Emerald Nursing & Rehab Brookside LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure reference number 175 NAC 12-006.12(D)(i) Based on record reviews, observations and interviews, the facility failed to store medications properly in medication rooms and medication carts for 2 (Resident 5 and Resident 14) of 2 sampled residents. The facility census was 96. Findings are: A. Record review of Resident 5's Clinical Census record dated 6/1/25 revealed admission to the facility was 7/18/24. Record review of Resident 5's Diagnosis record dated 6/1/25 revealed diagnosis of Alzheimer's disease (a progressive brain disorder that leads to memory loss, thinking difficulties, and behavioral changes), and unspecified dementia (a general term for a group of brain disorders that cause a decline in memory, thinking, and reasoning skills). Record review of Resident 5's 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 4/16/25 revealed: -Section C -Brief Interview for…

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(D) Based on record reviews, observations and interviews, the facility failed to ensure staff performed hand hygiene prior to applying gloves and in between glove changes during peri-cares for 1 (Resident 5) of 2 sampled residents, and failed to perform hand hygiene prior to applying gloves and in between glove changes during peri-cares and catheter care, and wear a gown for 1 (Resident 14) of 2 sampled residents to prevent potenial cross contamination. The facility census was 96. Findings are: A. Record review of the facilities Infection Control-Handwashing Policy revised 1/2024 revealed: Policy Statement - This policy considers hand hygiene the primary means to prevent the spread of infections. Use an alcohol-based hand rub containing at least 62% alcohol; or alternately, soap (antimicrobial or non-antimicrobial) and water for the following situations: -Before and after contact with residents -Before moving from a contaminated body site to a clean during resident…

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 12-006.09B Based on record review and interview, the facility failed to ensure that 4 Minimum Data Sets (MDS -a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) were coded correctly related to falls for 3 (Residents 1, 3, and 5) out of 5 sampled residents for falls. The facility census was 98. Record review of facility policy and procedures, titled Expanded Assessment Areas last updated 1/2024 revealed: -the facility shall prepare an interdisciplinary comprehensive assessment of the resident required by the Resident Assessment Instrument (RAI) using the Minimum Data Set (MDS) 3.0 and evidence based discipline assessment tools. -the assessment and the MDS information will be used to develop a comprehensive, person-centered careplan. Record review of the RAI manual dated October of 2024 revealed the definition of fall with injury to include abrasions, fractures or any fall related injury that causes the resident to…

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 12-006.10 Based on observation, interview and record review the facility failed to follow the physician's orders for 1 (Resident 6) of 3 sampled residents. The facility identified a census of 92. Findings are: A record review of the admission record reviewed on 3/3/25 revealed that Resident 6 had been admitted into the facility on [DATE] with a primary diagnosis of severe protein calorie malnutrition. A record review of the significant change 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 1/2/25, revealed Resident 6 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 13/15 indicating the resident had no cognitive impairment. A record review of the Order Summary for Resident 6, reviewed on 3/3/25, revealed the indication for use of the Omeprazole was Gastro-Esophageal…

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 12-009.11(A) Based on observation and interview; the facility failed to ensure a bathroom floor was maintained in a clean and sanitary manner for 1 (Resident 1) of 3 sampled residents. The facility census was 97. Findings are: In an observation on 1/21/25 at 3:27 PM of Resident 1's bathroom floor revealed the following: -4 cracked tiles in front of the toilet with one tile having a missing area -Large brown stained area out from base of toilet -Caulking around base of toilet with cracks and brown stains around the front of the toilet In an observation on 1/22/25 at 8:08 AM of Resident 1's bathroom floor revealed the same concerns as listed above. In an interview on 1/22/25 at 8:08 AM, the Administrator confirmed that the above-mentioned areas were present and confirmed that Resident 1's bathroom floor was not maintained in a clean and sanitary manner.

