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Complaint Investigation

Brookside Inn

March 6, 2025 · Castle Rock, CO · 1297 S Perry St
Citations 4
CMS Rating 2/5
Beds 126
Provider ID 065361
Healthcare Facility
Brookside Inn
Castle Rock, CO  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

BROOKSIDE INN in CASTLE ROCK, CO — inspection on March 6, 2025.

Found 4 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0600
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical

look fresh.

She said she did not know if LPN #1 was the one who actually caused the injuries on

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).

065361 03/06/2025

Brookside Inn 1297 S Perry St Castle Rock, CO 80104

desire to ambulate independently.

The resident was assisted back to bed and did not sustain any

The 1/5/25 interdisciplinary fall progress note documented Resident #2 sustained multiple abrasions

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.

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.

065361

Form Approved OMB

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

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.

065361

Form Approved OMB

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

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 CASTLE ROCK, CO, (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 INN or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


More Reports

About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.