookside Inn 1297 S Perry St Castle Rock, CO 80104

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 0600 The clinical consultant (CC) and the NHA were interviewed together on 3/5/25 at 3:09 p.m. The CC said there were staff call offs on 1/21/25 on the hallway where Resident #2 resided. He said CNA #1 was a Level of Harm - Actual harm floating CNA and was pulled to work that hallway due to the staff call offs. The NHA confirmed CNA #1 worked on Resident #2's hallway on 1/21/25. Residents Affected - Few

The NHA, the DON, social worker (SW) #1, SW #2 and the NE were interviewed together on 3/6/25 at 11:41 a.m. They all said they were not aware they were being recorded during Resident #2's care conferences. SW #1 said she was aware some residents at the facility had cameras in their resident rooms.

The DON said Resident #2's family brought up concerns regarding a specific staff member and asked that

the staff member not care for Resident #2 any longer. She said she remembered the resident's family showing her a picture of the CNA, but said she did not know who it was. She said she did not look at the staffing schedule, nor personnel file to determine who the CNA was.

The DON said she did not conduct an investigation, nor report to the State Agency following Resident #2's family report of rough treatment of facility staff toward Resident #2.

The NHA was interviewed on 3/6/25 at 12:10 p.m. The NHA said the word rough reported by Resident #2's family should have triggered an investigation. She said that was considered an allegation of abuse and an investigation should have been initiated and reported to the state agency. She said today (3/6/25) she had started an investigation, suspended CNA #1 and called the police.

She said angel rounds had been completed that morning and in the days that followed the 1/21/25 incident between Resident #1 and CNA #1. She said during the angel rounds they asked questions such as if residents were being treated with respect and dignity and if they felt they were harmed by a staff member or resident. She said the residents had not reported any mistreatment by staff.

She said the facility staff who attended the care conference on 1/23/25 said they thought the family had more of a customer service complaint, but the word rough was an allegation of abuse and should have been investigated as such.

48114

III. Incident of physical abuse by LPN #1 towards Resident #1

A. Facility investigation

The facility incident report, dated 4/12/24 at 11:15 p.m., was provided by the NHA on 3/5/25 at 3:25 p.m.

The report revealed an allegation of physical abuse involving Resident #1 and LPN #1. LPN #1 was working

on the secured unit and did not like that Resident #1 was reaching over to grab items off the nurse's medication cart. LPN #1 grabbed the items and attempted to remove Resident #1 from the area. LPN #1 grabbed Resident #1's arm. CNA #2 observed LPN #1 grab Resident #1's arm to remove the resident from a restricted area. Resident #1 was assessed by registered nurse (RN) #2 and bruising was noted on the resident's bilateral upper extremities in various areas.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065361 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brookside Inn 1297 S Perry St Castle Rock, CO 80104

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 0600 CNA #2 submitted a form on 4/12/24 that was completed by CNA #2 and dated 4/12/24. The report documented LPN #1 was blocking the entry to the nurse's office to all of the residents on the secured unit. Level of Harm - Actual harm LPN #1 grabbed Resident #1 by her forearm and twisted it, telling Resident #1 to go away while the resident was trying to enter the nurse's station. Resident #1 grabbed some items from the medication cart and threw Residents Affected - Few them at LPN #1. LPN #1 got upset and yelled at Resident #1. LPN #1 did not let the resident go and was yelling at the resident to stop. Resident #1 was getting more aggressive and combative. CNA #2 said she asked LPN # 1 to let the resident go and LPN #1 said no. CNA #2 told LPN #1 that yelling and grabbing Resident #1 would not help the situation. Resident #1 started hitting CNA #2. CNA #2 took Resident #1 away from LPN #1 and Resident #1 calmed down.

The investigation documented Resident #1 was cognitively impaired and did not recall the incident.

