Brookestone View

Licensure Reference Number 175 NAC 12-006.05(S) Based on observation, record reviews and interviews, the facility failed to ensure the resident environment was free of soiling and debris and cleaned consistently with facility practices for 1 resident (Resident 7) of 1 resident sampled. The facility census was 53. Findings are: A record review of an admission Record dated 6/3/2026 for Resident 7 revealed an admission date of 7/10/2019. A record review of the undated Care Plan for Resident 7 revealed the following for the resident:-The resident required extensive assistance with personal hygiene,-The staff were to keep their environment clean, and -The staff were to ensure an environment conducive to comfort. An observation on 6/1/26 at 11:37 AM with Resident 7 revealed the resident's wheelchair was found to have food in between the wheelchair frame, seat and armrest. The resident also had eggs and crumbs sitting in the lap crease of their shirt. An observation on 6/1/26 at 1:46 PM with Resident 7 revealed the wheelchair was still found to have food in between the wheelchair frame,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to notify a resident's responsible party of bed hold at the time of the resident's transfer from the facility for 1 (Resident 1) of 2 sampled residents, and failed to notify the ombudsman in writing of a resident's transfer from the facility as required for 1 (Resident 57) of 2 sampled residents. The facility census was 53. Findings are:A.Record review of a facility supplied document titled Notice of Bed Hold Policy and not dated revealed when a resident requires hospitalization or therapeutic leave, the facility advises the resident and the family of the bed hold policy in writing. In the case of an emergency transfer the notice is provided to the family within 24 hours of the transfer. Record review of Resident 1's Progress Notes revealed documentation on 12/29/2025 at 2:11 PM that Resident 1 was transferred out of the facility to the local emergency room and a copy of the facility's bed hold policy was sent with the resident. On 12/30/2026 the Social…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09(H)(iv) Based on record review, observation, and interview the facility failed to perform catheter cares in a manner to prevent the potential of cross contamination and infection for 1 (Resident 48) of 1 sampled resident. The facility census was 53. Findings are:A record review of Resident 48's undated Care Plan revealed the resident was admitted to the facility on [DATE], had a foley catheter (a tube that is inserted into the bladder to aide in draining urine), and was at risk for infection due to the history of Urinary Tract Infection. The Care Plan also contained an intervention for the staff to provide catheter care every shift with proper technique. In an observation completed on 06/03/2026 from 7:35 AM to 7:56 AM of catheter cares being provided to Resident 48 by Nurse Aide B (NA-B) the following was observed:-NA-B placed a package of disposable wipes, an incontinence product, and a box of disposable gloves on the foot of Resident 48's bed without first placing a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.18, 1-005.06 (D)(E)(F) The facility failed to ensure staff wore masks above the nose and below the chin, the laundry staff performed hand hygiene for at least 20 seconds, the CPAP (Continuous Positive Airway Pressure -a treatment that uses mild air pressure to keep your breathing airways open), mask was cleaned every day for Resident 109, failed to have a barrier on the counter outside of a Covid positive resident's room where laundry items were placed, provide peri care after incontinence for Resident 11, and staff failed to remove PPE (Personal Protective Equipment used to protect healthcare workers, patients, and others from potentially contacting and/or spreading potential infections) correctly when exiting a positive Covid 19 residents room to prevent the potential spread of Covid 19. This had the potential to affect all residents in the facility. The facility had a census of 56. Findings are: A) Observation on 2/24/25 at 11:00 AM the entry desk of the facility has…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY LICENSURE REFERENCE NUMBER 175-12.006.09(H)(iv)(2) Based on observations, interviews and record review, the facility failed to provide toileting interventions for one (Resident 11) of two sampled residents, which had the potential to cause skin breakdown and bladder infection. The facility identified a census of 56. Findings are: Record review of Resident 11's Census Data revealed the resident was readmitted to the facility on [DATE]. Record review of Resident 11's Face Sheet revealed the resident admitted to the facility with the following diagnosis: Unspecified dementia, unspecified severity, with behavioral disturbance, polyosteoarthritis, Parkinson's Disease and muscle weakness. Record review of Resident 11's annual Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 12/05/2024 revealed under Section C the Brief Interview for Mental Status (BIMS, a brief screener that aids…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY LICENSURE REFERENCE NUMBER 175 12-006.09(H)(iii)(1) Based on observations, interviews, and record review, the facility failed to put interventions in place to prevent a pressure ulcer for one (Resident 20) of three sampled residents. The facility identified a census of 56. Record review of Resident 20's Census Data revealed resident admitted [DATE]. Record review of Resident 20's Face Sheet admitted with the