Health inspection·December 22, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an allegation of employee-to-resident physical abuse was reported by the facility for one of three sampled residents (Resident 1) when on 11/17/25, the facility failed to report Resident 1's allegation of physical abuse by a Licensed Nurse to the state agency.This failure resulted in a delayed 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 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 12/22/25 at 12:45 PM, LN 2 stated that if he observed or heard a report of an alleged abuse, he would report it immediately to his DON or Administrator (ADM). LN 2 explained the process for reporting any type of alleged abuse including resident to resident, or staff to resident, was to check the resident head to toe and make sure the resident was safe and not injured. LN 2 further explained he would then call the doctor to notify him, report the incident to the police, complete the required abuse reporting forms, notify the Ombudsman (an appointed official to advocate for residents and resident rights), the state agency (state agency responsible for investigating alleged abuse and other resident complaints) and document the incident and who he notified in the resident's medical record. LN 2 stated in addition, we would monitor the residents for 72 hours to make sure the residents felt safe. LN 2 stated it was important to report allegations so that it did not happen in the future and to keep the residents safe. LN 2 further stated this was standard abuse allegation reporting procedures for all staff with knowledge of an alleged abuse.During an interview on 12/22/25 at 1:54 PM, CNA 1 stated that on 11/17/25 she was outside in the hallway around 7:30 to 7:45 AM passing breakfast trays to other residents and only walked past Resident 1's room but did not go inside of the room. CNA 1 further stated she remembered that there was a problem with Resident 1 feeding stray cats and that Resident 1 looked upset and LN 1 was in Resident 1's room. CNA 1 explained when the police came and took the report, she was surprised she was listed as a witness because CNA 1 stated she did not witness anything and was not in the room during the time of the allegation. During a concurrent interview and record review on 12/23/25 at 8:55 Page 1 of 3 055304 055304 12/22/2025 Brookside Care Center 1221 Rosemarie Lane Stockton, CA 95207

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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] 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. 055304 Page 2 of 3 055304 12/22/2025 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 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 055304 Page 3 of 3