The investigation documented LPN #1 was interviewed on 4/17/24 at 8:31 a.m. LPN #1 said when she arrived on the unit, the nurse's station had residents roaming around it. She said that after escorting the residents out of the nurse's station, she used the medication cart to block the door. LPN #1 said a CNA was assisting her. LPN #1 said

Resident #1 was grabbing things off the cart which she was allowing to happen until she was going for the computer on the cart. LPN #1 said that was when she intervened and was attempting to stop Resident #1. LPN #1 said the altercation was short and that she was not even aware that this was an issue until being suspended.

Pictures were included in the investigation that was provided by the NHA on 3/5/25. A picture taken on 4/13/24 revealed round bruising to Resident #1's left wrist. A picture taken on 4/15/24 revealed round bruising to the resident's left lower elbow. Another picture taken on 4/15/24 revealed round bruising on the resident's right arm below the elbow.

The facility's investigation revealed that, although Resident #1 presented with bruising, she had a history of sundowning behaviors. The facility concluded they were unable to substantiate physical abuse due to the pattern of Resident #1's bruising that was not consistent with twisting.

-However, abuse occurred as CNA #2 observed LPN #1 willfully grab Resident #1's arm.

The investigation documented, to help prevent a recurrence, LPN #1, an agency employee, was removed from returning to the facility.

B. Resident #1

1. Resident status

Resident #1, age greater than 65, was admitted on [DATE REDACTED]. According to the March 2025 CPO, diagnoses included mood disorder and dementia.

The 1/2/25 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of three out of 15. She required supervision/touching assistance with eating and toileting.

The assessment indicated Resident #1 did not exhibit any physical or verbal behavioral symptoms directed towards others.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065361 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brookside Inn 1297 S Perry St Castle Rock, CO 80104

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 0600 2. Record review

Level of Harm - Actual harm The mood care plan, initiated 9/14/22, documented Resident #1's short-term memory had continued to decline since she was admitted to the facility. Resident #1 was easily overstimulated and did not do well in Residents Affected - Few loud environments. The care plan documented loud environments caused her agitation and delusions to increase which led to increased exit seeking and striking out at staff. The care plan documented her mood fluctuated from pleasant to angry in a short time. She could verbally and physically strike out during these episodes. Her delusions caused her to become angry and distressed. Interventions included encouraging Resident #1 to participate in activities that may be of interest to her, redirecting the resident if the activity appeared to be overstimulating or triggering to her, ensuring the resident was in a safe place when her anger appeared to be escalating and providing oversight as able to ensure safety.

The health status note, dated 4/7/24, documented staff were monitoring Resident #1's arms for redness and irritation.

The resident had no redness or irritation noted, lotion was applied and the resident denied itching or pain.

The health status note, dated 4/13/24, documented the manager on duty (MOD) was notified by the previous shift's nursing staff during shift change that there was an incident that had happened between Resident #1 and LPN #1. A skin assessment was completed and Resident #1 had bruising to her bilateral upper extremities (BUE), three bruises to her left arm that were 1 centimeter (cm) by 1cm on her wrist, 0.5 cm by 0. 5 cm on her lower elbow and 1 cm by 1 cm on her upper elbow. She also had a 0.3 cm by 0.3 cm bruise to her right upper elbow. All other skin areas were clean, dry and intact.

The health status note, dated 4/13/24, documented the NHA and the DON were notified of the bruising to the resident's right hand and left wrist/forearm. The NHA and the DON advised staff to call the police. The note documented the police were notified and arrived to investigate.

The physician note, dated 4/15/24, documented Resident #1 had bruising on her bilateral arms but denied any pain.

-A review of Resident #1's EMR did not reveal any documentation that indicated the resident had sustained

the bruising prior to the incident on 4/12/24, where LPN #1 grabbed Resident #1's arm.

3. Staff interviews

CNA #3 was interviewed on 3/5/25 at 3:56 p.m. CNA #3 said she was not working when the abuse incident happened on 4/12/24. She said she heard that a nurse was rough with a resident

CNA #3 said if she saw abuse, it was her duty to report it right away. She said she would report the abuse to

the NHA, the DON and the manager on duty (MOD). She said she would fill out an incident sheet. She said

the incident binder was located at the nurse's station. She said she had never witnessed resident abuse.

