Health inspection·August 13, 2025

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some immediacy was removed. There was no non-compliance identified at a lower level upon removal.Findings: 1a. During a review of Resident 1's clinical document titled, admission RECORD, the document indicated Resident 1 was admitted to the facility on [DATE], with a diagnosis which included respiratory failure (a serious condition that makes it difficult to breathe on your own), hypoxia (a condition where there was an inadequate supply of oxygen to the body's tissues), and the presence of a tracheostomy. A review of Resident 1's clinical document titled, Order Summary, dated 7/29/25, ordered by the Medical Director, (Med Dir - a physician who oversees resident care), the document indicated, .Perform suctioning via tracheostomy PRN [as needed] for audible secretions, visible mucus, increased work of breathing, or [oxygen saturation; the amount of oxygen you have circulating in your blood] < [less than] 92% [percent]. Use sterile technique [free from germs] with suction catheter [a sterile, flexible tube, used to remove secretions and other fluids from the airways of residents who cannot clear them on their own].pre oxygenate [the administration of oxygen to a resident before a procedure]. During a concurrent observation and interview on 8/7/25, at 9:15 AM, with Resident 1, in Resident 1's room, Resident 1 was observed to have a tracheostomy. Resident 1 stated she had asked the facility staff to please perform her tracheostomy care, stating the last time it was done was on 8/5/25, two days prior. Resident 1 stated the facility staff informed her that there was not anyone able to do her tracheostomy care. Resident 1 stated the last time she had tracheostomy care was on 8/5/25. During an interview on 8/7/25, at 12:47 PM, with Licensed Nurse (LN; a Licensed Vocational Nurse, LVN) 2, LN 2 stated she had asked Respiratory Therapist (RT) 2, on 8/5/25, if the RT staff would provide tracheostomy care for Resident 1. LN 2 stated RT 2 refused and stated she was leaving the facility and would no longer work for the facility. LN 2 stated she asked LN 4, a registered nurse on duty on 8/5/25, to provide tracheostomy care to Resident 1, but LN 4 told her that he did not know how to do tracheostomy care. LN 2 stated the RTs were only on duty on the day shift and RNs were not available when the residents with tracheostomy's were first admitted to the facility. 1b. During a review of Resident 2's clinical document titled, admission RECORD, the document indicated Resident 2 was admitted to the facility on [DATE], with diagnoses which included respiratory failure with hypoxia and the presence of a tracheostomy. A review of Resident 2's clinical document titled, Order Summary, dated 7/29/25, the document indicated, .Perform suctioning via tracheostomy PRN for audible secretions, visible mucus, increased work of breathing, or [oxygen saturation] < 92%. Use sterile technique with suction catheter.pre oxygenate. During an interview on 8/7/25, at 12:47 PM, with LN 2, LN 2 stated that the LVNs expressed concerns about caring for Resident 1 and Resident 2's tracheostomy needs because the facility had not provided the competencies needed to provide tracheostomy care. During an interview on 8/7/25, at 2:33 PM, with RT 1, RT 1 stated the RNs and RTs had not received any in-service (activities or training that take place while someone is employed, often to improve their skills or knowledge for their current role) training for tracheostomy care and tracheal suctioning. During a concurrent interview and record review on 8/7/25, at 2:47 PM, facility documents titled, Tracheostomy and T-Piece Care Competency Evaluation Form, dated 7/25, and the undated Suctioning In-Service Training, were reviewed with the Director of Nursing (DON). The DON confirmed both forms were blank (no names listed), which indicated there were no competencies completed for the RTs and LNs (both LVN's and RNs) for tracheostomy care and tracheal suctioning. The DON explained that the facility should have provided training for the RTs and LNs (both LVNs and RNs) to ensure the RTs and LNs had the competencies to provide safe tracheostomy and care and tracheal suctioning. During an interview on 8/7/25, at 2:54 PM, with RT 2, RT 2 stated she had not conducted or scheduled competencies with any of the licensed staff (additional RTs and/or RNs) to care for residents with tracheostomies (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055304 If continuation sheet Page 2 of 10 Printed: 05/15/2026 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 055304 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2025 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some (Resident 1 and Resident 2). RT 2 stated she did not work at the facility any longer. During an interview on 8/7/25, at 4:06 PM, with RT 1, RT 1 stated the RTs were not hired to do tracheostomy care and suctioning, they were hired to do incentive spirometer (a handheld medical device used to help residents breathe deeply and regularly, particularly after surgery or for those with lung conditions) and acapella (a handheld device that helped residents with respiratory conditions clear mucous; thick, slippery, and usually clear substance produced by the body to protect and