Pennsylvania Department of Health
BROOKSIDE HEALTHCARE AND REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

BROOKSIDE HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

There are 176 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


BROOKSIDE HEALTHCARE AND REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on a Medicare/Medicaid Recertification survey and an Abbreviated survey in response to a complaint completed December 3, 2025, it was determined that Brookside Healthcare and Rehabilitation Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care as they relate to the Health portion of the survey.

Plan of Correction:

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:

This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.60(i) Food safety requirements.
The facility must -

§483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

§483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Observations:
Based on policy review, observation, and staff interview, it was determined that the facility failed to properly store food and maintain sanitary conditions in the dietary department.

Findings include:

Review of the facility policy entitled, "Food Storage: Cold Foods," dated May 21, 2025, revealed that all foods were to be dated.

Observations during the tour of the dietary department on September 30, 2025, at 10:30 a.m., revealed the following:

In the dry storage room, there was an unsealed bag of bran cereal that was exposed to air with a winged insect on the cereal. There were three winged insects flying around the dry storage room and landing on various food packages including an opened bag of rice cereal.

In the trayline reach-in cooler, there was a large pan of sliced deli turkey that was not dated.

On the bread storage rack, there was a bread bag that was torn open and the bread was exposed to air. There were three winged insects that landed directly on the bread.

In the walk-in freezer, there was an opened bag of ravioli that was not dated. There was a box of broccoli with a hole torn in the side of the box and in the plastic bag which was exposing the product directly to air. There was a piece of broccoli directly touching the shelf.

In the walk in cooler, there was a crate with 20 juice cups that were removed from the original packaging and not dated.

Observation during the lunch meal service on October 1, 2025, at 12:14 p.m., revealed a winged insect that landed on a plastic lid used to cover food at meal time.

In an interview on September 30, 2025, at 10:50 a.m., the Director of Dining confirmed that foods in the cooler and freezer should be dated.

CFR 483.60(i) Food Safety Requirement
Previously cited 11/1/24

28 Pa. Code 201.14(a) Responsibility of licensee.

Plan of Correction - To be completed: 12/05/2025

All items were corrected immediately and/or discarded; all items contacted by winged insects were discarded during surveyor initial inspection.

-All dietary staff must participate in and complete the following educations prior to returning to work: Cold food storage Policy; Receiving and Storage of Food In-service; Environment Policy and Procedure; Cleaning Procedures In-service; Cleaning and Sanitizing In-service.

Audit:

-FSD (or designee) will complete Audit monitoring log 2x daily, 5 days a week, for 30 days.

Monitor and QAPI:

FSD/Designee will complete weekly audits x4 weeks. DON/Designee will report findings to QA and Administrator. The QAPI committee will determine the need for any further audits and/or action plans.

483.25 REQUIREMENT Quality of Care:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Observations:
Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure physician's orders were implemented for one of 23 sampled residents. (Resident 12)

Findings include:

Review of the policy entitled, "Administering Medications," last reviewed May 21, 2025, revealed that staff were to obtain vital signs if necessary and document physician indicated medication administration information. In an interview with the Director of Nursing on October 14, 2025, at 2:25 p.m., the vital signs were to be entered into the Medication Administration Record (MAR).

Clinical record review revealed that Resident 12 had diagnoses that included hypertension (high blood pressure). On July 9, 2025, the physician ordered staff to administer a blood pressure medicine (diltiazem) three times a day. Staff were not to administer the medication if the heart rate (the number of times a heart beats in one minute) was less than 60 beats per minute. Resident 12's MAR for August, September, and October 2025, revealed that staff administered the medication 189 times with no documented evidence that the heart rate was assessed prior to medication administration per the physician's order.

In an interview on October 14, 2025, at 2:26 p.m., the Director of Nursing confirmed there was no documented evidence that the heart rate was taken prior to medication administration per the physician's order and it should have been documented in the MAR.

CFR 483.25 Quality of Care
Previously cited 11/1/24

28 Pa. Code 211.10(d) Resident care policies.

28 Pa. Code 211.12(d)(1)(5) Nursing services.

Plan of Correction - To be completed: 12/05/2025

What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
-Resident 12 Resident is receiving medications as per physician orders. Order was immediately updated to include HR hold parameters

How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?

-The Director of Nursing (DON) or designee will conduct randomized audits to ensure residents are assessed prior to medication administration as per physician orders. All current orders with hold parameters to be audited.

What measures will be put into place or what system changes will you make to ensure that the deficient practice does not recur?

-The facility Educator or designees will in-service licensed staff regarding hold parameters, and following Dr orders.

How the corrective action will be monitored to ensure that the deficient practice will not recur; i.e., what quality assurance programs will be established?

-The Director of Nursing (DON) or designee will audit New admissions' Charts and new orders to ensure hold parameters are correctly in place as per Dr order weekly for 4 weeks.

-DON/Designee will report findings to QA and Administrator. The QAPI committee will determine the need for any further audits and/or action plans.

483.60(f)(1)-(3) REQUIREMENT Frequency of Meals/Snacks at Bedtime:

§483.60(f) Frequency of Meals
§483.60(f)(1) Each resident must receive and the facility must provide at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care.

§483.60(f)(2)There must be no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack is served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span.

§483.60(f)(3) Suitable, nourishing alternative meals and snacks must be provided to residents who want to eat at non-traditional times or outside of scheduled meal service times, consistent with the resident plan of care.