following diagnosis: Pain in right hip, pain in right knee, Type 2 Diabetes Mellitus (DM II), Primary Hypertension (HTN), chronic kidney disease (CKD), Muscle weakness, Difficulty in walking, Chronic Pain, Lead Induced Gout. Record review of Resident 20's admission Minimum Data Set (MDS) (A federally mandated assessment that captures the resident physical and mental capabilities and care needs) dated 01/02/2025 revealed the following: Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment: score:13-15: cognitively intact, 8-12: moderately impaired, 0-7: severe…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY LICENSURE REFERENCE NUMBER 175-12-.006.09(H)(v) Based on observations, interviews and record reviews the facility failed to provide therapy or restorative services for one (Resident 38) of one sampled resident to prevent decline of resident condition. The facility identified a census of 56. Findings are: Record review of Resident 38's Census Data revealed the resident was admitted [DATE]. Record review of Resident 38's Face sheet revealed the resident was admitted with the following diagnosis: Weakness, Parkinsonism, Pain in left hip, Age related Osteoporosis without current pathological fracture, other Chronic pain. admitted to hospice 4/30/2024, removed from hospice 12/13/2024 due to slowed progression of disease and overall improvement. Record review of Resident 38's Significant change Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a residents functional capabilities and helps nursing home staff identify health problems) dated 12/20/2024 significant change: Section…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09(H)(vi)(3) Based on interview, observations and record reviews, the facility failed to obtain a physician's order for the settings of CPAP (Continuous Positive Airway Pressure -a treatment that uses mild air pressure to keep your breathing airways open), and ensure the machine has a filter for one (Resident 109) of one sampled residents. The facility had a census of 56. Record review of Resident 109's admission record dated [DATE] revealed Resident 109 admitted to the facility on [DATE]. Observation on [DATE] at 1:35 PM revealed Resident 109's CPAP machine has no filter in the machine. Record review of Resident 109's Physician orders dated [DATE] revealed: -CPAP per home settings, on at HS (hour of sleep) off in AM every day and night shift -start date [DATE]. Record review of Resident 109's assessment dated [DATE] revealed Resident's BIMS (Brief Interview for Mental Status, a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Liscensure Reference Number 12-006.18C Liscensure Reference Number 12-006.17D The facility failed to ensure proper hand hygiene and gloving was performed during wound care for Resident 29, failed to ensure contaminated laundry was carried in a manner to prevent cross contmination and hand hygiene was performed after transportation, failed to ensure Resident 21's Neb kit was cleaned after each treatment. The facility census was 52. B. A record review of the facility's undated Medication Aide Procedure Checklist Topical (applied to skin) Medication revealed the facility staff was to apply gloves, apply the topical medication according to the five rights, remove gloves and discard into waste container, then wash and dry hands thoroughly when applying topical medication. A record review of facility's Hand Hygiene (cleaning) policy with a revision date of 09/12/2017 revealed the staff were to use gloves before contact with blood and body fluids, and non-intact skin (skin that was open). The policy revealed the staff…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12.006.09D Based on interview and record review; the facility failed to ensure parameters (a range) for 1 (Resident 17) of 5 sampled resident's Amlodipine (a blood pressure medication) were followed, and at least 8 ounces of fluid were given to 1 (Resident 17) of 5 sampled resident's four times a day per the physician's order. The facility census was 52. Findings are: In an interview on 03/20/2024 at 3:45 PM, the facility's Administrator confirmed the facility did not have a following provider orders policy, procedure, or guideline. A record review of Resident 17's Clinical Census dated 03/19/2024 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 17's Medical Diagnosis dated 03/21/2024 revealed the resident had diagnoses of: Essential (Primary) Hypertension (high blood pressure), Unspecified Systolic (Congestive) Heart Failure, Cardiomyopathy, Unspecified (disease of the heart muscle), Atherosclerotic Heart Disease of Native Coronary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12.006.09D6(5) Based on observation, interview, and record review, the facility failed to ensure a valid oxygen order was followed for 1 (Resident 30) of 2 sampled residents. The facility census was 52. Findings are: In an interview on 03/20/2024 at 3:45 PM, the facility's Administrator confirmed the facility did not have an oxygen policy, procedure, or guideline. A record review of Resident 30's Clinical Census dated 03/20/2024 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 30's Medical Diagnosis dated 03/20/2024 revealed the resident had diagnoses of Unspecified Bacterial Pneumonia, Obstructive Sleep Apnea (periods of not breathing when sleeping), Acute Combined Systolic (congestive) and Diastolic (Congestive) Heart Failure, Cerebral Infarction, Unspecified (stroke), and Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety (confusion without behaviors). A…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.