Old Brownlee Community Care Center

In the surveyor’s words

From the most serious findings on record at Old Brownlee Community Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF689Jul 9, 2025

  Based on record review, observation and interviews, the facility failed to ensure the resident's environment remained free of accident hazards by failing to ensure a quarterly Safe Smoking Assessment had been completed for 1 (#37) of 1 (#37) resident reviewed for smoking with severe cognitive impairment. Findings: Review of the facility's Smoking Policy dated 10/25/2022 revealed in part: 1.1 Purpose: To establish guidelines for safe smoking practices for residents, visitors, and employees. 1.5 Policy: ______ facility buildings are smoke-free. Smoking, including use of any tobacco products, such as vaping and/or electronic cigarettes are permitted only in outdoor designated smoking areas. Visitors and residents are not permitted to give or leave smoking paraphernalia with any resident. […]

• No harm, potential for more than minimal, patternF700Jul 9, 2025

  Based on record review, observations and interviews, the facility failed to ensure a resident had a physician's order in place and had been care planned for the use of side rails for 1 (#30) of 2 (#30 and #34) residents reviewed for bed rails. Findings: Review of the facility's Bed/Side Rails policy dated 11/28/2017 revealed in part: Policy: Even when bed rails are compatible with the bed and mattress, are properly designed to reduce the risk of entrapment or falls, and are used appropriately, they still can be hazardous for certain individuals, particularly to people with physical limitations or altered mental status, such as dementia or delirium. Side rails should only be used to improve a person's functional abilities, such as repositioning and to aid in getting out of bed . […]

• No harm, potential for more than minimal, patternF610Apr 24, 2024

  Based on record review and interviews, the facility failed to protect 5 (#1, #2, #3, #4, #5) of 5 sampled residents investigated for abuse from the potential of further abuse during the investigation process of an allegation of physical abuse. The facility failed to remove S6 CNA (Certified Nursing Assistant) from duties involving resident care after Resident #1 alleged S6 CNA had hit him. This deficient practice had the potential to affect all of the residents in the building. Findings: Abuse Components Plan Elder Justice Act and Affordable Care Act (Original effective date 09/11/2018, Revision #5 effective date 10/24/2022) in part: The Administrator or designee will immediately ensure that any further potential abuse, neglect, exploitation or mistreatment is prevented. […]

• No harm, potential for more than minimal, patternF695Jun 29, 2022

  Based on observations, record reviews and interviews the facility failed to provide the necessary care and services in accordance with accepted professional standards of practice for 4 (#3, #20, #52, #192) out of 5 (#3, #20, #52, #192, #193) residents reviewed for respiratory care. The facility failed to ensure: 1. Humidification bottles and oxygen tubing were changed, dated, and initialed weekly for Residents #3, #20 and #52. 2. Oxygen tubing was changed, dated, and initialed weekly for Resident #192. Findings: Review of the facility's Departmental (Respiratory Therapy) - Prevention of Infection policy revealed in part: Purpose - The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment . Steps in Procedure - . 3. […]

• No harm, potential for more than minimal, patternF656Jun 24, 2021

  Based on record reviews, observations and interviews the facility failed to ensure residents' plan of care was implemented for 2 (#12, #73) of 26 total sampled residents reviewed. The facility failed to ensure the correct intravenous fluids were administered to Resident #12 and failed to ensure vital signs were monitored for Resident #73 as ordered by the physician. Resident #12 Observation on 6/21/2021 at 10:00 AM revealed [MEDICATION(S)] 0.45% infusing to Resident #12's left arm at 100ml (milliliter)/hr (hour). Observation on 6/22/2021 at 9:00 AM revealed [MEDICATION(S)] 0.45% infusing to Resident #12's left arm at 100ml/hr. […]