RN #1 was interviewed on 3/5/25 at 4:10 p.m. RN #1 said she received abuse and dementia training when

she first started. She said residents on the secured unit required more redirection and cuing.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 12 065361 Department of Health & Human Services Printed: 09/05/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065361 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brookside Inn 1297 S Perry St Castle Rock, CO 80104

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 0600 RN #1 said de-escalation skills helped and she tried to incorporate calmness on the secured unit. RN #1 said getting the residents outside for fresh air and walking with them helped keep the residents calm. Level of Harm - Actual harm RN #1 said if she saw resident abuse she would ask that staff member to leave immediately. She said she Residents Affected - Few would approach the resident and de-escalate the situation. She said she would report the abuse to the DON.

She said she would document what she witnessed in the resident's EMR

The DON was interviewed on 3/6/25 at 10:40 a.m. The DON said agency staff received a large packet of training information that contained abuse, reporting and risk management. She said before agency staff worked at the facility, they had to read and acknowledge the information received.

The DON said the residents on the secured unit were not able to verbalize their needs and feelings. She said

the unit served residents of all different needs. She said the staff on the unit were trained to anticipating the residents' needs. She said the staff made sure the residents had a good quality of life, dignity, care and felt safe.

The DON said she was not sure why the abuse investigation from 4/12/24 was unsubstantiated.

The NHA was interviewed on 3/6/25 at 10:54 a.m. The NHA said the abuse investigation was unsubstantiated

because LPN #1 said she only grabbed Resident #1's hand and the bruising was on her arms. She said the bruises on Resident #1's arm were not fingerprints. She said the bruising looked old and did not look fresh.

She said she did not know if LPN #1 was the one who actually caused the injuries on Resident #1's arms.

-However, review of Resident #1's EMR did not reveal documentation that the bruising was present prior to

the incident on 4/12/24.

The NHA said she was not at the facility when the police officer and nurse spoke to Resident #1. She said

the police officer thought the injuries were not from the nurse. She said the police officer said the way the bruising displayed did not match up. She said the bruising showed one finger and there would have been more fingerprints on her arm. She said the police officer made the determination to unsubstantiate the findings.

-However, abuse occurred due to CNA #2 observing LPN #1 willfully grab Resident #1's arm to move Resident #1 out of the way (see facility investigation above).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 12 065361 Department of Health & Human Services Printed: 09/05/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065361 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brookside Inn 1297 S Perry St Castle Rock, CO 80104

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 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38185 potential for actual harm Based on interviews and record review, the facility failed to ensure residents were free from physical Residents Affected - Few restraints imposed for staff convenience and not required to treat medical symptoms for one (#2) of three residents reviewed for restraints out of three sample residents.

Specifically, the facility failed to ensure Resident #2, who had a history of getting up out of bed unassisted, was kept free from physical restraints.

Findings include:

I. Facility policy and procedure

The Restraint Free Environment policy and procedure, undated, was provided by the nursing home administrator (NHA) on 3/6/25 at 1:55 p.m. It revealed in pertinent part, It is the policy of [the facility] that each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits

the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints.

Physical restraint refers to any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body.

Discipline means any action taken by the facility for the purpose of punishing or penalizing residents.

Convenience refers to any action taken by the facility to control a resident's behavior or manage a resident's behavior with a lesser amount of effort by the facility and not in the resident's best interest.

The resident has the right to be treated with respect and dignity, including the right to be free from any physical or chemical restraint imposed for the purpose of discipline or staff convenience, and not required to treat the resident's medical symptoms.

Behavioral interventions should be used and exhausted prior to the application of a physical restraint.

II. Resident #2

A. Resident status

Resident #2, age greater than 65, was admitted on [DATE REDACTED] and discharged to the hospital on 2/2/25. According to the February 2025 computerized physician orders (CPO), diagnoses included dementia with severe agitation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 12 065361 Department of Health & Human Services Printed: 09/05/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065361 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brookside Inn 1297 S Perry St Castle Rock, CO 80104

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 0604 The 11/14/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of five out of 15. She required partial to moderate Level of Harm - Minimal harm or assistance with bed mobility, toileting, dressing and personal hygiene and was dependent upon staff for potential for actual harm transfers.

