Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Brookestone Gardens during CMS and state inspections, most recent first.
Daily nursing staff postings were missing required information. Surveyors observed the Nursing Staff Information form at the front desk without the date or census, and record review showed the form listed facility name, shift hours, team members, and total staffing hours but not the required date or census. The SDN confirmed the postings provided to surveyors were undated and did not include the census.
Baseline Care Plan Not Reviewed or Offered to Residents: The facility failed to review the baseline care plan with the resident or RP and failed to offer a copy before the comprehensive care plan was completed for multiple residents. Records showed missing documentation of baseline care plan review, signatures, and offers of copies, and in some cases current orders or medication details were not attached. Residents involved had diagnoses including stroke with hemiplegia and depression, diabetes, HTN, anxiety, heart failure, CKD, CAD, pulmonary fibrosis, and a femur fracture.
Failure to ensure required physician face-to-face visits. Surveyors found that residents were being seen for initial and follow-up physician visits by APRNs, PAs, or NPs instead of a physician, despite facility policy and CMS F712 requiring physician involvement for the initial comprehensive visit and alternating visits thereafter. Affected residents had significant chronic conditions, and records showed repeated provider visits documented by non-physician practitioners as the primary care provider.
Reusable sit-to-stand lift equipment was not disinfected between resident uses for multiple residents. Staff competency records showed training on lift use and medical device disinfection, but observations found an NA using the same lift with several residents and returning it to the enclosure without cleaning it. An NA and another aide both stated staff sometimes forget to clean the lift, even though it is supposed to be cleaned after every use.
PRN Diazepam Lacked Documented Rationale: A resident with anxiety, brief psychotic disorder, and cognitive intactness had PRN diazepam orders that were changed from anxiety to muscle spasms without a documented clinical rationale. The pharmacist noted that continued PRN psychotropic use beyond 14 days required rationale and duration, but the rationale section was left blank; the DON and DCS confirmed the reason for the change was unclear and that text-message clarification was not the facility’s process.
Failure to Monitor Pressure Ulcers on Both Buttocks A resident with MS and functional quadriplegia had bilateral buttock pressure ulcers that were being followed by an outpatient wound clinic, but the facility did not consistently document weekly assessments and measurements as required. The wounds were recorded on the wrong assessment form, several weekly entries lacked measurements, and one entry for the left buttock repeated the right buttock description. The DON confirmed the resident’s buttock pressure ulcers required weekly size documentation and that the required measurements were not documented on multiple assessments.
A facility failed to follow its constipation management protocols for a resident receiving hospice care, leading to inconsistent administration of prescribed interventions and lack of physician communication. Despite the resident's care plan indicating a risk of bowel issues due to narcotic use, the facility did not consistently implement interventions like prune juice and suppositories. Interviews with staff revealed discrepancies in protocol adherence, and the DON confirmed the protocols were not followed as written.
A facility failed to follow the manufacturer's instructions for administering fast-acting insulin to a resident with diabetes. The resident received Fiasp insulin but did not consume any caloric intake until 46 minutes later, despite the requirement to receive nutrition within 15 minutes to prevent low blood sugar. The delay was due to dietary staff not providing the correct meal promptly, and the resident only had access to non-caloric beverages during this time.
A facility failed to monitor and replace oxygen administration supplies for a resident, potentially risking respiratory infections. The resident's care plan lacked interventions for replacing oxygen tubing and nasal cannula, and observations showed undated supplies. The DON confirmed the absence of individual documentation for weekly replacement, indicating a systemic issue in infection control.
Daily Nursing Staff Posting Missing Required Information
Penalty
Summary
The facility failed to ensure that the daily posting of nursing hours included the required information. During observations on 12/10/25, 12/11/25, 12/15/25, and 12/16/25, the staff posting titled Nursing Staff Information form was seen at the front entrance receptionist desk and was missing both the date and the census for the day. The facility census was 50. A record review showed the staff posting included the facility name, shift hours, number of team members, and total staffing hours, and the form had a revision date of 9/2025, but it did not include the date or census. During an interview on 12/16/25, the Staff Development Nurse confirmed that the Nursing Staff Information forms provided to surveyors did not include the census and were undated, and stated that the dates were written on the copies by the SDN. The SDN also stated that the daily sheets, which include the census, are dated and the Nursing Staff Information forms are stapled to them the following day or next business day and filed.