lubricate various surfaces) from their lungs). RT 1 explained Resident 1 and Resident 2 were at risk for desaturation and pneumonia (infection in the lungs) when the facility did not have RNs who had the competencies to care for Resident 1 and Resident 2's tracheostomy care needs. During an interview on 8/8/25, 3:30 PM, with the Medical Director (Med Dir), the Med Dir stated the facility should have ensured they had staff that could care for, assess, and provide safe tracheostomy care and tracheal suctioning. The Med Dir stated that the facility should have ensured that staff received appropriate training and had the necessary competencies to care for residents with tracheostomies. The Med Dir further explained Resident 1 and Resident 2 were at risk of death because the staff did not have the appropriate training and competencies to manage tracheostomies. A review of the facility titled, Competency Evaluation, dated 2024, the document indicated, . Policy . It is the policy of this facility to evaluate each employee to assure they meet appropriate competencies and skill for performing their job . Competency . a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual need to perform work roles or occupational functions successfully . A review of the facility policy titled, Tracheostomy Care-Suctioning, dated 2024, the document indicated, . Tracheal suctioning is performed by a Competent Registered Nurse and Respiratory Therapist to clear the throat and upper respiratory tract of secretions that may block the airway . A review of the facility policy titled, Tracheostomy Care, dated 2024, the document indicated, . The facility will ensure staff responsible for providing tracheostomy care including suctioning are trained and competent according to professional standards of practice . 2. During a concurrent interview and record review on 8/7/25, at 4:55 PM, Resident 1's and Resident 2's electronic medical record was reviewed with the DON. The DON confirmed no care plans and/or baseline care plan (care plans developed during the first 48 hours of the residents stay at the facility) had been developed for Resident 1 and Resident 2 regarding tracheostomy care and tracheal suctioning. The DON explained the importance of the care plans was to direct the care of the residents. A review of a facility policy titled, Comprehensive Care Plans, dated 2025, the document indicated, . The comprehensive care plan will describe, at a minimum . services that are to be furnished to attain and maintain the resident's highest practicable physical, mental, and psychosocial well-being . A review of the facility policy titled, Tracheostomy Care, dated 2024, the document indicated, . Based on the resident assessment, attending physician's orders, and professional standards of practice, the facility in collaboration with the resident/resident's representative will develop a care plan that includes appropriate interventions for respiratory care . 3. During a concurrent interview and record review, on 8/7/25, at 4:40 PM, the facility staffing sheets (documents that outline the number and types of staff scheduled to work at a facility on a given shift and/or day) from 7/28/25 through 8/7/25 were reviewed with the DON. The DON confirmed the following shifts (AM shift was 6:30 AM to 3 PM, PM shift was 2:30 PM to 11 PM, NOC (night) shift was 11 PM to 7 AM) and/or portions of shifts were without a RN assigned to work on the floor: 7/28/25 NOC shift, 7/29/25 NOC shift from 11 PM to 1 PM, 7/30/25 AM shift and PM shift, 7/31/25 AM shift and NOC shift, 8/1/25 AM shift and PM shift, 8/4/25 PM shift, 8/5/25 PM shift, 8/6/25 AM shift, and 8/7/25 AM shift. During a concurrent interview and record review, on 8/8/25, at 3:10 PM, the Facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055304 If continuation sheet Page 3 of 10 Printed: 05/15/2026 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 055304 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2025 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Assessment (a comprehensive evaluation of a facility's ability to provide skilled nursing care, rehabilitation services, and other related health services to residents), dated 8/8/24, was reviewed with the Administrator (ADM). The ADM stated the facility had not met the facility assessment staffing plan which indicated .Based on the facility's resident population and their needs for care and support, the facility's general approach to staffing is to ensure that it has sufficient staff members with the appropriate competencies and skill sets to meet the needs of the residents. The ADM explained his expectations were whenever there was a resident in the facility with a tracheostomy the facility would have an RN in the building 24 hours a day to provide tracheostomy care, and that the staff would have the required competencies. The ADM also explained the risk to the residents with tracheostomies could have been a negative clinical outcome (an undesirable or unfavorable result for a patient receiving medical care). Event ID: Facility ID: 055304 If continuation sheet Page 4 of 10 Printed: 05/15/2026 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 055304 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to ensure medications were administered within professional standards of practice, to one resident (Resident 4) in a sample of four, when Resident 4's medications were left at her bedside.This failure had the potential for Resident 4 not taking her medications and/or another resident taking Resident 4's medication, negatively impacting the resident's health and well-being.Findings:During a concurrent interview and observation, on 8/6/25, at 12:50 PM, Resident 4 was in her room and two liquid medications were observed to be on her bedside table. Resident 4 explained the medications were her protein and her lactulose.A review of Resident 4's clinical document titled, Medication Administration Record (MAR), dated 8/1/25 through 8/31/25, the document indicated, .Lactulose [promotes bowel movements] . and, .