Licensure Reference Number 175 NAC 12-006.05Q Based on record review and interviews, the facility failed to ensure that residents could access their personal resident fund money on weekends, holidays, or during evening/overnight hours. This affected 65 of 65 residents with a personal fund account. The facility census was 112. An interview on 08/20/2024 at 8:22 AM with Resident 9 revealed Resident 9 had concerns that they were only able to access their money in their personal fund account during business hours when the business office is open, or sometimes when certain front receptionists are working but was unable to get any monies in the evening or on the weekends. An interview with the Business Office Manager (BOM) on 08/21/2024 at 8:17 AM confirmed that residents who have money in a personal fund account at the facility can only access their money Monday through Friday, 8:00 AM to 5:00 PM at the front desk or the Business Office. BOM confirmed that there are 65 residents who have a personal fund account at the facility. A record review of the policy titled Facility…

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 12-006.04(B)(ii) Based on interview and record review; the facility failed to provide the required 12 hours of ongoing training for 5 (Medication Aide (MA)-B, MA-E, NA-G, NA-H, and MA-J) of 5 sampled direct care staff. This had the potential to affect all the residents residing in the facility. The facility census was 112. Findings are: Record review of 5 direct care staff files who have been employed a year or more revealed all 5 direct care staff had not completed the required 12 hours of ongoing training. An interview on 8/21/24 at 2:10 PM the Human Resources Director revealed that the 12 hour ongoing training had not been being completed for any direct care staff, confirmed that the 12 hours of ongoing training had not been completed on the 5 sampled direct care staff and should have been.

Licensure Reference Number 175 NAC 12-006.11 Based on observation, record review and interview, that facility failed to follow menus when preparing resident meals. This had the potential to affect 110 residents who received food from the kitchen. The facility identified a census of 112. Findings are: A record review of the facility policy titled Food Preparation Guidelines, dated 11/17, contained the following guidelines: The cook, or designee, should prepare menu items following he facility's written menus and standardized recipes. Food should be protected from contamination while being stored, prepared, and transported. An observation on 08/21/24 at 9:37 AM of meal preparation being completed by Cook-A revealed a recipe was out for meatloaf preparation. The observation on 08/21/24 at 9:37 AM of the meatloaf preparation being completed by Cook-A revealed (gender) had washed (gender) hands and donned gloves, then retrieved 6 of the 5lb (pound) packages of ground beef. Cook-A to cut open 2 tubes of ground beef packaging with the knife and dumped the ground beef into a large mixing…

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 12-007.03(N), Licensure Reference Number 12-006.18, Licensure Reference Number 12-006.18(B), Licensure Reference Number 12-006.18(D) Based on observations, interviews, and record reviews, the facility failed to ensure a functioning handwashing sink was available in the laundry, failed to maintain enhanced barrier precautions during peri cares (the practice of washing the genital and anal areas of the body) and a transfer for Resident 56, failed to ensure hand hygiene was performed during peri cares in a manner to prevent cross contamination for Resident 56, and failed to ensure oxygen tubing was stored in a manner to prevent cross contamination for 3 (Resident 15, 72, 76) of 5 residents with oxygen. The facility census was 112. The findings are: A. An observation on 08/21/2024 at 9:12 AM revealed no working hand sink or eye wash station in the laundry. An interview with Environmental Manager on 08/21/2024 at 9:12 AM confirmed that the hand washing station in the laundry area…

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 NAC12-006.10(D) Based on observations, record review and interviews, The facility failed to ensure proper storage and labeling of medications on 3 stations (stations 1, 2, and 4) out of 5 nursing stations in the building, and the facility failed to properly store medications for Resident 42. The facility identified at census of 112. Findings are: A. An observation on 08/21/2024 at 10:54 AM with Medication Aid-B (MA-B), this station [station 1] medication storage room contains a small sized refrigerator. The door of this refrigerator had a sheet of paper taped to the outside of it. Furhter observation revealed it was a blank form dated 11/16/23 to record refrigerator temperatures. An interview on 08/21/2024 at 10:54 A.M. with MA-B reveals this sheet of paper was to record the temperatures of the refrigerator. This form contains a written date recorded as 11/16/2023. The form has no recorded temperatures out of 31 possible entries on it. MA-B stated they were unsure of who was responsible for recording the daily temperatures of the refrigerator. MA-B…

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 12-006.10 A(i) Based on record review, observation and interview, the facility failed to evaluate 1 (Resident 6) of 5 sampled residents' ability to self-medicate and ensure security of medications. The facility had a total census of 112 residents. Findings are: According to Resident 6's admission Record, Resident 6 admitted to the facility on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease, Unspecified (a common lung disease causing restricted airflow and breathing problem) and Unspecified Intellectual disabilities (a term used when a person has certain limitations in cognitive functioning, conceptual, social and practical skills). Record review of a quarterly MDS (Minimum Data Set, a federally mandated assessment utilized to determine a resident's functional capabilities and care) dated May 28, 2024, revealed that Resident 6 had a BIMS (Brief Interview for Mental Status, an interview used to determine cognition) of 15, which indicated the resident is…