Baseline Care Plan Not Reviewed or Offered to Residents
Penalty
Summary
The facility failed to review the required baseline care plan with the resident or resident representative and failed to offer a copy of the baseline care plan summary before completion of the comprehensive care plan for 6 of 6 residents reviewed. The report states that the facility’s baseline care plan guidelines were dated 3/2021 and directed staff to complete the baseline care plan within 24 hours, but the guidelines also referenced review with the resident or representative before the comprehensive care plan was completed. The facility admission agreement likewise stated that the baseline care plan would be developed within 24 hours of admission and that a summary would be provided to the resident and/or representative before completion of the comprehensive care plan. For Resident 17, progress notes did not show that the resident or representative was given a copy of the baseline care plan prior to the comprehensive care plan meeting or at admission. For Resident 3, the baseline care plan was signed by the DON and included diagnoses such as cellulitis of the left lower leg, diabetes, pulmonary fibrosis, heart failure, chronic kidney disease, coronary artery disease, and a history of transient ischemic attacks, but the current physician, therapy, or treatment orders were not attached. The baseline care plan indicated a current medication list had been given to the resident, yet the progress notes did not document that the resident or representative received a copy of the baseline care plan before the comprehensive care plan meeting or at admission. For Resident 55, the baseline care plan was signed but not dated by RN D and included a diagnosis of displaced intertrochanteric fracture of the left femur, but current orders were not attached. The plan did not indicate that a current medication list had been given to the resident or representative, and the Care Plan Acknowledgement Form was absent. Progress notes did not document that the resident or representative was given a copy of the baseline care plan before the comprehensive care plan meeting or at admission. The DON stated that no care plan meeting had been held to discuss this resident or with the resident’s representative. For Resident 7, the MDS showed admission with stroke, hemiplegia, and depression. The baseline care plan dated 7/23/25 had no resident or representative signature and no documentation that a copy was offered or provided. Progress notes also lacked documentation that the baseline care plan was reviewed with the resident or representative, and the care conference note documented only the comprehensive care plan discussion. For Resident 40, the MDS showed admission with diabetes, high blood pressure, and anxiety. The baseline care plan dated 10/8/25 had no resident or representative signature and no documentation that a copy was offered or provided, and progress notes and the care conference note did not document review, offer, provision, or refusal of the baseline care plan summary. The DON confirmed that the facility did not review and offer a copy of the baseline care plan to Residents 7 and 40 or their representatives as required.
Failure to Ensure Required Physician Face-to-Face Visits
Penalty
Summary
The facility failed to ensure that residents were seen face-to-face by a physician at the required initial 30-day visit and at least every alternate visit thereafter. Surveyors found that some residents were being seen only by advanced practice providers, including nurse practitioners and physician assistants, even though the facility policy and CMS F712 required physician involvement for the initial comprehensive visit. Interviews with the Medical Records Director, Director of Nursing, and Director of Clinical Services confirmed that the facility was using APRNs and PAs as primary providers for these visits and that staff did not understand that an actual physician was required for the initial visit and alternating visits. Resident 2 had multiple chronic conditions, including congestive heart failure, major depressive disorder, hypertension, neurogenic bladder, epilepsy, anxiety, depression, paroxysmal atrial fibrillation, unsteady gait, and gastroesophageal reflux disease. The resident’s clinical profile listed an APRN as the physician and primary caregiver. Record review showed repeated physician visits completed by an APRN, including visits documented as 60-day physician visits, rather than by a physician. Resident 5 was admitted with medically complex diagnoses including cancer, hypertension, gastroesophageal reflux disease, thyroid disorder, arthritis, anxiety, depression, macular degeneration, overweight, bicipital tendinitis, and allergies, and took medications for anxiety, depression, pain, and infections. The resident’s clinical profile listed a PA as the physician and primary caregiver. Record review showed the initial 30-day physician visit and multiple subsequent physician visits were completed by a PA or APRN instead of a physician. Resident 7’s admission record listed an NP as the primary care provider, and the 30-day nursing home visit and later follow-up visits were completed by the NP. The DON confirmed that Resident 7’s initial 30-day visit was completed by the NP and not by a physician as required.
