Resident 1 was changing his brief with CNA 1 on September 25 when the nursing assistant instructed him to turn to his left side. As soon as he did, the air mattress deflated on the left side, sending him tumbling to the floor.
Only CNA 1 was present during the incident.
The resident told inspectors he can turn by himself, but since the fall, two staff members now assist him during care. The air mattress was removed the same day he fell.
The mattress had been moved from another resident's room without proper authorization or setup. Facility staff switched the bed and air mattress from Resident 3's room to Resident 1's room after Resident 3 was discharged, the administrator confirmed during interviews with federal inspectors in October.
Nobody had a physician's order for Resident 1 to have an air mattress.
The assistant director of nursing told inspectors she was "unsure who decided to move Resident 3's bed to Resident 1's room." She confirmed that Resident 1's treatment records never included the proper mattress settings, so nurses couldn't verify the equipment was working correctly during each shift.
"If an air mattress was applied to a resident's bed without a physician's order, there would be a risk of injury to the resident using the mattress," the assistant director of nursing told inspectors during a phone interview on November 3.
The facility's own protocol required verifying that air mattress settings matched the resident's weight and checking the overall firmness before use. Nurses were trained to ensure mattresses remained properly inflated and weren't flat, according to the Director of Staff Development.
Both the Director of Staff Development and Director of Rehabilitation had trained staff on proper air mattress repositioning. They emphasized that residents who were immobile or morbidly obese should be turned with assistance from two CNAs at a time.
CNA 1 violated that protocol by working alone.
The facility wrote up CNA 1 the same day as the fall. A corrective action memo dated September 25 cited "failure to follow company protocol regarding repositioning or doing ADL's care for morbid obesity patients have to be 2 people assist to prevent fall."
The memo classified the violation as breaking safety rules.
Federal inspectors reviewed the air mattress invoices with the administrator and assistant director of nursing on October 30. The mattress had been ordered from the facility's vendor on September 19 for Resident 3, not for the resident who eventually fell.
When Resident 3 was discharged, facility staff simply moved the entire bed setup to Resident 1's room without following proper procedures for installing medical equipment.
The facility's policy on assistive devices and equipment, revised in October 2024, required that "equipment or device will be used according to its intended purpose and will be measured to the resident's size and weight as much as possible." It also stated that "requests or the need for special equipment should be referred to the appropriate Department."
None of that happened.
The policy further required addressing personal fit and other factors "to decrease the risk of avoidable accidents associated with devices and equipment." Specialty mattresses were specifically listed among devices that "assist with resident mobility safety and independence."
Facility job descriptions required nursing assistants to "assist resident with or performs activities of daily living for resident in accordance with the care plans and established policies and procedures." CNAs were also required to "establish a culture of compliance by adhering to all facility policies and procedures."
Federal inspectors found the facility violated federal requirements for ensuring residents receive treatment and care in accordance with professional standards of practice. The violation caused actual harm to few residents.
The resident who fell told inspectors the experience changed how he receives care. What had been routine assistance from one nursing assistant now requires two staff members every time he needs help turning in bed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Brookside Care Center from 2025-10-30 including all violations, facility responses, and corrective action plans.