Brookestone Acres

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09(F)(iii) Based on record review and interviews, the facility failed to complete the care plan (a comprehensive, written document that outlines the personalized healthcare needs, goals, and interventions for a resident, based on a thorough assessment of the medical, functional, and psychosocial status) and to conduct the interdisciplinary care conference on three residents (Resident 1, 21, and 46) out of three residents sampled. The facility census was 74. Findings are: During an interview on 9/09/2025 at 2:15 PM the administrator confirmed the facility is behind on care plan conferences but the facility had an active Performance Improvement Plan (PIP) in place due to past non-compliance with the resident care conferences. During an interview on 09/09/2025 at 3:54 PM the Social Services (SS) confirmed that the care conferences have been behind. The facility started a plan on 8/1/2025 to get the care conferences caught up. A. During an interview on 9/8/25 at 1:24 pm…

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 The facility failed to ensure physician orders for CPAP ( Continuous Positive Airway Pressure) devices included the required pressure setting for Residents 53 and 60.F695 - Respiratory CareLicensure Reference Number: 175 NAC 12-006.09(H)(vi)(3)(g) Based on observation, interview, and record review the facility failed to ensure that physician orders for Continuous Positive Airway Pressure (CPAP) therapy (a type of non-invasive ventilator that delivers pressurized air through a mask to keep the airway open during sleep) included complete and specific settings (pressure, ramp time, humidity, or other specifications) for 2 of 2 sampled residents (Resident 53 and Resident 60) in a facility census of 74. This failure had the potential to result in inadequate or unsafe respiratory care delivery.A.A record review of resident 53's Care Plan (a detailed document that outlines the specific healthcare needs, goals and interventions for the resident) dated September 9, 2025 revealed an intervention listed as CPAP as ordered…

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(l)(i)(3) Based on observations, record review, and interviews; the facility failed to implement, to revise and/or develop new interventions to prevent further falls for 2 (Residents 14 and 41) of 4 sampled residents. The facility census was 75. Findings are: A. Review of the facility Fall Prevention/Management Standard with a revised date of 1/2024 revealed the following guidelines: -residents were to be reviewed during the pre-admission/admission process to identify and determine risk for falls. -when a resident was identified at risk for falls, the care plan was to reflect the potential for injury/safety risk. Approaches/interventions were to be implemented and maintained related to identified areas of risk. All team members were to be knowledgeable of the resident's fall interventions. -falls were to be investigate as they occurred, and the staff were to collect factual evidence related to the fall event using the Root Cause Analysis process. The Root Cause…

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.

Licensure Reference Number 175 NAC 12-006.09D Based on record review and interview; the facility failed to have a diagnosis for the use of an antipsychotic (a drug or substance that affects how the brain works) medication and to attempt a gradual dose reduction (GDR) and/or have a documented contraindication for use of the antipsychotic medication for 1 (Resident 50) of 5 sampled residents. The facility census was 75. Findings are: A. Review of the Psychoactive Medication and Medication Regimen Review Management Standard dated 6/2024 revealed the following: -residents were not given psychotropic drugs unless the medication was necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication was beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication. -psychotropic medications included antipsychotics, antidepressants, anti-anxiety, and hypnotics. -attending physicians assumed leadership in medication management by developing, monitoring, and modifying regimens in…

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 12-006.17 Based on observations, record review and interview, the facility failed to wear personal protective equipment (PPE) and clean reusable equipment in accordance with facility policy to prevent the potential spread of Covid-19. The sample size was 22 and the facility census was 57. Findings are: A. Review of the facility policy Cleaning, Storage, and Maintenance dated 2/2019 revealed the following related to cleaning and disinfecting of mechanical lifts/sling pads (an assistive device used to transfer a person safely from one location to another): -When handling contaminated slings, disposable protective gloves shall be used. Additional PPE should be used when appropriate. -Slings must be laundered when used for residents on isolation precautions. -Disinfect all surfaces that come in direct contact with the resident's skin with a [NAME] Health Services (VHS) approved disinfectant between each resident use. B. Review of the facility policy Covid-19 Guidelines dated…

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 Based on record review and interview, the facility failed to notify the provider for a condition change for 1 resident (Resident 39). The sample size was 1 and the facility census was 57. Findings are: A. Review of Resident 39's Nursing Progress Notes dated 5/25/23 at 1:37 PM revealed the resident was being monitored for a potential Urinary Tract Infection (UTI) related to symptoms of aggression, very odorous urine and the resident was more lethargic (a state of fatigue involving a lack of energy and motivation for physical and mental tasks). Review of Resident 39's record Monitoring for Suspected Urinary Tract Infections dated 5/25/23 through 5/28/23 revealed the following regarding the resident's urinary status: -on 5/25/23, the urine was cloudy with a foul odor, had symptoms of lethargy, malaise (a general feeling of discomfort, illness or uneasiness) and a change in mental status; -on 5/26/23, the urine had a foul odor and symptoms of malaise and lethargy were…

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.

Licensure Reference Number 175 NAC 12-006.02(1) Based on record review and interview, the facility failed to submit transfer and discharge notifications to the State Ombudsman (an official appointed to investigate individuals' complaints and serves as a consumer advocate) as required for Resident 9. The facility census was 57. Findings are: Review of Resident 9's Census List revealed the resident was discharged to the hospital on 4/19/23, 5/22/23, and 6/24/23. Review of Resident 9's Medical Records revealed no evidence the State Ombudsman was notified of any discharges from 4/19/23 through 6/24/23. During an interview on 8/2/23 the Social Services Director confirmed the facility did not notify the State Ombudsman of Resident 9's hospital discharges.

