Brooklyn Community Estates
Brooklyn Community Estates in Brooklyn, IA — inspection on May 28, 2026.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of the Care Plan, initiated 9/18/24, revealed a Focus area for Resident #25 moderate risk for falls related to history of falls prior to admission, gait/balance problems, incontinence, side effects of antidepressants, and hearing problems.
Interventions included the following, in part: Rail attempted with pool noodle to block the arm going down between the bed mattress and rail, which extreme force was not effective, so tried a padded overlay.
Grab bar would be less boundary and she might roll out quicker but low bed for now.
Grab bars are not considered safe or effective as assistive devices like the half rail.
Date initiated: 4/23/26.
Low bed.
Date initiated 4/21/26.
Housekeeping and maintenance look at spacing with mattress and rail.
Date initiated: 4/21/26.
Review of the Restraint/Device/Enabler Assessment, dated 3/12/26, identified the use of four half bed side rails on Resident #25's bed that did not restrict or prevent normal/independent movement due to physical limitations as resident cannot voluntarily exit the bed.
The Section #5: Device/Enabler Assessment with Subcategory: Safety Assessment, revealed the following, in part: #2e: Has the risk of injury when enabler or device(s) are in use been addressed? Assessment response left blank. #2f: Select additional safety measures used.
Assessment response left blank.
During an observation, on 5/27/26 at 9:45 AM, Resident #25 laid in bed with four half bed rails in upright position. A half bed side rail on both top left and top right of the bed were in the upright position. A half bed side rail on both bottom left and bottom right of the bed were also in the upright position.
During an interview on 5/28/26 ay 10:05 AM, the DON stated that an informed consent had not been obtained on Resident #25's four half side rails prior to implementation and explained this was because the side rails were not used as a restraint.
The DON was unable to provide documentation of alternative interventions attempted prior to installation of the four half side rails on Resident #25's bed.
Review of the facility policy titled, Side Rails Use Policy, not dated, revealed the purpose of policy was to prevent injury to a resident and allow for independent bed mobility.
The Section titled Procedure, instructed the following, in part: Explain the purpose of side rails to the resident.Elevate side rails on those residents determined in need by the Care Plan process.Check the resident frequently for safety and security of side rails.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.