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 State Statue Number 71-6022(1) Based on record review and interview, the facility failed to provide a written notice of the reason for transfer for 3 (Residents 42, 61 and 84) of 3 residents sampled for Hospitalizations. The facility identified a census of 112. Findings are: A record review of the facility policy Bed Hold and Return to Facility, revised 1-2024 revealed the following: It is the policy of this facility that residents who are transferred to the hospital or go on a therapeutic leave are provided with written information about the State's bed hold duration and payment amount before the transfer. Residents and their representative will be provided with bed hold and return information at admission and before a hospital transfer or therapeutic leave. Nursing and social work staff are educated about the resident's bed hold and return rights to ensure that required information is provided at the time the resident leaves the facility. A. A record review of Resident 42's medical record revealed Resident 42…

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 interviews, the facility failed to provide a written notice of bed hold policy to residents or their representatives within 24 hours of them being transferred to the hospital for 3 (Residents 42's, 61 and 84) of 3 residents sampled for Hospitalizations. The facility identified a census of 112. Findings are: A record review of the facility policy Bed Hold and Return to Facility revised 1-2024 revealed the following: It is the policy of this facility that residents who are transferred to the hospital or go on a therapeutic leave are provided with written information about the State's bed hold duration and payment amount before the transfer. Residents and their representative will be provided with bed hold and return information at admission and before a hospital transfer or therapeutic leave. Nursing and social work staff are educated about the resident's bed hold and return rights to ensure that required information is provided at the time the resident leaves the facility. A. A record…

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 12-006.09(I) Based on record review and interview, the facility failed to monitor head injuries identified for 1 (Resident 165) of 1 sampled resident. The facility identified a census of 112. Findings are: A record review of the facility policy titled Accidents/Neuro Checks, dated 11/22; 1-2024 read as follows; The purpose of this procedure is to provide guidelines for a neurological assessment: Neurological assessments are indicated: following a fall or other accident/injury involving head trauma; or when indicated by resident's condition. A record review of the document titled admission Record dated 9/11/23 revealed Resident 165 had been accepted into the facility on 9/11/23 with a primary diagnosis of Dementia (a loss of cognitive functioning that affects a person's ability to think, remember, learn, and make decisions). A record review of the MDS (Minimum Data Set, a comprehensive assessment of each resident's physical and mental functional capabilities) dated 3/16/24 revealed Resident 165 had a BIMS (Brief Interview for Mental Status, a test…

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 12-006.19 Based on observations and interviews, the facility failed to maintain the cleanliness of the floors and station 1, 3, and 4 within the facility. The facility identified a census of 110. Findings are: Observations made on 7/23/24 at 4:40 PM, and on 7/24/24 at 7:20 AM, 10:40 AM, 11:53 AM, and 1:55 PM: -Station 1 - There was free standing pieces of insulation along the window seal on the wall. -Station 3 - The hallway floors had clumps of a black substance, debris, food, stains, and sticky areas of unknown substances. There were four colored candy pieces at the end of the station 3 hall, 2 dead bugs next to the mat that is found at the end of the hallway. The mat was covered with dirt, dust, and rubber bands. - There were cobwebs and dust under the curio cabinet on the station 3 hallway. - Station 4 - The hallway was dirty with brown and black type debris and there was a sticky areas of unknown substances. - In the activity area next to the stove pieces of torn up paper towel were found. The entry way to the activity room had dried food…

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 12-006.18A(1) Based on observation, and interviews the facility failed to maintain a clean environment for rooms 113,211,212, and 312. The facility failed to maintain a clean floors for 400 and 300 hallway and clean carpets for 100 and 200 hallways and the facility failed to maintain clean tray tables for rooms 211-212-312. The facility census was 107. An observation on 4/8/24 at 9:30 AM revealed that room [ROOM NUMBER] had a brown sticky substance on the floor by tray table. Observation of the trash can in room [ROOM NUMBER] 's bathroom was overflowing with paper towels. Observation of the tray table in room [ROOM NUMBER] revealed Resident 9 that had a pitcher of water sitting on the tray table that was dirty with dry substance on top of tray table and base of tray table had a dry brown and yellow colored substance covering the base of the tray table. An observation on 4/8/24 at 9:45 AM revealed that in rooms [ROOM NUMBER] the floors had a sticky substance throughout the room.…