[brand name liquid protein] .During an interview with Licensed Nurse (LN) 1, on 8/6/25, at 1:05 PM, LN 1 confirmed he had left Resident 4's liquid protein and lactulose on her bedside table. LN 1 stated he should not have left the medications there. LN 1 explained he should have watched Resident 4 take her medications. LN 1 further explained there was a risk for another resident taking Resident 4's medication and there was a risk Resident 4 would not have taken her medication that was left on her bedside table.During an interview with the Assistant Director of Nursing (ADON), on 8/6/25, at 1:35 PM, the ADON stated the importance of not leaving medications at the residents bedside was another resident could take the medication, placing that resident at risk.A review of the facility policy titled, Medication Administration, dated 2025, the document indicated, .Medications are administered by licensed nurses . in accordance with professional standards of practice . Observe resident consumption of medication . Event ID: Facility ID: 055304 If continuation sheet Page 5 of 10 Printed: 05/15/2026 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 055304 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2025 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to ensure one of four sampled residents (Resident 4) received food that was safe and at an appetizing temperature when Resident 4's lunch meal on 8/7/25 was served cold and Resident 4's cold drink was served warm.This failure had the potential for Resident 4 to not obtain her nutritional requirements due to unpalatable food, negatively affecting Resident 4's health and well-being. Findings:During an interview with Resident 4, on 8/6/25, at 12:50 PM, Resident 4 stated the food was always cold and the drinks were always warm.During a concurrent observation and interview with Dietary Aide/Cook (DA/Cook) 1, on 8/6/25, at 12:56 PM, in Resident 4's room, the DA/Cook 1 took the temperatures of the food items on Resident 4's lunch tray that had been delivered at 12:52 PM. The temperatures were as follows: Taco Casserole 115 degrees Fahrenheit (F - a unit of measure); Mixed Vegetables 102 degrees F; Cranberry Juice 60 degrees F. During an interview with the Registered Dietitian (RD), on 8/12/25, at 1:59PM, the RD stated the above food items were in the danger zone for food safety with the danger zone (temperatures that allow for rapid bacteria growth) being 40 degrees F to 140 degrees F for hot foods and above 40 degrees F for cold drinks. The RD explained the safe holding temperature for food was &gt; 140 degrees F. The RD further explained foods in the danger zone could cause foodborne illness when consumed. According to the Food Safety and Inspection Service U.S. Department of Agricultures website, .Danger Zone (40 F - 140 F) .Leaving food out too long at room temperature can cause bacteria (such as Staphylococcus aureus, Salmonella Enteritidis, Escherichia coli O157:H7, and Campylobacter) to grow to dangerous levels that can cause illness. Bacteria grow most rapidly in the range of temperatures between 40 F and 140 F, doubling in number in as little as 20 minutes. This range of temperatures is often called the Danger Zone . https://www.fsis.usda.gov/food-safety/safe-food-handling-and-preparation/food-safety-basics/danger-zone-40f-140f Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055304 If continuation sheet Page 6 of 10 Printed: 05/15/2026 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 055304 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a clean and sanitary kitchen environment when:1. Spoiled grapes were available for resident consumption; and,2. Water from a floor sink (a drain in the floor that dirty water flows into) overflowed into the walk-in refrigerator; and,3. The resident refrigerator/freezer was not clean, contained outdated items, contained staff lunch bags and undated food containers, and was not monitored for temperature. 