Reusable Lift Equipment Not Disinfected Between Resident Uses
Penalty
Summary
The facility failed to clean and disinfect reusable resident medical equipment between resident uses for 4 of 14 residents sampled, involving the sit-to-stand lift used with Resident 4, Resident 38, Resident 24, and Resident 33. Facility competencies for direct care staff stated that all surfaces of the full body lift and sit-to-stand lift that come into direct contact with a resident's skin are to be wiped with an approved disinfectant between each resident use, whether visibly soiled or not, and heavily soiled equipment may require soap and water scrubbing before disinfecting. A 2025 skills competency fair checklist and a nurse aide competency checklist showed staff were checked off for lift and medical device disinfection competencies, although one aide had not yet been checked off for full body lift competency or medical device disinfection competency and had not signed the checklist. During observations, NA-A used the sit-to-stand lift in Resident 4's room and then returned it to the lift enclosure without cleaning it. NA-B later used the same lift in Resident 38's room and also returned it without cleaning it, and then NA-A used the same lift again in Resident 24's room and failed to clean it afterward. In the bathhouse, NA-C used the sit-to-stand lift with Resident 33 and then moved it to the lift enclosure without cleaning it. When interviewed, NA-C stated the lift did not get cleaned after use and said sometimes staff do not get to it or forget, while also stating it is supposed to be cleaned after every use. NA-C then cleaned the lift. NA-B also stated that staff sometimes forget and do not get to clean it, and said the lifts are to be cleaned after every patient.
PRN Diazepam Lacked Documented Rationale
Penalty
Summary
The facility failed to ensure that a PRN psychotropic medication had a documented rationale for use for one resident. The resident was admitted with diagnoses including anxiety, brief psychotic disorder, muscle weakness, cognitive communication deficit, and insomnia, had a BIMS score of 14 indicating cognitive intactness, and had no behaviors of wandering or prior MDS behavior history to compare. The resident’s care plan noted potential out-of-character responses related to anxiety, including agitation, restlessness, difficulty sleeping, becoming easily worked up, and sexually inappropriate, accusatory, threatening, and demanding behaviors toward staff. Record review showed the resident had PRN diazepam orders that changed from use for anxiety to use for muscle spasms, despite no diagnosis for muscle spasms being identified. The pharmacist’s MRR stated that for PRN psychotropic use greater than 14 days, the prescriber must document a clinical rationale and duration for continued use, but the rationale section was left blank. The physician signed the review and later wrote to continue the medication for now and consider it once the resident moved back to assisted living. The DON stated she did not know why the rationale changed from anxiety to muscle spasms, and the DCS confirmed that the text-message communication used to clarify the order was not the facility’s process and that waiting to review the medication later was not a rationale.
Failure to Properly Monitor Bilateral Buttock Pressure Ulcers
Penalty
Summary
The facility failed to monitor pressure ulcers for one resident with bilateral buttock wounds, preventing evaluation of wound condition progress. The resident was admitted with diagnoses including multiple sclerosis and functional quadriplegia, and the record showed ongoing outpatient wound clinic care for pressure ulcers on both buttocks. The wound clinic note described the right buttock pressure ulcer as not improving and documented dark discoloration to both buttocks, with the right wound worse than the left, but no measurements were recorded in the wound clinic note. Observation of the resident showed wounds on both buttocks with discolored wound beds and multiple dark reddish-purple scab-like areas. The right buttock wound was visually estimated at approximately 18 cm by 11 cm, and the left buttock wound at approximately 16 cm by 12 cm. The right wound also had an irregular dark reddish-purple scab or eschar-like area at the top. During the observation, the nurse applied Critic Aid Clear AF ointment to both buttock wounds. The facility’s skin and wound management standard required weekly assessment, staging, and measurement of pressure ulcers, including documentation of length, width, depth, odor, drainage, pain, wound bed, and peri-wound appearance. Although the treatment record directed weekly measurement and description of the bilateral buttock wounds, the assessments were documented on the Non-Pressure Skin Condition Record rather than the Pressure Ulcer Record. Several weekly entries lacked required measurements, including assessments where the wounds were described as dry skin with no open areas or where the left buttock documentation repeated the right buttock description. The DON confirmed that the resident had pressure ulcers on both buttocks that went through phases of being open and closed, that weekly size documentation was expected, and that measurements were not documented as required on multiple weekly assessments.
