Brookestone of David City

In the surveyor’s words

From the most serious findings on record at Brookestone of David City, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF886Dec 2, 2021

  Based on interview and record review, the facility failed to ensure 3 facility employees [NA-C (Nurse Aide), NA-D, and RN-F (Registered Nurse)] of 16 sampled unvaccinated staff members were tested for COVID-19 in accordance with CMS (Centers for Medicare and Medicaid Services) guidelines and per the County Community Transmission Rate recommendation. This had the potential to affect all residents that resided in the facility. Facility census was 54. Findings are: Review of a Centers for Medicare and Medicaid Services (CMS) memo QSO-20-38-ND revised 09/10/2021 revealed that routine testing of unvaccinated staff should be based on the extent of the virus in the community. Facilities should use their community transmission level as the trigger for staff testing frequency. […]

• No harm, potential for more than minimal, patternF761Jun 3, 2026

  License reference number 175 NAC 12-006.12(D)(i)Based on observations, record reviews and interviews, the facility failed to ensure medications were securely stored to prevent potential unauthorized access on the 200 and 300 hallways. This had the potential to affect 14 residents that were independent with ambulation and wheelchair mobility. The facility census was 53.Findings are: Record review of the facility's Medication Storage and Utilization policy last reviewed on 03/19 revealed all medication storage areas, rooms and carts must be locked. An observation on 06/01/2026 at 10:05 AM revealed the 300-hall medication cart was unlocked with no staff near the medication cart. During this time, staff members are observed to walk past the unlocked medication cart. […]

• No harm, potential for more than minimal, isolatedF583Jun 3, 2026

  .Licensure Reference Number 175 NAC 12-006.05(S) Based on observations, record reviews and interviews, the facility staff failed to provide privacy during the provision of personal care for 1(Resident 1) of 4 sampled residents. The facility staff identified a census of 53.Findings are: Record review of Resident 1's admission Record dated 6/1/2026 revealed an admission date to facility of 07/08/2025. Record review of Resident 1's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used for care planning) dated 04/09/2026 revealed the facility staff assess the following about the resident:-Brief Interview for Mental Status (BIMS- a screening tool used to assess cognition relating to the mental process involved in knowing, learning, and understanding things). […]

• No harm, potential for more than minimal, isolatedF637Jun 3, 2026

  Licensure Reference Number 175 NAC 12-006.09(C)(ii) Based on interviews and record reviews, the facility failed to complete a 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), within 14 days following the determination that a significant change had occurred for two (Residents 5 and 25) of 15 residents sampled. The facility census was 53 at the time of the survey. […]

• No harm, potential for more than minimal, isolatedF641Feb 13, 2025

  Licensure Reference Number 175 NAC 12-006.09B Based on record review and interview; the facility failed to ensure the Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) reflected hypoglycemic (medication used to help reduce the amount of sugar present in the blood) medication use for two (Resident 23 and Resident 28) of 15 sampled residents. The facility census was 57. Findings are: A review of the CMS's (Centers for Medicare and Medicaid [NAME]) RAI (Resident Assessment Instrument) Version 3.0 Manual, dated October 2024, revealed the following regarding hypoglycemic (including insulin) medication use: Check if a hypoglycemic medication was taken by the resident at any time during the 7-day observation… […]