Residents Affected - Few The assessment documented Resident #2 did not utilize a physical restraint.

B. Resident #2's representative interview

The resident's representative was interviewed on 3/4/25 at 4:50 p.m. She said Resident #2 had a recent decline since November 2024 and December 2024. She said her family members felt the facility had broken

a lot of trust over the course of her stay at the facility and they were concerned with how staff were treating Resident #2, so they installed a hidden camera in Resident #2's room and recorded the care conferences.

She said one of the nurses said during a care conference that Resident #2 would often misbehave and that comment was concerning for the resident's family members.

The resident's representative said the facility was constantly complaining to the family members that Resident #2 was attempting to get out of bed unassisted.

The resident's representative said the camera was placed facing the head of the bed.

The resident's representative said she came to visit Resident #2 multiple times, as well as did her daughter almost every night to assist the resident with eating. She said when she or her daughter would enter the room, they often times found the recliner chair pushed up against the bed, with Resident #2 lying in bed. She said Resident #2 was unable to move the recliner chair out of the way. She said she felt this was the facility staff's way of keeping Resident #2 in her bed.

The resident's representative said based on the video and pictures the family took, the recliner chair was pushed up against the resident's bed on 1/21/25 at 7:32 p.m. and on at least two other occasions. She described the pictures as follows:

Picture one: The head of the bed was facing the window. The resident's bed was pushed up against the wall

on the resident's right side. The recliner chair was pushed directly against the bed. It was approximately two feet from the head of the bed and the chair extended down until approximately one foot from the foot of the bed.

Picture two: The bed was positioned in the same way, against the wall on the resident's right side. The chair was pushed directly up against the bed in the same location as picture 1. The resident was laying sideways with her head up against the wall, her knees bent and legs curled up against the back of the recliner. It appeared as though the sheets were tangled up and she was holding them in her hand.

The resident's representative was interviewed again on 3/6/25 at 11:13 a.m. She said there was a video taken on 1/21/25 at 7:32 p.m. of a care interaction between a CNA and Resident #2. She said the video was one minute and twenty seconds long.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 12 065361 Department of Health & Human Services Printed: 09/05/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065361 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brookside Inn 1297 S Perry St Castle Rock, CO 80104

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 0604 The resident's representative described the video, The camera is sitting behind the top of [the resident's] bed looking at her head and body from the top of the bed. We see a CNA enter the frame on the left side with Level of Harm - Minimal harm or pillows in her hands. She is moving quickly and being quite brusque. She picks up a pillow, folds it in half and potential for actual harm begins touching near the end of the bed where [the resident's] legs are. [The resident] says something unclear and then or are you going to touch me again? The CNA says, nope, I' m going to touch you again. Residents Affected - Few

She continued to describe the video by saying the CNA then roughly pushes something near [the resident's] legs (presumably the pillow but it is not seen) and [the resident] cries out, Ow, I don' t want to be touched like that! It hurts! The CNA picks up another pillow and folds it in half. The CNA says, Well, we need you to stay

in bed, so you don' t fall. The CNA forcefully pushed [the resident] over onto her right side, towards the wall,

a loud thud is heard and [the resident] screams out in pain Ooooowwweee!

She said the video continued and she said While the CNA is forcefully pushing the pillows under her, [the resident] says I hate it, I don' t want that to happen again. Is that clear?! The CNA moves to the top of the bed and again forcefully pushes [the resident] towards the wall. [The resident] says Oh, that hurts me then rolls back on her back and screams AHHH, Stop it! The CNA pulls on the pillow under [the resident's] head and [the resident] asks

Why are you being rough on me? The CNA answers sharply, Because I need you to stay in bed! You then see [the resident] trying to fix her blankets and says, You shouldn' t do that to me, you shouldn' t be here.

The CNA is observed pushing the recliner chair directly up against the resident's bed. And the video ends.

Cross reference