Observations:
Based on review of the facility's meal schedule, observations, and resident and staff interviews, it was determined that the facility failed to ensure that meals were served at regularly scheduled times in accordance with resident needs on one of two nursing units (Susquehanna Unit) and in the main dining room.

Findings include:

Review of the facility's meal schedule for the Susquehanna nursing unit revealed that the scheduled time for lunch delivery in the short hall was 12:15 p.m. and in the long hall was 12:45 p.m. Review of the meal schedule for the main dining room revealed that delivery was 1:00 p.m. A ten minute grace period was allowed before it was considered late.

Observation on September 30, 2025, on the Susquehanna nursing unit, short hall, revealed the meal cart arrived on the nursing unit at 12:45 p.m., 20 minutes after the scheduled delivery time. On the Susquehanna nursing unit, long hall, the meal cart arrived on the nursing unit at 1:20 p.m., 25 minutes after the scheduled delivery time. In interviews at that time, Residents 4 and 15 stated that meals were typically late in the Susquehanna unit long hallway.

Observation of the main dining room on September 30, 2025, at 1:28 p.m., revealed that the lunch meal had not yet been served. In interviews at the time, Residents 17 and 32 stated that meals were typically served late in the main dining room. Further observation revealed that the residents seated in the main dining room were served their lunch trays from 1:29 p.m. through 1:40 p.m., 19 to 30 minutes after the scheduled meal time.

In an interview on October 14, 2025, at 10:58 a.m., the Administrator confirmed the meal service should have been delivered according to the scheduled delivery times.

28 Pa. Code 201.14(a) Responsibility of licensee.

28 Pa. Code 201.18(b)(3) Management.

Plan of Correction - To be completed: 12/05/2025

Retroaction to mitigate the lateness of the start of meal delivery was not possible during said meal period.

-Resident interviews were conducted after the meal period to follow up with the residents affected by the start of service.

Steps to prevent reoccurrence:

-All dietary staff must participate in and complete the following educations prior to returning to work: Frequency of Meals Policy.

-The food service director will participate in immediate training and complete the following educations prior to returning to work: Individual resident interviews policy; Food committee policy and procedure.

Audit:

-FSD or designee will complete 5 tests trays weekly (consisting of a minimum of one test tray from each meal period) for 30 days;

-FSD or designee will complete 1 resident satisfaction survey weekly, with a minimum of 10 residents for 4 weeks.

Monitor and QAPI:

-FSD/Designee will complete weekly audits x4 weeks. DON/Designee will report findings to QA and Administrator. The QAPI committee will determine the need for any further audits and/or action plans.

483.10(e)(1), 483.12(a)(2), 483.45(c)(3)(d)(e) REQUIREMENT Right to be Free from Chemical Restraints:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.10(e) Respect and Dignity.
The resident has a right to be treated with respect and dignity, including:

§483.10(e)(1) The right to be free from any . . . chemical restraints
imposed for purposes of discipline or convenience, and not required to treat the
resident's medical symptoms, consistent with §483.12(a)(2).

§483.12
The resident has the right to be free from abuse, neglect, misappropriation of
resident property, and exploitation as defined in this subpart. This includes but is
not limited to freedom from corporal punishment, involuntary seclusion and any
physical or chemical restraint not required to treat the resident's medical
symptoms.
§483.12(a) The facility must-. . .
§483.12(a)(2) Ensure that the resident is free from . . . chemical restraints
imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms.
. . . .
§483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic.

§483.45(d) Unnecessary drugs-General. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-
(1) In excessive dose (including duplicate drug therapy); or
(2) For excessive duration; or
(3) Without adequate monitoring; or
(4) Without adequate indications for its use; or
(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or
(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section.

§483.45(e) Psychotropic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that--

§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

§483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

§483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

§483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

§483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.

Observations:
Based on clinical record review and staff interview, it was determined that the facility failed to ensure that residents were free from chemical restraints for one of five sampled residents who received psychotropic medications. (Resident 1)

Findings include:

Clinical record review revealed that Resident 1 had diagnoses that included anxiety and depression. Review of the Minimum Data Set assessment dated September 10, 2025, revealed that the resident was cognitively impaired and had been administered an anti-anxiety medication.

On September 9, 2025, a physician ordered staff to administer an anti-anxiety medication, (lorazepam), every six hours as needed for anxiety. There was no date in the order that indicated when staff was to stop administering the as needed medication. Review of Resident 1's Medication Administration Record revealed that staff had administered the lorazepam on October 4, 7, and 11, 2025. There was no documented evidence that the physician had re-evaluated continued use of the as needed anti-anxiety medication beyond 14 days.

In an interview on October 14, 2025, at 12:53 p.m., the Director of Nursing confirmed that there had been no date added to the order to indicate when staff were to stop administering the anti-anxiety medication.

28 Pa. Code 211.12(d)(1)(5) Nursing services.

Plan of Correction - To be completed: 12/05/2025

What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
-Resident 1 lorazepam order has a PRN and routine order . The PRN was immediately updated with a stop date.

How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?

-The Director of Nursing (DON) or designee will audit all current PRN psychotropic orders and ensure there is a stop date.

What measures will be put into place or what system changes will you make to ensure that the deficient practice does not recur?

-Nursing will review the Point Click Care dashboard every day during work week to evaluate any new orders to ensure they have a stop date.

How the corrective action will be monitored to ensure that the deficient practice will not recur; i.e., what quality assurance programs will be established?

-DON/Designee will complete weekly audits x4 weeks. DON/Designee will report findings to QA and Administrator. The QAPI committee will determine the need for any further audits and/or action plans.

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