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 174 NAC 12-006.04C3a(6) Based on record review and interview the facility failed to obtain daily weights for 1 (Resident 8) of 3 sampled residents as ordered by the Physician, and the facility failed to obtain labs for 1 (Resident 5) of 3 sampled residents as ordered by the Physician. The facility census was 107. Findings are: A. Record review of Physician Orders revealed that Resident 8 has orders for daily weights dated 12/2/23 for congestive heart failure, Fax recordings weekly to Physician. Call if weight gain of 2-3 pounds for 2 consecutive days, weight gain of 5 pounds in one week. Weights had not been documented as completed on the following dates: -4/3/24 -4/4/24 -3/29/24 -3/27/24 -3/26//24 -3/25/24 -3/24/24 -3/23/24 -3/22/24 -3/13/24 -3/6/24. Record review of the Weight Monitoring Policy created 1/2024 revealed compliance Guidelines: 1) Suggested weight schedule C) If clinically indicated-more frequent than weekly An interview on 4/8/2024 at 11:30 AM with Director of Nursing (DON) confirmed that daily weights had not been completed for Resident 8…

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 12-006.17D Based on observation, interview and record review, the facility failed to ensure hand hygiene was performed to prevent the spread of infection or prevent cross contamination during and after catheter (a soft, plastic or rubber tube that is inserted into the bladder to drain the urine) care with appropriate change of gloves for 1 (Resident 7) of 3 sampled residents. The facility census was 107. Findings are: Observation on 4/9/24 from 10:01 AM to 10:13 AM of catheter care for Resident 7 with Medication Aide (MA)-A and the Nurse Consultant (NC) revealed the following: MA-A donned (put on) gloves prior to entering Resident 7's room. MA-A completed no hand hygiene prior to donning gloves. MA-A entered Resident 7's room and removed a new trash bag from the trash can and placed on the tray table, raised the bed with the bed remote, lowered the blinds and obtained supplies for catheter care. MA-A completed catheter care with no concerns. After catheter care was completed, MA-A rolled Resident 7 onto [gender] right side and found that [gender]…

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 12-006.09D1c Change to F550 Based on record review and interview, the facility failed to follow a resident's preference for bathing for 1 (Resident 10) of 3 sampled residents. The facility census was 107. Findings are: In an interview on 2/5/24 at 3:10 PM, with Resident 10 revealed, Resident 10 had not received any showers last week, and [gender] preferred to have a shower twice a week. Resident 10 also revealed there had been other weeks when [gender] had not received a shower or any other sort of bathing. Resident 10 further revealed, that when [gender] had not received a shower [gender] felt dirty and smelly. A review of Resident 10's Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care), dated 11/22/23, revealed the following: -Resident was admitted on [DATE]. -Brief Interview for Mental Status (BIMS- 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 Licensure Reference Number 175 NAC 12-006.09D Based on record review and interviews, the facility failed to follow a provider's order to change a Foley catheter (a medical device that helps drain urine from the bladder) monthly for 1 ( Resident 1's) of 1 sampled resident. The facility census was 107. Findings are: A record review of Resident #1 revealed they were admitted on [DATE] with diagnoses of: neuromusular dysfunction of bladder, paraplegia, colostomy, hypertension, pulmonary fibrosis, osteomyelitis of vertebra. A record review of Resident #1's Physician Orders revealed an order to Change Resident #1's 16 french/5 milliliter (mL) Foley catheter on the 25th of every month for neurogenic bladder related to Neuromusclar dysfunction of the bladder. A record review of Resident #1's Treatment Administration Record (TAR) revealed in the month of October 2023, November 2023 and December 2023, there was not documentation the Foley cather was changed on the 25th. Was it signed out on a specific date? A record…

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 Based on record review and interviews, the facility failed to provide necessary care and treatment for colostomy (a hole (stoma) in the abdominal wall allows waste to leave the body) for 2 (Resident 1 and Resident 6) of 2 sampled residents. The facility census was 107. Findings are: A. A record review of Resident 1's Physicians Diagnosis list dated 02/02/2023 revealed a diagnosis of having a colostomy. A record review of Resident 1's Physician Orders dated 02/02/2023 revealed, there was no orders for the colostomy bag (a colostomy bag attaches to the stoma to collect the waste) and wafer to be changed. A record review of Resident 1's Progress Notes for December 2023 and January 2024 revealed, there was no documentation of colostomy cares being done. A record review of Resident 1's Comprehensive Care Plan dated 02/10/2023 (CCP- written instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care)…

