Brookside Care Center

During an interview with the Director of Staff Development (DSD) on 10/21/25 at 2:09 PM, the DSD stated that the facility's protocol for a newly installed air mattress included verifying that the mattress settings were appropriate for the resident's weight and checking the overall firmness of the bed.

Additionally, nurses were trained to ensure that the mattress remains properly inflated and is not flat.

The DSD further stated that both he and the Director of Rehabilitation (DOR) trained staff on proper air mattress repositioning.

They emphasized that residents who were immobile or morbidly obese should be turned with the assistance of two CNAs at a time.

Regarding Resident 1, CNA 1 was the only staff member assisting him during the incident and was subsequently written up for not following the protocol. A review of the facility's memo titled, CORRECTIVE ACTION MEMO dated 9/25/25 indicated, .Type of Violation: Violation of Safety Rules.employee [CNA 1].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.During a concurrent interview and record review with the Administrator (ADM) and the assistant director of nursing (ADON) on 10/30/25 at 12:15 PM, the air mattress invoices were reviewed.

The ADM stated that an air mattress was ordered from their vendor on 9/19/25 for another resident (Resident 3).

When Resident 3 was discharged from the facility, facility staff switched Resident 3's bed, including the air mattress, with Resident 1's bed.

The ADON confirmed the settings for Resident 1's air mattress were never added to Resident 1's treatment or medication administration record so the nurses could verify the mattress settings every shift.

During a concurrent interview and record review of Resident 1's medical record with the ADON on 10/30/25 at 2:15 PM, the ADON stated she was unsure who decided to move Resident 3's bed to Resident 1's room, as there was no physician order for an air mattress for Resident 1.During a phone interview with the ADON on 11/3/25 at 10:35 AM, the ADON stated that 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.A review of the facility's Policy titled, Sufficient Staffing revised 10/2024 indicated, .Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care. A review of the facility's undated Certified Nursing Assistant - Job Description indicated, .Major Duties and Responsibilities.Assist resident with or performs activities of daily living for resident in accordance with the care plans and established policies and procedures.Additional Assigned Tasks.Establish a culture of compliance by adhering to all facility policies and procedures.A review of the facility's policy titled, Assistive Devices and Equipment revised 10/2024 indicated, .Devices and equipment that assist with resident mobility safety and independence are provided for residents.

These include.Specialty mattresses.The following factors will be addressed to the extent possible to decrease the risk of avoidable accidents associated with devices and equipment.Personal fit.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.Requests or the need for special equipment should be referred to the appropriate Department.

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