1. During an interview with Resident 4, on 8/5/25, at 2:22 PM, Resident 4 stated when she had asked for fresh fruit, she had been given a bag of ‘rotten grapes'.During a concurrent observation and interview, on 8/6/25, at 11 AM, with the Dietary Manager (DM), in the walk-in refrigerator, three bags of grapes were observed to be in a box dated 7/14/25. The grapes were removed and were soft with blackened patches and white patches on the grapes, in a slimy liquid. The DM confirmed the appearance of the grapes. The DM stated when the grapes arrived they were good for 4-5 days, not 3 weeks.During an interview with the Registered Dietitian (RD), on 8/12/25, at 1:59 PM, the RD stated the grapes should have been thrown away and not available for resident consumption. The RD explained if there were signs of mold on the grapes it could potentially spread to other food in the refrigerator and could cause foodborne illness among residents receiving food from the kitchen.A review of the facility policy titled, Food Safety Requirements, dated 2025, indicated, .Food safety practice shall be followed throughout the facility's entire food handling process .Storage of food in a manner that helps prevent deterioration or contamination of the food, including growth of microorganisms (germs) .2. During a concurrent observation and interview with the Dietary Manager (DM), in the walk-in refrigerator, on 8/6/25, at 11 AM, a blanket was noted to be on the floor of the walk-in refrigerator. The DM stated there had been a leak in the walk-in refrigerator the day before. During an interview with the Maintenance Director (MNT Dir), on 8/6/25, at 11:35 AM, the MNT Dir stated the leak in walk-in refrigerator had not been a leak. The MNT Dir explained the floor sink on the other side of the wall overflowed due to a cap covering the drain, and the dirty water went through the wall into the walk-in refrigerator.During a follow up interview with the DM, on 8/6/25, at 11:45 AM, the DM stated the water from the floor sink had been mopped up yesterday and the blanket left on floor. The DM explained the refrigerator had been cleaned the day prior, however the DM also confirmed the moderate amount of debris still on the floor of the walk-in refrigerator consisting of one hair-net, 3 butter packets, 4x8 inch piece of box material and tape, an 8 1/2 x 11 sheet of stickers, and a stalk of celery with blackened edges.During an interview with the Registered Dietitian (RD), on 8/12/25, at 1:59 PM, the RD stated the water leaking into the refrigerator was concerning as it could mean the refrigerator may not be properly sealed. The RD explained the water provides a damp environment that could encourage mold and bacteria growth (germs), spoiling the food and rendering the food unsafe to eat. The RD further explained the risk to the residents was foodborne illness. 3. During a concurrent observation and interview with certified nursing assistant (CNA) 1, on 8/13/25, at 12:55 PM, in the East Wing room where the resident refrigerator was located, the contents of the refrigerator were as follows:two cups containing food items with a paper towel over the top, no date, no name, one cup contains a pinkish pudding like substance, the other one contains grapes;A tamale, dated 7-19-25, room [ROOM NUMBER]A; A thawed frozen food item in the refrigerator with no thaw date, has resident name, no received date.;Four containers of ‘chocolate blood (pork blood)' no name, no date on containers;One medium sized container with a green lid containing chicken and vegetables, no name no date on container;Two cartons of eggs, no name no received date, sell by date of 7/2/25;One (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055304 If continuation sheet Page 7 of 10 Printed: 05/15/2026 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 055304 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete open can of coconut water, no name no date;Three staff lunch bags one green, one red, one black;One medium container with a red lid containing cooked beans, no name no date;One medium sized container with a red lid containing vegetable looking items, pineapple chunk looking items, tapioca looking items and a pink pudding substance with a black plastic spoon in the container, undated and unlabeled;One bag, dated 8/8/24, room [ROOM NUMBER]A, with a container of rice and a cake with use by date of 8/12/24;One medium sized, opaque container, with a blue edging on the lid, containing food items, unlabeled and undated; One white container with an opaque lid containing food items, undated and unlabeled;One bag of grapes undated and unlabeled;One bag, containing lunch meat, undated for room [ROOM NUMBER]B;The top rack in refrigerator contained unidentifiable debris, a caked on red sticky red substance, and a moderate amount of clean liquid.The freezer contained loose debris, with stains and a brownish substance on the left side and bottom of the freezer. The food items in the freezer were as follows:One piece of cake between two paper plates undated and unlabeled; Ice cream bars undated and unlabeled;One bottle of brand named water undated and unlabeled;An opaque container with a blue lid containing food items undated and unlabeled;CNA 1 confirmed the above items and lack of cleanliness of the refrigerator and freezer.The red signage on refrigerator door, undated, indicated NOTIFICATION This is a Resident Only Refrigerator All food placed in the Refrigerator must have residents name and a date. Food has a shelf life of 72 hours and then the food must be removed from the Refrigerator and thrown away Before throwing the food away notify the Resident that the food had been stored for 72 hours and must be thrown away Refrigerator will be cleaned every Friday by EVS/housekeepingAn observation of the signage on the front of the refrigerator titled, Fridge/Freezer Temperature Log, dated 7/2025, indicated the refrigerator temperature was taken one time in July, on July 23rd, with