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 NAC 12-006.11E, 12-007.01A Based on observations, interviews, and record review, the facility failed to store, prepare, and serve food in a manner to prevent cross contamination to prevent the potential for food borne illness. The facility practice had the potential to effect 101 out of 104 residents who ate food from the kitchen. The facility staff identified a census of 104. Findings are: A. An observation during the initial kitchen tour on 9/20/23 from 7:23 AM to 8:05 AM revealed the microwave to be dirty both on the outside and the inside with crumbs and an uncovered plate of hard cooked eggs. Dry hard macaroni pieces were noted inside of microwave as well. A large trash can with trash like matter was placed next to and touching a rack of clean plate toppers and hot plates. The windowsill behind the microwave with old crumbs and dust present. There were clean plates with crumbs on them sitting on windowsill as well. The outside of the refrigerator had grease like build up on it.…

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 12-006.07C Based on observation, record reviews, and interviews, the facility Quality Assessment Performance Improvement Plan failed to identify ongoing issues relevant to F550, F580, F610, F656, F677, F686, F759, F812, F880, and F882 and implement plans of action to identify and correct the deficient practice. The QAPI failed to ensure repeated deficiencies at F686 and F880 were corrected and the correction was maintained. This deficient practice had the potential to affect all residents who reside in the facility. The facility identified a census of 104 at the time of survey. Findings are: Record review of an undated facility Quality Assurance and Performance Improvement (QAPI) Plan revealed the following information: -Objective: -1. Provide a means to identify and resolve present and potential negative outcomes related to care and services. -2. Reinforce and build upon effective systems and processes related to the delivery of quality care and services. -3. Provide structure and processes to correct identified quality and/or deficiencies. -4.…

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.

Based on interview and record review, the facility failed to employee an Infection Preventionist (IP, a facility staff member that looks for patterns, observes, and educates staff on infection control, and compiles infection data for the facility) at least part-time, that was not the Director of Nursing (DON). This had the potential to affect all 104 residents in the facility. Total census was 104. Findings are: A record review of The Centers for Disease Control and Prevention (CDC) Certificate dated 3/11/2023 revealed the facility's Infection Preventionist (IP) was the DON (Director of Nursing). In an interview on 9/25/23 at 9:30 AM, the Administrator confirmed that the DON was the full-time DON and the facility's only Infection Preventionist. The Administrator confirmed the facility did not have a different IP that was employed at least part-time.

Licensure Reference Number 175 NAC 12-006.05(21) Based on the record review and interview, the facility failed to ensure resident dignity was maintained while at an appointment for 1 (Resident 208) of 3 sampled residents. The facility census was 104 at the time of survey. Findings are: Record review of Resident 208's Comprehensive Care Plan (CCP- written instructions needed to provide effective and person centered care of the resident that meet professional standards of quality care) initiated 10/20/20 revealed Resident 208 needed extensive assist with personal hygiene cares. Interview on 09/25/23 11:45 AM with Director of Nursing (DON) confirmed there was no documentation of refusals of cares or baths for Resident 208 noted in progress notes from 1/5/23 through 1/25/23. Interview on 9/27/23 at 1:14 PM with staff member at the Dialysis Center revealed that Resident 208 was transferred to the dialysis center the morning of 1/16/23 and was noted to have blood in hair, face and was wearing a hospital gown. Interview on 9/26/2023 at 10:54 AM with the DON confirmed the expectation is…

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 LICENSED REFERENCE NUMBER 175 NAC 12-006.04C3a(6) Based on observation, record review, and interview; the facility failed to notify the practitioner of a significant weight loss for 1 (Resident 24) of 4 sampled residents. The facility staff identified a census of 104. Findings are: Record review of Resident 24's admission Record sheet revealed that Resident 24 was admitted to the facility on [DATE]. Resident 24 was admitted with diagnoses of closed fracture right femur, psychosis, dementia without behaviors, nonverbal and severe developmental delays, and anxiety. Record review of Resident 24's current diet order revealed: regular diet puree with nectar thickened liquids. Record review of Resident 24's weight record sheet revealed the following: -4/24/2023, Resident 24's weight was 124.0 pounds (lbs). -5/11/2023, Resident 24's weight was 119.0 lbs. -5/19/2023, Resident 24's weight was 118.0 lbs. -5/21/2023, Resident 24's weight was 117.0 lbs. Record review of Resident 24's Nutritional admission Data Collection…

