Health inspection·November 21, 2025

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to implement its written abuse policies and procedures when staff did not follow the required steps for responding to and reporting a documented allegation of resident-to-resident abuse after Resident 1 reported that Resident 2 threw 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 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 - to such an extent that it interferes with a person's daily life and activities) 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 incident.Review of Resident 1's electronic medical records titled, Progress Notes, dated 10/13/25 4:25 p.m., indicated, . RESIDENT [Resident 1] CAME TO ACTIVITIES AND STATED ROOMMATE [Resident 2] IS THROWING OBJECTS AT HER. URINATING ON HER SIDE OF THE ROOM AND SHE [Resident 1] FEELS UNSFAFE- NOTIFIED DON/ADON/SS.Review of Resident 2's electronic medical records titled, Progress Notes, dated 10/13/25 at 4:24 p.m., indicated, . ROOMMATE [Resident 1] CAME TO ACTIVITIES AND STATED RESIDENT [Resident 2] IS PEEING ON HER SIDE OF THE ROOM, THROWING CUPS, UTENSILS AT HER- DOES NOT FEEL SAFE.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 there was no follow-up documentation, no nursing notes, and no investigation was done after the incident. The ADON stated that it put Resident 1 and Resident 2 at risks 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 3:40 p.m. with the Activities Director (AD), Resident 1 and Resident 2's progress notes were reviewed. The AD verified that she documented both progress notes for the two residents involved with the incident. The AD stated that the DON took over the investigation and therefore she did not complete any further follow-up or documentation.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 stated that she was Residents Affected - Few Page 1 of 3 055304 055304 11/21/2025 Brookside Care Center 1221 Rosemarie Lane Stockton, CA 95207

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. 055304 Page 2 of 3 055304 11/21/2025 Brookside Care Center 1221 Rosemarie Lane Stockton, CA 95207

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 055304 Page 3 of 3