Emerald Nursing & Rehab Brookside LLC

Inspectors wroteLicensure reference number 175 NAC 4-006.12(D)(i) Based on observations, interviews, and record review, the facility failed to ensure all medications were stored and locked in a secure manner to provide resident safety. The facility census was 92.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)(iii)(3)Based on record review and interview, the facility failed to perform or document skin assessments for Resident 1. This affected 1 of 4 residents reviewed for skin protection. The facility census was 92.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.18Based on observations, record review, and interviews, the facility failed to follow infection control standards of practice during wound care for Resident 2 and during wound care and resident care for Resident 4. This affected 2 of 4 residents reviewed for wound care. The facility census was 92.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04(F)(i)(5)Based on record review and interviews, the facility failed to notify the Guardian and or Power of Attorney of 2 (Resident 5 and Resident 8) of 5 sampled residents of leaving the facility against medical advice (AMA) and the facility failed to notify the physician of 5 of 5 sampled residents (Residents 5, 6, 7, 8, and 9) of the resident's leaving the facility AMA with no services. The facility census was 98.

Inspectors wroteNebraska Licensure reference: 175 NAC 12-006.19Based on observation and interview, the facility failed to maintain a sanitary, orderly and comfortable interior. All residents who reside at this facility have the potential to be affected by these deficient practices. The facility census was 94.

Inspectors wroteLicensure Reference Number 175 12-007.04 (D) The facility failed to ensure resident bathroom ventilation was functional in four resident rooms (room's 308, 502, 504, and 505) out of 14 resident rooms sampled. The facility census was 95 at the time of the survey.

Inspectors wroteBased on record review and interviews, the facility failed to transmit a Minimum Data Set (MDS - a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) record to the Centers for Medicare and Medicaid Services (CMS) within the prescribed time frame for 1 (Resident 88) of 1 sampled residents. The facility census was 95 at the time of survey.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)(i)(3)Based on observation, interviews, and record review, the facility failed to provide assistance with nail care for one (Resident 10) of three sampled residents. The facility census was 95.

Inspectors wroteLicensure Reference Number 175 NAC-12-006.06 Licensure Reference Number 175 NAC-1-005.04Based on record reviews and interviews, the facility failed to ensure that the Grievance Official (GO, a designated staff member responsible for receiving, investigating and resolving formal complaints regarding resident care) responded to and followed up on concerns of cold food recorded at 6 different Resident Council (RC, a group of residents who meet monthly to discuss the care provided by the facility) meetings. This had the potential to affect all residents who receive meals from the kitchen. The census at the time of the survey was 95.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04(I)(i)Based on interviews and record reviews, the facility failed to employ a qualified social worker on a full-time basis. This had the potential to affect all residents residing at the facility. The facility census was 95.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.18Based on observation, record reviews and interviews, the facility failed to ensure Enhanced Barrier Precautions (EBP- an infection control strategy that focuses on the prevention of the spread of multi-drug resistant organisms [MDRO]) were followed when wound care was provided and failed to ensure hand hygiene was completed between glove changes for 1 (Resident 1) of 5 sampled residents. The facility's census was 106. A record review of an admission Record printed on 10/06/2025 revealed that Resident 1 was admitted to the facility on [DATE] with a diagnosis of Diabetes Mellitus Type 2 (DMT2 a common form of diabetes mellitus that develops especially in adults that is characterized by high blood sugar levels, resulting from impaired insulin utilization coupled with the body's inability to compensate with increased insulin production). [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.02 (H) The facility failed to report an allegation of abuse on two residents (Resident 1 and Resident 2), out of four sampled residents. The facility census was 102.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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. [...]

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure Reference Number NAC 175 12-006.09 and 12-006.09(I) Based on record review, observation, and interviews; the facility staff failed to implement interventions to prevent hot liquid burns for 1 (Resident 1) of 1 sampled residents, and failed to evaluate for potential injuries from a fall prior to moving the resident for 1 (Resident 2) of 3 sampled residents . The facility staff identified a census of 107. The facility Administrator was notified on 10/17/24 at 4:30 PM of an Immediate Jeopardy (IJ) which began on 08/05/24. The IJ was removed on 10/17/24 at 6:30 PM, as confirmed by surveyor onsite verification.

Inspectors wroteLicensure 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. [...]

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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.

Inspectors wroteState 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.

Inspectors wroteBased 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.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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. [...]

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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.

Inspectors wroteBased 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.

Inspectors wroteLicensure 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.

Inspectors wroteLICENSED 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.

Inspectors wroteLICENSURE 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.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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

Inspectors wroteLICENSURE 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.