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 NAC 12-006.02(8) The facility failed to report significant falls with injury within the required time frame for 2 (Resident 8 and 208) of 4 sampled residents and the facility failed to submit a written investigation for accidents in 5 working days for 2 (Residents 8, 208) of 4 sampled residents. The facility also failed to submit a written investigation for an abuse allegation in 5 working days for 1 (Resident 59) of 4 sampled residents. The facility identified a census of 104. Findings are: A. Record review of Resident 8's face sheet revealed the resident admitted to the facility 10/9/2019 with diagnoses of Unspecified Intellectual Disabilities, Major Depressive Disorder with Psychotic symptoms and Chronic Obstructive Pulmonary Disease. Record review of Resident 8's Minimum Data Set (MDS) (an assessment used to determine resident needs) dated 8/28/2023 revealed in Section C, the resident had a Brief Mental Status (BIMS) (an assessment to determine a resident's cognitive status) score of 15.…

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 NAC 12-006.09C Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 (Resident 45) of 22 sampled residents. The facility identified a census of 104 residents. Findings are: A record review of Resident 45's Face Sheet dated 8/28/23 revealed the resident was admitted on [DATE] and included the following diagnoses: Chronic diastolic heart failure (CHF) (the heart is not strong enough to pump blood), Chronic respiratory failure with hypoxia (a condition making it difficult to breathe), type 2 diabetes mellitus (a disease causing too much sugar in the blood), asthma (a disease making it difficult to breathe), Chronic obstructive pulmonary disease (a respiratory disease that makes it difficult to breathe), peripheral vascular disease (reduced blood flow throughout the body) , hypertension (when blood pressure is elevated), anxiety (a state of fear due to thoughts) , depression (feelings of sadness), Chronic kidney…

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 12-006.09D1c Based on observations, record review and interviews, the facility failed to provide oral cares and failed to follow resident preference for bathing for one resident (Resident 54) out of 8 sampled residents who required assistance with hygiene and bathing. The facility census was 104 at the time of survey. Findings are: A. Observation on 9/20/2023 at 8:45 AM revealed Resident 54 was in their room. Further observations revealed Resident 54 had food debrie in their mouth and there was not a toothbrush in the residents room. An interview on 9/20/23 at 8:46 AM with Resident 54 revealed Resident 54's teeth had not been brushed and had white matter on them. During the interview Resident 54's breath had a foul odor. Observation on 09/21/23 at 8:00 AM revealed Resident 54's teeth had white film noted and breath with foul odor. There was not a toothbrush found in Resident 54's room or in bathroom. An interview on 9/21/23 at 8:02 AM was conducted with Resident 54. During the interview Resident 54 reported their teeth had not been brushed.…

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 12-006.10D Based on observation and record review, the facility failed to ensure it was free of a medication error rate of less than 5% or greater. Observation of 41 medications administered revealed 3 errors resulting in a medication error rate of 7.31%. The medication errors affected 2 residents (38 and 54) out of 6 residents sampled. The facility identified with a census of 104 at the time of survey Findings are: A. Observation on 9/25/23 at 7:30 AM of medication aide (MA)-C administering Albuterol Sulfate HFA Inhalation Aerosol (inhaler) and Breztri Aerosphere (inhaler) to Resident 38. Albuterol Sulfate HFA Inhalation Aerosol was administered to Resident 38 by MA-C who gave Resident 38 1 puff and immediately after gave a 2nd puff of the inhaler. The Breztri Aerosphere inhaler was given 4 minutes after the Albuterol Sulfate HFA Inhalation Aersol inhaler. MA-C gave Resident 38 one puff of the Breztri Aerosphere (inhaler) and immediately after gave a 2nd puff of the inhaler. A record review of Residents 38's active orders revealed: -Albuterol…

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 12-006.17 Based on observations, record review and interview, the facility staff failed to ensure Oxygen tubing for 1 (Resident 77) of 4 residents was maintained in a manner to prevent contamination and failed to complete hand hygiene during the provison of personal care for 1 (Resident 45) of 3 sampled residents. The facility staff identified a census of 104. Findings are: A. On 9/21/2023 at 10:41 AM observation of Resident 77 oxygen (O2)tubing was undated and lying found on the floor next to concentrator. Record review of Resident 77's Medication Administration Record for September 2023 revealed orders for Continuous Oxygen at 2 liters per minute (LPM)via Nasal Cannula(NC)to keep oxygen saturations above 90% at Hour of sleep(HS)every evening and night shift. On 9/21/2023 at 2:15 PM an observation of O2 tubing on the floor between the bed and concentrator and is undated. On 9/25/2023 at 10:15 AM an interview with Resident 77 revealed that(gender) uses O2 only at night time when in bed. On 9/25/2023 at 10:15 AM observation of O2 tubing undated and…

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.