Failure to Follow Constipation Management Protocols
Penalty
Summary
The facility failed to adhere to its policy and procedures for constipation management and prevention, affecting one resident, identified as Resident 31. The facility's Bowel and Bladder Management Standard and Elimination Protocol outlined specific interventions for managing constipation, including the administration of prune juice, milk of magnesia, and suppositories, as well as the need for physician communication if interventions were unsuccessful. However, these protocols were not consistently followed for Resident 31, who was receiving hospice care and had a history of constipation related to narcotic medication use. Resident 31's care plan indicated a potential for bowel elimination issues due to narcotic medications, with instructions for nursing staff to follow the facility's bowel management protocol. Despite this, the resident experienced multiple days without bowel movements, and the interventions outlined in the protocol were not consistently implemented. For instance, there was no documented administration of prune juice, and there were gaps in the administration of prescribed medications like bisacodyl suppositories. Additionally, there was no evidence of physician communication regarding the resident's constipation issues, contrary to the protocol's requirements. Interviews with facility staff, including an LPN and the DON, revealed discrepancies in the implementation of the Elimination Protocol. The LPN described a process that did not fully align with the protocol, particularly regarding physician communication. The DON confirmed that the bowel and elimination protocols were not followed as written, contributing to the deficiency in care for Resident 31. Observations and interviews with the resident and their family member further highlighted ongoing issues with constipation management, underscoring the facility's failure to adhere to its established procedures.
Failure to Administer Insulin with Timely Nutritional Intake
Penalty
Summary
The facility failed to adhere to the manufacturer's instructions for administering Fiasp FlexTouch insulin to Resident 24, who has diabetes and a potential for abnormal blood sugars. The physician's order required the administration of 6 units of Fiasp insulin before meals, which is a fast-acting insulin that should be given at the start of a meal or within 20 minutes after starting a meal. On the observed date, Registered Nurse-H administered the insulin at 11:53 AM, but Resident 24 did not receive any caloric intake until 12:39 PM, 46 minutes after the insulin was given. During this time, Resident 24 only had access to diet coke and coffee, which do not provide caloric value. Interviews with facility staff, including Registered Nurse-K and the Director of Nursing, confirmed that residents receiving fast-acting insulin are expected to receive nutrition with caloric value within 15 minutes of administration to prevent low blood sugar complications. However, the dietary staff did not provide Resident 24 with a meal until much later, and the initial meal offered was not what the resident ordered, causing further delay. This oversight in ensuring timely caloric intake after insulin administration led to a deficiency in the facility's pharmaceutical services for Resident 24.
Failure to Monitor and Replace Oxygen Supplies
Penalty
Summary
The facility failed to ensure proper monitoring and replacement of oxygen administration supplies for a resident, identified as Resident 41, which could potentially lead to respiratory infections. The resident, who was admitted to the facility and required oxygen therapy, had no documented interventions in their care plan to replace the oxygen tubing and nasal cannula. Observations revealed that the oxygen concentrator, tubing, nasal cannula, and humidification bottle in the resident's room were not dated, indicating a lack of adherence to infection control protocols. Interviews with the Director of Nursing (DON) confirmed that the facility's practice was to change oxygen supplies weekly, but there was no individual documentation to verify that this was done for each resident. The monthly cleaning log, which was supposed to track the replacement of respiratory supplies, did not list individual residents and lacked specific documentation for Resident 41. The DON acknowledged the absence of records showing that the oxygen supplies were replaced weekly as required, highlighting a systemic issue in the facility's infection prevention and control program.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 85 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Kearney
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mt Carmel Home - Keens Memorial | 1.7 mi | ★★★★★ | 9 | 0 |
| Mother Hull Home | 2.2 mi | ★★★★★ | 14 | 0 |
| Good Samaritan Society - St John's | 2.5 mi | ★★★★★ | 18 | 0 |
| Good Samaritan Society - St Luke's Village | 3.7 mi | ★★★★★ | 14 | 0 |
| Bethany Home, Inc | 15.6 mi | ★★★★★ | 0 | 0 |
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