Licensure Reference Number 175 NAC 12-006.05(1) Based on record review and interview, the facility failed to provide Resident 9 or the resident's representative, bed hold information when the resident was transferred to the hospital. The sample size was 22 and the facility census was 57. Findings are: Review of the undated facility Notice of Bed Hold Policy revealed the facility advised the resident and or family of the bed hold policy, in writing within 24 hours of an emergency transfer to inform them of the bed hold rate (daily cost/rate for the type of room being held for the resident). Review of Resident 9's Census List revealed the resident was transferred to the hospital on 4/19/23, 5/22/23, and again on 6/24/23. Review of Resident 9's medical record from 4/19/23 through 6/25/23 revealed no evidence the resident or the resident's representative were notified of the facility bed hold policy. During an interview on 8/1/23 at 3:15 PM the Director of Nursing confirmed the facility had no documented evidence that Resident 9 or their representative were provided with the required…

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 12-006.09B1 Based on record review and interview, the facility failed to ensure Resident 4's Minimum Data Set (MDS-federally mandated comprehensive assessment used to develop resident care plans) was coded to reflect the resident's health status. The sample size was 22 and the facility census was 57. Findings are: Review of Resident 4's Preadmission Screening and Resident Review (PASRR-federally required screening required for all individuals being considered for nursing facility admission, to determine if the person has or was suspected of having a mental illness, intellectual disability, or related disorder, and used to ensure that individuals were not inappropriately placed in nursing homes for long term care) dated 2/25/20 revealed the resident had a level 2 (extended) assessment completed and the facility needed to document this by marking yes to question 1500A on the MDS indicating the resident had a serious mental illness, developmental disability, or related disorder.…

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.

License Reference Number 175 NAC 12-006.09C3 Based on record review and interview, the facility failed to complete a discharge summary for Resident 56. The sample size was 3 and the facility census was 57 residents at the time of the survey. Findings are: Record review of Resident 56's Progress Note dated 6/26/2023 at 9:15 PM, revealed the resident had been transferred to the hospital. Review of Resident 56's records revealed there was no discharge summary. An interview with the Administrator on 8/2/2023 at 8:00 AM, revealed Resident 56 had discharged to the hospital on 6/26/2023 and did not return to the facility. An interview with the Administrator on 8/2/2023 at 8:27 AM confirmed the facility did not do a discharge summary for Resident 56. An interview with the Director of Nursing on 8/2/2023 at 10:31 AM revealed the facility had a process they followed for discharges and a discharge summary needed to be completed within 30 days. The DON confirmed a discharge summary had not been completed for Resident 56.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09D7 Based on observation, interview, and record review: the facility failed to implement interventions to protect from a potential burn from a hot liquid spill for Resident 10. The sample size was 5 and the facility census was 57. Findings are: Review of the Hot Liquid Management Guidelines policy dated 3/2016 revealed if residents were assessed at high risk upon admission, readmission, quarterly and with a significant change the following elements were to be implemented: - reduce the temperature of the hot liquid, - use adaptive equipment/clothing as necessary, - update the care plan, - place hot items towards the center of the table but within a comfortable reaching distance for the resident, - remind residents that you have served them a hot beverage, and - residents with hot liquids should not be left unsupervised. Review of Resident 10's Hot Liquid Screening form on admission dated 2/20/23 revealed therapist recommendations for cool hot liquids and all drinks would…

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.

Licensure Reference Number 175 NAC 12-006.09D Based on record review and interview, the facility failed to ensure Resident 9's antipsychotic (medication that works by altering brain chemistry to help reduce psychotic symptoms like hallucinations (seeing things not present), delusions (fixed and firm belief not supported by evidence), and disordered thinking) medication had an appropriate indication for use. The sample size was 5 and the facility census was 57. Findings are: Review of Resident 9's Minimum Data Set (MDS-federally mandated comprehensive assessment used to develop resident care plans) dated 7/4/23 revealed 1.) diagnoses of hypertension, urinary tract infection, diabetes, anxiety, and depression. 2.) the resident received extensive assistance with bed mobility, transfers, toileting, and dressing, 3) the resident was frequently incontinent of bladder, received anti-anxiety and antidepressant medication 5 of the previous 7 days, and had no indication of hallucination, delusion, disordered thinking, or insomnia (inability to sleep). Review of Resident 9's Progress revealed…

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.

Licensure Reference Number 175 NAC 12-006.10B1 Based on observation, record review and interview the facility failed to ensure 1 resident (Resident 13's) medications were properly secured. The sample size was 1 and the facility census was 57. Findings are: A. An observation of Resident 13 on 07/31/23 revealed the following: -At 10:30 AM the resident was seated in [gender] room alone and had a small, clear plastic cup with multiple medications inside on a table. -At 10:35 AM there were 8 loose medications sitting on top of the resident's table. The resident asked this surveyor what the brown and white capsules (3 of them) were and was unsure if [gender] should take them due to an upcoming medical procedure. -At 10:55 AM Licensed Practical Nurse (LPN)-A, was asked to assist the resident with the medication concern and LPN-A informed the resident the 3 brown and white capsules were Budesonide capsules and were prescribed for [gender] lungs to help with breathing. The resident stated [gender] thought the medication was to stop diarrhea and did not want to take it, if that was what 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.