a note stating no thermometer for freezer. An observation in the freezer revealed there was no thermometer in the freezer.During a concurrent observation and interview with the Director of Nursing (DON), on 8/13/25, at 1:14PM, the DON stated there was one resident refrigerator in the East Wing. The DON confirmed the contents and lack of cleanliness of the refrigerator and freezer. The DON stated the temperature log on the refrigerator was not sufficient as there was only one recorded temperature for the month of July, 2025. The DON explained the temperature should be taken daily to ensure the food in the refrigerator was safe to eat. The DON explained the importance of maintaining a clean refrigerator, ensuring items were not outdated, and only contained resident food was to ensure residents did not get sick from eating outdated, contaminated food. The DON stated staff items should not be kept in the resident refrigerator/freezer due to potential cross contamination that could cause foodborne illness to residents. The DON confirmed there was not a thermometer in the freezer and stated there should have beenA review of the facility policy titled, Use and Storage of Food Brought in by Family or Visitors, dated 2025, indicated, . It is the right of the residents of this facility to have food brought in by family or other visitors .food must be handled in a way to ensure the safety of the resident .Refrigerate labeled and dated prepared items .If not consumed within 3 days, food will be thrown away . Event ID: Facility ID: 055304 If continuation sheet Page 8 of 10 Printed: 05/15/2026 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 055304 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2025 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview the facility failed to ensure outside garbage bins were kept covered.This failure could have been a contributing factor in the facility harboring pests (cockroaches, flies, ants) with the potential to negatively impact the health and well-being of residents residing in the facility. Findings:During observations made on 8/6/25 at 10:38 AM, 8/7/25 at 11 AM, and 8/13/25 at 10 AM., the lids of the outside garbage bins were noted to be open. During a concurrent observation and interview on 8/13/25 at 10:11 AM, with the Director of Nursing (DON), the DON confirmed the presence of one cockroach on the wall in the conference room. During a concurrent observation and interview on 8/6/25 at 11:45 AM, with the Dietary Manager (DM), the DM confirmed the outside garbage bin lids were left open. The DM explained the outside garbage bin lids should have been kept closed so pests were not attracted to the kitchen. The DM stated the residents could become ill because pests carry germs (a very small virus or bacteria that can make a person ill).During an interview with the Registered Dietitian (RD), on 8/15/25, at 11:47 AM, the RD stated she and the DM were aware of the pests. The RD explained pests should not be in the kitchen. The RD further explained that cockroaches opened up the opportunity for food contamination and the residents would be at risk for foodborne illness (nausea, vomiting, and/or diarrhea caused by eating contaminated food). Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055304 If continuation sheet Page 9 of 10 Printed: 05/15/2026 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 055304 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2025 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure that the kitchen oven was in good working order when the right oven door was hanging open and could not be closed.This failure had the potential to delay meal service and have hot foods not maintained at a safe food temperature (Hot food should be kept at 140 degrees Fahrenheit ( F - unit of measurement) or above to avoid rapid bacteria (germs) growth, which could negatively affect the health of 87 residents who received food from the kitchen. During an observation on 8/6/25, at 11:40 AM, in the kitchen, the right-side door of a double oven was hanging open and the right-side door of the oven was not attached to the oven.During a concurrent observation and interview with Dietary Aide/Cook (DA/Cook) 1, on 8/6/25, at 11:45 AM, the DA/Cook 1 stated the right-hand oven door had been broken for three to four months. During an interview on 8/12/25, at 1:59 PM, with the Registered Dietitian (RD), the RD stated a kitchen audit was completed on 5/21/25. The RD stated that the Dietary Manager (DM) and herself were aware the right-hand oven door was broken and had informed the Administrator (ADM). The RD explained the oven was a crucial part of the kitchen and there were food safety concerns when it was broken. The RD further explained she was worried about foods cooked in the oven obtaining and maintaining food safe temperatures (temperatures where rapid bacteria growth is minimal).During an interview on 8/15/25, at 1:12 PM, with the Administrator (ADM), the ADM confirmed the right-hand oven door had been broken from at least 5/21/25 through 8/13/25. The ADM explained the oven should not be broken for three months. The ADM further explained the importance of keeping the oven in good working order was food safety. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055304 If continuation sheet Page 10 of 10